HIV/AIDS Prevention among Female Sex Workers in AVAHAN districts of India

COMMUNITY GROUP, PHYSICAL VIOLENCE AND HIV/AIDS PREVENTION IN INDIA 1 Title: Impact Evaluation of Community Group Membership on Physical Violence and HIV/AIDS Prevention among Female Sex Workers in AVAHAN districts of India Authors: Diwakar Yadav 1, Prabuddhagopal Goswami 1, Lakshmi Ramakrishnan 1, Shreena Ramanathan 1, Bitra George 1, Shrabanti Sen 1, Ramesh S Paranjape 2 Affiliation: 1 FHI 360, H-5, Ground Floor, Green Park Extension, New Delhi, INDIA 2 National AIDS Research Institute, Pune, INDIA Corresponding author E-mail addresses: DY: diwakaryadav@fhi360.org PG: pgoswami@fhi360.org LR: lramakrishnan@fhi360.org SR: sramanathan@fhi360.org BG: BGeorge@fhi360.org SS: SSen@fhi360.org RSP: rparanjape@nariindia.org

COMMUNITY GROUP, PHYSICAL VIOLENCE AND HIV/AIDS PREVENTION IN INDIA 2 ABSTRACT Using propensity score matching methodology, this paper examine the impact of community group membership on experience of physical violence, any positive sexual transmitted infections, HIV tested and collected result and consistent condom use with regular partners among female sex workers (FSWs) in India. A cross sectional survey was administered in 2009-2010 and covered 7,806 FSWs through probability sampling. About 37 percent of FSWs reported being member of community group and majority of FSWs were aged above 24 years, currently married, street based FSWs by typology, had experience of physical violence, had HIV test done and collected result and consistent condom use with regular partners. The average effect of treatment (being a member of community group) on treated (experience of physical violence and consistent condom use with regular partner) was 21% and 10%, respectively. The average effect of membership was marginally high among those who tested for HIV and collected results. On sexually transmitted infections, average impact was 5% higher compared to those who did not have any STIs. These finding suggest that community group membership are an effective intervention strategy to increase consistent condom use with regular partner, and reduce risk of STIs and HIV among the FSWs.

BACKGROUND COMMUNITY GROUP, PHYSICAL VIOLENCE AND HIV/AIDS PREVENTION IN INDIA 3 Avahan, the India AIDS Initiative was launched in 2003, and one of the major components of the programs includes formation of community group (CG) under community mobilization as a strategy for empowering female sex workers (FSWs) to addresses the structural barriers. In addition to working with FSWs, Avahan supported interventions among other high risk groups such as clients of FSWs, men who have sex with men/transgenders, injecting drug users and truckers in six high prevalence states of India. A few of studies found that community mobilization interventions helped to FSWs to handle crisis situation in condom use, increased empowerment, and access social entitlements. There is dearth of evidence on the impact of community group membership on experience of physical violence and HIV prevention outcomes. This research paper enquires about the association between community group membership, physical violence and HIV prevention outcomes such as condom use with regular partner, HIV tested and collected result and STI prevalence. This paper describes the characteristics of community group members and examine its impact on physical violence, had any STI, HIV tested and collected result and consistent condom use with regular partners. METHOD AND MATERIALS Data and Variables The data used in current analysis are from the Integrated Behavioural and Biological Assessment (IBBA) survey (2009-2010) and covered 7,806 FSWs through probability sampling with two stage cluster sampling in 23 districts of Andhra Pradesh (3,225 FSWs), Maharashtra (2575 FSWs) and Tamil Nadu (2006 FSWs) states of India.

