[Show abstract][Hide abstract] ABSTRACT: This study aimed to: (1) examine the relationship between interpersonal as well as social-demographic, cultural and structural factors, and condom non-use by sex workers' main intimate or other non-paying male sex partners (NPPs), as reported by a sample of sex workers; and (2) understand HIV/sexually transmitted infections (STIs) risk (e.g., numbers of sexual partners; condom use with different partners) among couples comprised of a sub-set of sex workers and their NPPs. Bivariate and multivariable logistic regression was used to identify factors associated with condom non-use at last sex by the main NPP, as reported by sex workers. Adjusted odds ratios and 95% confidence intervals are reported (AOR[95%CIs]). Data were drawn from cross-sectional surveys in Bagalkot District, Karnataka State, South India. Responses by sex workers whose main NPPs agreed to enrol in the study and the main NPP enroled were linked; these responses by couples (pairs of sex workers and NPPs) were examined for responses to sexual risk for HIV/STIs. Overall, this study included 257 sex workers and 76 NPPs. The data from 67 couples (88.2%) could be linked. In over a quarter of partnerships, at least one (SW or NPP) partner reported having another type of partner besides each other (and clients of SWs). In multivariable analysis, significantly increased odds of condom non-use at last sex with the main NPP were found for the following key factors: planning to have a child with their main NPP (AOR = 3.71[1.44-9.58]); and having decisions about condom use made by their main NPP (AOR = 9.87[4.03-24.16]) or both equally (AOR = 3.18[1.39-7.80]) (instead of by the sex workers herself). Our study highlights the potential risk for HIV/STI acquisition and transmission between NPPs and sex workers, and between NPPs and their non-sex workers wives and other sex partners. Study results underscore the need for HIV/STI prevention approaches that incorporate informed decision-making about childbearing and parenting, and empowerment strategies for sex workers within the context of NPPs.
AIDS Care 08/2015; DOI:10.1080/09540121.2015.1050981 · 1.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Global literature on female sex workers suggests that being in an intimate relationship is associated with barriers to practising safe sex behaviours. Condom use within intimate relationships is often seen as a sign of infidelity and fosters mistrust which could affect longevity, trust and intimacy within partnerships. Using qualitative data from Devadasi sex workers and their intimate male partners in Bagalkot District, Karnataka, India, we examined both partners' perspectives to understand the quality and dynamics of these relationships and the factors that influence condom use in intimate relationships. Our thematic analysis of individual interviews conducted in May 2011 with 20 couples suggests that many Devadasi sex workers and their intimate partners define their relationships as 'like marriage' which reduced their motivation to use condoms. Evidence from this study suggests that active participation in sex workers' collectives (sanghas) can increase condom use, education and family planning services, among other things, and could be helpful for both Devadasis and their intimate partners to better understand and accept safer sexual practices. Our work has direct implications for designing couple-based health interventions for traditional Devadasi sex workers and their intimate partners in India.
Global Public Health 08/2014; 9(10):1-13. DOI:10.1080/17441692.2014.948480 · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper explores how the Gates-funded HIV Initiative in India, known as Avahan, produces sociality. Drawing upon ethnographic research conducted between 2006 and 2012, we illustrate how epidemiological surveillance procedures, undergirded by contemporary managerial and entrepreneurial logics, entwine with and become transformed by the everyday practices of men who have sex with men (many of whom sell sex). The coevolution of epidemiology and sociality, with respect to these communities, is explored in relation to: 1) how individual identities are reproduced in association with standardized units of space and time; 2) how knowledge of mapping and enumeration data is employed in the making up of group membership boundaries, revealing how collective interests come to cohere around the project of epidemic prevention; and 3) how knowledge of epidemiological surveillance and procedures provides a basis on which groups collectively realize and execute local security strategies. While monitoring and evaluation (M&E) specialists continually track and standardize the identities, behaviours and social spaces of local populations (through various mapping, typologization and random sampling procedures, which treat space and time as predictable variables), community members simultaneously retranslate and reroute these standardizing processes into "the local" through everyday spatial management practices for health protection. These grounded epidemiologies, we argue, point to vital sites in the co-creation of scientific knowledge-where the quotidian practices of sex workers reassemble epidemiology, continually altering the very objects that surveillance experts are tracking. We further argue that attention to these re-workings can help us unravel the tremendous successes that have been claimed under Avahan in terms of HIV infections averted.
Social Science [?] Medicine 04/2014; 112C:51-62. DOI:10.1016/j.socscimed.2014.04.034 · 2.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper explores how the Gates-funded HIV Initiative in India, known as Avahan, produces sociality. Drawing upon ethnographic research conducted between 2006 and 2012, we illustrate how epidemiological surveillance procedures, undergirded by contemporary managerial and entrepreneurial logics, entwine with and become transformed by the everyday practices of men who have sex with men (many of whom sell sex). The coevolution of epidemiology and sociality, with respect to these communities, is explored in relation to: 1) how individual identities are reproduced in association with standardized units of space and time; 2) how knowledge of mapping and enumeration data is employed in the making up of group membership boundaries, revealing how collective interests come to cohere around the project of epidemic prevention; and 3) how knowledge of epidemiological surveillance and procedures provides a basis on which groups collectively realize and execute local security strategies. While monitoring and evaluation (M&E) specialists continually track and standardize the identities, behaviours and social spaces of local populations (through various mapping, typologization and random sampling procedures, which treat space and time as predictable variables), community members simultaneously retranslate and reroute these standardizing processes into “the local” through everyday spatial management practices for health protection. These grounded epidemiologies, we argue, point to vital sites in the co-creation of scientific knowledge—where the quotidian practices of sex workers reassemble epidemiology, continually altering the very objects that surveillance experts are tracking. We further argue that attention to these re-workings can help us unravel the tremendous successes that have been claimed under Avahan in terms of HIV infections averted.
[Show abstract][Hide abstract] ABSTRACT: Numerous factors have the potential to lead to suicidal ideation in individuals, including stigmatization and social exclusion. Individuals whose behaviors or identities do not conform to India’s socially acceptable norms, including those related to gender roles, sexual behavior, and/or sexual identity, are highly stigmatized and discriminated against. The internalization of frequent experiences of stigma and discrimination may result in depression, anxiety, and other mental health conditions. The inability to address mental health issues through HIV & AIDS prevention programme have compelled Karnataka Health Promotion Trust (KHPT) to lead an independent Mental Health Project and Study in partnership with Samara & Sangama, with support from Swabhava and National Institute of Mental Health and Neuro Sciences (NIMHANS). The quantitative questionnaire was administered to a total of 282 respondents of which 108 participants identified as Hijra, 137 as Kothi and 37 as others (double decker/bisexual). The mean age of the respondents was 32 and the median being 30. Eighty six percent of the respondents followed Hinduism. About 59% of the total respondents have completed more than ten years of schooling. About 23% of the total respondents are into ‘basti’ (begging) and 18% of the respondents are into sex work. It is alarming to note that 30% of the respondents had thoughts about committing suicide in the month preceding the interview. About 6% of the respondents deliberately tried to injure themselves and 59% of the respondents attempted suicide at least once in their life. The study findings suggest that low self-esteem and high vulnerability is greater among respondents who identified as Kothi and Hijra. The study also implies that respondents who are better equipped to handle problems or crisis situations, either on their own strength or through supportive friends, tend to have higher self-esteem.
[Show abstract][Hide abstract] ABSTRACT: Evidence suggests that in India, the early stages of a woman's career as a sex worker may be an important period to target for HIV and sexually transmitted infection prevention. Before such an intervention is designed and implemented, it is necessary to first understand the life circumstances of women at the start of their sex work careers. We performed a review to bring together available literature pertaining to entry into sex work in India and to highlight knowledge gaps. We found that historical traditions of dedication into sex work, financial insecurity, family discord, violence and coercion, and desire for financial independence are commonly reported reasons for entering into sex work. We also found that families and the broader sex worker community play an important role in the early stages of a woman's sex work career. We suggest that HIV-prevention programmes in India would substantially benefit from a deeper understanding of the life circumstances of new and young women sex workers. Further research should be conducted focusing on family and community involvement in women's entry into sex work, and on the important period of time after a woman's first commercial sex encounter, but before self-identification as a sex worker.