COMMUNITY GROUP, PHYSICAL VIOLENCE AND HIV/AIDS PREVENTION IN INDIA 4 Conventional cluster sampling was used for FSW in brothel based, home based and lodged based settings and time location cluster sampling for street based FSWs. The unit of analysis are female sex workers, and individual level data on community groups membership ( Are you member of a community group (self-help group /community based organization?), and physical violence (How many times would you say someone has beaten (hurt, hit, slapped, pushed, kicked, punched, choked, burned but not used a weapon) you?), and other behavioural and biological information were used. We calculated any STI on the basis of biological examination (laboratory test) and it includes Rapid Plasma Regain (RPR) test for syphilis antibodies, indirect heamagglutination test (TPHA), Ganorrhoea (N. Ganorrhoeae) and Clamydia (C. Trachomatis). Another indicator of HIV/AIDS was developed by the question: did you ever take HIV/AIDS test and also collected the test result? The consistent condom use (CCU) with regular partner indicator was derived from the question: did regular (noncommercial sexual) partner used condom with you. Analysis approach We used nearest-neighbor (NN) matching with replacement of propensity score matching (PSM) methodology to assess the impact of community group membership on different outcomes and estimates comparing between exposed (treated) and unexposed (untreated) groups. This matching methodology reduces the number of distinct non-participants used to construct the counterfactual outcome and thereby increases the variance of the estimator. This type of matching has a strong advantage in that the calculations are simple and the program runs quickly when the sample size is

COMMUNITY GROUP, PHYSICAL VIOLENCE AND HIV/AIDS PREVENTION IN INDIA 5 large. Average treatment effect on the treated (ATT) was used to measure average impact. We assessed the impact of CG membership on the following outcomes: (i) ever had violence; (ii) any type of (biological-positive) sexual transmitted infections (STI); (iii) ever taken HIV test and collected result; (iv) consistent condom use with regular partner. First/Initial step of the PSM methodology is to estimate a logistic regression model of the probability on a set of background characteristics with membership of CG and run test checks to assess whether the model achieves balance. We estimated the ATT which is the difference in the outcome among the treated (those exposed to the intervention) and matched untreated (not exposed to the intervention) groups. In order to assess whether the ATT is statistically significant, we estimated bootstrapped SE around the estimates. We used pscore, psmatch and ptest command in STATA version 11.0 for all analyses. RESULTS Association between community group membership and socio-demographic characteristics Overall, 38 percent of FSWs were reported being a member of community groups. Table 1 shows the proportion of FSWs who were member of CGs by selected background characteristics in India. Among the members of CGs, majority of FSWs were aged above 24 years (86 percent), currently married (73 percent), sexual debut at age 15 and above (73 percent), and street based FSWs typology (81 percent) had experience of physical violence (23%), had tested and collected result for HIV (76%) and CCU with regular partner (14%). Despite of the membership, eight out of 10 FSWs were started sex work after age 20 years.

COMMUNITY GROUP, PHYSICAL VIOLENCE AND HIV/AIDS PREVENTION IN INDIA 6 Impact of the CG using propensity score matching The impact of community group membership on matched sample of exposed and unexposed of physical violence, any positive STI, HIV tested and collected result and CCU with regular partner were presented in table 2. The average treatment effect among the treated ATT is the difference (exposed-unexposed) in outcome indicators. Overall model balance was achieved for all significant impact presented, confirming that there was no significant difference in covariate between exposed and unexposed, and hence that the ATT estimate obtained from the model is consistent. We found that nearly 22% of FSWs who were member of CGs had reported any physical violence compared to 0.5% of the matched unexposed. The average impact of membership on who had any STI (exposed) was nearly 5%. The effect of being a member of CGs on exposed and unexposed of HIV tested and collected result was statistically significant. Being a member of CGs had a larger impact on who faced physical violence (ATT=21%). Consistent condom use with regular partner was 10% higher compare to unexposed and statistically significant among member of CGs. CGs membership had an additional impact on experience of physical violence compared to non-membership among FSWs. It was also found that membership of CGs was linked to 21.3 percentage point increase in who experienced any physical violence over did not experience of physical violence. One possible reason behind high impact of membership on physical violence could be the victim of harsh experience with their clients or other non-regular partners. The experience may be in terms of hurt, hit, slapped, kicked, punched, choked, burred. Finding indicates that experiences of physical violence among sex workers or vulnerable population are more likely to join community groups for

COMMUNITY GROUP, PHYSICAL VIOLENCE AND HIV/AIDS PREVENTION IN INDIA 7 betterment of life. Although further studies are needed to understand the process that enhance the capacity and improve capability to engage in economic activity with CGs. Another study supported that unwillingness to put on a condom is resultant to adverse behavior and sexually coerced by clients. In addition, also, violence has significantly associated with HIV risks particularly inconsistent condom use in last two years and STI symptoms in last six months among who experienced violence. Additionally, high impact of membership on physical violence suggests that there are need to develop new strategies to address physical violence in intervention programmes. Information on self-help group provided by peer outreach workers to be the most important package of services to increase condom use, reduce the risk of STI and HIV. Finding suggests that HIV status did not have an additional impact as compared to nonmembership of CGs among FSWs. However, CGs membership had an additional impact on consistent condom use with regular partners compared to non-members. One possible reason behind the success of CGs membership in increasing consistent condom use with regular partner could be the one-to-one discussions among their social network with outreach workers. CONCLUSION This study has highlighted the significance of CGs membership in influencing physical violence and HIV prevention outcomes among FSWs. These results provide support for CGs that address to reduce stigma and discrimination and to improve the quality of life of FSWs. Targeted interventions are required to start advocacy to reduce physical violence through community groups. Efforts should also focus on FSW s need of reproductive health and it should integrate with local area specific family planning

COMMUNITY GROUP, PHYSICAL VIOLENCE AND HIV/AIDS PREVENTION IN INDIA 8 programmes. Although, major efforts are underway to reduce the HIV risk among FSWs, it is essential that targeted interventions are expanded to integrated maternal health and family planning programme services for FSWs and address the community group or collective group roles within their environment. These finding suggest that community group membership are an effective intervention strategy to increase consistent condom use with regular partner, and reduce risk of STIs and HIV among the FSWs.

COMMUNITY GROUP, PHYSICAL VIOLENCE AND HIV/AIDS PREVENTION IN INDIA 9 Table 1 Percentage distribution of demographic and bio-behavioral characteristics of female sex workers by membership and non-membership of community group, India, IBBA, 2009. Background Variables Non-membership of community group (%) Membership of community group (%) p value (n=4867) (n=2939) Age group Less than 25 years 18.7 13.6 25 years or more 81.3 86.4 <0.001 Literacy Illiterate 56.1 50.7 Literate 43.9 49.3 <0.001 Source of income other than sex work Yes 52.2 58.9 No 47.8 41.1 <0.001 Current marital status Unmarried 10.9 4.8 Married 69.6 73.0 Others 19.5 22.2 <0.001 Age at sexual debut Below 15 years 18.6 27.2 15 years or more 81.4 72.8 <0.05 Age at starting sex work Below 20 years 16.0 16.0 20 years and above 84.0 84.0 <0.001 Usual place of solicitation Home 6.5 11.7 Brothel/Lodge/dhaba 17.4 6.9 Others 76.2 81.4 <0.001 Sex client volume per week Less than 10 67.7 56.9 10 or more 32.3 43.1 0.949 Regular Clients Yes 83.6 90.4 No 16.4 9.6 <0.001 Occasional clients Yes 94.4 97.4 No 5.6 2.6 <0.001 Regular Non-paying male partner Yes 67.5 74.5 No 32.5 25.5 <0.001

COMMUNITY GROUP, PHYSICAL VIOLENCE AND HIV/AIDS PREVENTION IN INDIA 10 Ever had physical violence Yes 13.3 22.9 No 86.7 77.1 <0.001 Any STI (NG/CT/RPRTITER/TPHA) Yes 8.2 4.5 No 91.8 95.5 <0.001 HIV tested and collected result Yes 60.6 75.6 No 39.4 24.4 <0.001 Condom use with regular partner Yes 13.4 14.0 No 86.6 86.0 0.822 Table 2 Estimated impact of community group membership on the physical violence and other HIV prevention outcomes among female sex workers Treatment/ exposure variable CGs membership versus No CGs membership Outcome variables Treated # Untreated $ ATT SE Z value p value Physical violence 21.8 0.47 21.3 0. 83 9.20 <0.001 Any STI 5.4 0.51 4.8 0.57-7.94 <0.001 HIV tested and collected result 76.0 71.3 4.7 1.03 13.74 <0.001 #Treated (exposed); $-Untreated (Unexposed); ATT- Average treatment effect on the treated