[Show abstract][Hide abstract] ABSTRACT: The Bill and Melinda Gates Foundation has poured a tremendous amount of resources into epidemic prevention in India's high HIV prevalence zones, through their Avahan initiative. These community-centred programmes operate under the assumption that fostering community-based organisational development and empowering the community to take charge of HIV prevention and education will help to transform the wider social inequalities that inhibit access to health services. Focusing on the South Indian state of Karnataka, this paper explores a troubling set of local narratives that, we contend, hold broader implications for future programme planning and implementation. Although confronting stigma and discrimination has become a hallmark in community mobilisation discourse, communities of self-identified kothis (feminine men) who were involved in Avahan programme activities continued to articulate highly negative attitudes about their own sexualities in relation to various spheres of social life. Rather than framing an understanding of these narratives in psychological terms of 'internalized stigma', we draw upon medical anthropological approaches to the study of stigma that emphasise how social, cultural and moral processes create stigmatising conditions in the everyday lives of people. The way stigma continues to manifest itself in the self-perceptions of participants points to an area that warrants critical public health attention.
[Show abstract][Hide abstract] ABSTRACT: Community-based participatory research (CBPR) has gained considerable popularity in recent decades given its ability to address social inequities, improve health outcomes and enhance community participation and ownership with respect to various health-related interventions. This paper describes the engagements of a community of self-identified men who have sex with men, most of whom also identified as male sex workers, in a long-term iterative and systematic process of knowledge production, reflection, and action. The project took place in 2006 in Mysore, South India, under the larger umbrella of an HIV intervention formed by the University of Manitoba and the sex workers collective known as Ashodaya Samithi, funded by the Bill & Melinda Gates Foundation (Avahan). CBPR is revealed as uniquely suited for tackling stigma and discrimination as subjects of scientific inquiry and as key methodological obstacles. As the community cultivated their own analysis around stigma, the concept became a key rallying point for increasing equity with respect to access to health services for this community. CBPR proved highly effective in mobilizing community participation and increasing access to sexual health services, over the long-term, because it was supported by and was able to feed community insights into a much larger infrastructure that sought to mobilize sexual minorities. More broadly, by highlighting various positive effects arising from CBPR, we have sought to further emphasize the greater possibilities of public health practitioners working more democratically with disenfranchised and highly stigmatized communities.
Critical Public Health 01/2013; 24(1). DOI:10.1080/09581596.2013.791386 · 0.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In this paper we examined the role of Devadasi brothel madams in promoting safe sex practices among sex workers. Qualitative, in-depth interviews were conducted with twelve brothel madams as a follow-up of a larger cohort study that aimed to understand the patterns and determinants of sex workers migration from northern Karnataka to southern Maharashtra, in India. Our research identified that madams were ex-sex workers, who entered into sex work through the traditional Devadasi system and currently manage Devadasi sex workers in their own brothels. The social and kinship relations between the madams and the sex workers form the basis on which these brothels function. Brothel madam's role in the promotion of safe sex and their influence on sex workers in seeking health care is tied to reciprocal kinship relations, reveals an important area of opportunity for HIV prevention efforts to fully exploit these positive aspects of these relationships within intervention design and service delivery to achieve more desirable health outcomes and to effectively address HIV risk and vulnerabilities within the context of brothel environment.
[Show abstract][Hide abstract] ABSTRACT: Background
Since the completion of three clinical trials indicating that voluntary medical male circumcision (VMMC) is an effective method to reduce men’s chances of acquiring HIV, use of the procedure has been advocated in Kenya. Media messages shape popular understandings of the benefits and limitations of male circumcision. The objectives of this study were to (1) investigate promotion messages in a popular online newspaper to determine how the limitations of male circumcision are represented, and whether condom use is still being promoted; and (2) gain insight into popular understandings of the limitations of this new procedure through newspaper reader comments.
A content analysis was conducted on 34 online media articles published by the Daily Nation between January 1, 2008 and December 31, 2010. Information about condom promotion, partial immunity, limitations and complications of the procedure, as well as emergent themes, were analyzed.
Results demonstrated an irregular and occasionally misleading presentation of these topics and a perceived lack of objective information about the risks and limitations of VMMC.
There is a need for governmental and non-governmental public health organizations to engage with the media to improve risk messaging.
BMC Public Health 06/2012; 12(1):465. DOI:10.1186/1471-2458-12-465 · 2.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To meet the HIV prevention needs of sex workers in India, some community-based organizations have begun integrating peer education and community mobilization into community-led structural interventions. As the role of community-based organizations continues to expand into new service areas, it is important to understand how these new interventions are received. This agency assessment was done in collaboration with Ashodaya Samithi in 2009. Ashodaya Samithi is a community-based organization led by female, male, and transgendered sex workers. In the past year, HIV-positive sex workers of Ashodaya have registered their own organization, known as Ashraya. Based on qualitative findings, this study describes how community-based organizations can play an important role in improving access to care and antiretroviral treatment for sex workers. The rapid growth of Ashraya and its success at fostering social solidarity and large-scale structural interventions hold valuable lessons for community-based organizations and public health practitioners working in the field of HIV/AIDS.
Journal of HIV/AIDS & Social Services 04/2012; 11(2):152-168. DOI:10.1080/15381501.2012.678132
[Show abstract][Hide abstract] ABSTRACT: There is a lack of information on sexual violence (SV) among men who have sex with men and transgendered individuals (MSM-T) in southern India. As SV has been associated with HIV vulnerability, this study examined health related behaviours and practices associated with SV among MSM-T.
Data were from cross-sectional surveys from four districts in Karnataka, India.
Multivariable logistic regression models were constructed to examine factors related to SV. Multivariable negative binomial regression models examined the association between physician visits and SV.
A total of 543 MSM-T were included in the study. Prevalence of SV was 18% in the past year. HIV prevalence among those reporting SV was 20%, compared to 12% among those not reporting SV (p = .104). In multivariable models, and among sex workers, those reporting SV were more likely to report anal sex with 5+ casual sex partners in the past week (AOR: 4.1; 95%CI: 1.2-14.3, p = .029). Increased physician visits among those reporting SV was reported only for those involved in sex work (ARR: 1.7; 95%CI: 1.1-2.7, p = .012).
These results demonstrate high levels of SV among MSM-T populations, highlighting the importance of integrating interventions to reduce violence as part of HIV prevention programs and health services.
PLoS ONE 03/2012; 7(3):e31705. DOI:10.1371/journal.pone.0031705 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Increasing sex workers' (SWs) access to and utilisation of health care services is a key part of HIV prevention. An HIV prevention project in Mysore, India, has been particularly successful in fostering a new norm of health care seeking among local SWs while facilitating community ownership of health care delivery. This paper describes how the use of occupational health ideologies, along with the creation of enabling environments, facilitated the uptake of project healthcare services and transformed power relationships between SWs and their healthcare providers. These changes led Mysore's SWs to initiate health-enhancing actions that moved beyond project imperatives to serve self-identified community needs.
Global Public Health 03/2012; 7(7):779-91. DOI:10.1080/17441692.2012.668918 · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Bhutan's sustained low HIV prevalence can be attributed to its political commitment to maintain isolation from foreign cultural influence. Recently, rising HIV prevalence has coincided with the increase in human traffic along Bhutan's borders. The majority of infections, occurring primarily through sexual contact, have appeared in the urban environments that are situated along the main transport routes. This qualitative study explored the sexual networks that form at entertainment venues in the capital city of Thimphu. To more fully understand sexual network formation at theses venues, one must take into account an emerging modernity that reflects a convergence of cultural, economic and political influences emanating from Bhutan's unique 'middle-path' modernisation scheme. The growing appearance of transactional sex in Thimphu not only points to an emergent form of exploitation wrought by larger economic transformations and widening social inequalities; the power inequalities that surround its practice are also significantly exacerbated by the local cultural politics and moral ideologies that arise as Bhutan proceeds along the path towards global capitalism. Discourses of Bhutanese sexual morality articulate with broader political economic transformations to forcefully position village women engaging in transactional sex within a field of power relations that leaves them open to various forms of subjugation.