Social Cohesion, Social Participation, and HIV Related Risk among Female Sex Workers in Swaziland

Institut Pluridisciplinaire Hubert Curien, France
PLoS ONE (Impact Factor: 3.23). 01/2014; 9(1):e87527. DOI: 10.1371/journal.pone.0087527
Source: PubMed
ABSTRACT
Social capital is important to disadvantaged groups, such as sex workers, as a means of facilitating internal group-related mutual aid and support as well as access to broader social and material resources. Studies among sex workers have linked higher social capital with protective HIV-related behaviors; however, few studies have examined social capital among sex workers in sub-Saharan Africa. This cross-sectional study examined relationships between two key social capital constructs, social cohesion among sex workers and social participation of sex workers in the larger community, and HIV-related risk in Swaziland using respondent-driven sampling. Relationships between social cohesion, social participation, and HIV-related risk factors were assessed using logistic regression. HIV prevalence among the sample was 70.4% (223/317). Social cohesion was associated with consistent condom use in the past week (adjusted odds ratio [AOR] = 2.25, 95% confidence interval [CI]: 1.30-3.90) and was associated with fewer reports of social discrimination, including denial of police protection. Social participation was associated with HIV testing (AOR = 2.39, 95% CI: 1.36-4.03) and using condoms with non-paying partners (AOR = 1.99, 95% CI: 1.13-3.51), and was inversely associated with reported verbal or physical harassment as a result of selling sex (AOR = 0.55, 95% CI: 0.33-0.91). Both social capital constructs were significantly associated with collective action, which involved participating in meetings to promote sex worker rights or attending HIV-related meetings/ talks with other sex workers. Social- and structural-level interventions focused on building social cohesion and social participation among sex workers could provide significant protection from HIV infection for female sex workers in Swaziland.

Full-text

Available from: Deanna Kerrigan, Feb 07, 2015
Social Cohesion, Social Participation, and HIV Related
Risk among Female Sex Workers in Swaziland
Virginia A. Fonner
1
*, Deanna Kerrigan
2
, Zandile Mnisi
3
, Sosthenes Ketende
4
, Caitlin E. Kennedy
1
,
Stefan Baral
4
1 Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America, 2 Johns Hopkins Bloomberg
School of Public Health, Department of Health, Behavior, and Society, Baltimore, Maryland, United States of America, 3 Swaziland National AIDS Program, Mbabane,
Swaziland, 4 Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, United States of America
Abstract
Social capital is important to disadvantaged groups, such as sex workers, as a means of facilitating internal group-related
mutual aid and support as well as access to broader social and material resources. Studies among sex workers have linked
higher social capital with protective HIV-related behaviors; however, few studies have examined social capital among sex
workers in sub-Saharan Africa. This cross-sectional study examined relationships between two key social capital constructs,
social cohesion among sex workers and social participation of sex workers in the larger community, and HIV-related risk in
Swaziland using respondent-driven sampling. Relationships between social cohesion, social participation, and HIV-related
risk factors were assessed using logistic regression. HIV prevalence among the sample was 70.4% (223/317). Social cohesion
was associated with consistent condom use in the past week (adjusted odds ratio [AOR] = 2.25, 95% confidence interval [CI]:
1.30–3.90) and was associated with fewer reports of social discrimination, including denial of police protection. Social
participation was associated with HIV testing (AOR = 2.39, 95% CI: 1.36–4.03) and using condoms with non-paying partners
(AOR = 1.99, 95% CI: 1.13–3.51), and was inversely associated with reported verbal or physical harassment as a result of
selling sex (AOR = 0.55, 95% CI: 0.33–0.91). Both social capital constructs were significantly associated with collective action,
which involved participating in meetings to promote sex worker rights or attending HIV-related meetings/ talks with other
sex workers. Social- and structural-level interventions focused on building social cohesion and social participation among
sex workers could provide significant protection from HIV infection for female sex workers in Swaziland.
Citation: Fonner VA, Kerrigan D, Mnisi Z, Ketende S, Kennedy CE , et al. (2014) Social Cohesion, Social Participation, and HIV Related Risk among Female Sex
Workers in Swaziland. PLoS ONE 9(1): e87527. doi:10.1371/journal.pone.0087527
Editor: Ce
´
dric Sueur, Institut Pluridisciplinaire Hubert Curien, France
Received Apri l 8, 2013; Accepted December 29, 2013; Published January 31, 2014
Copyright: ß 2014 Fonner et al. This is an open-access article distributed under the terms of the Creative Comm ons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The study was implemented by USAID|Project SEARCH, Task Order No.2, which is funded by the U.S. Agency for International Development under
Contract No. GHH-I 00-07-00032-00, beginning September 30, 2008, and supported by the President’s Emergency Plan for AIDS Relief. The Research to Prevention
(R2P) Project is led by the Johns Hopkins Center for Global Health and managed by the Johns Hopkins Bloomberg School of Public Health Center for
Communication Programs (CCP). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: vtedrow@jhsph.edu
Introduction
In sub-Saharan Africa, female sex workers have a 12-fold
increase in odds of being HIV infected as compared to all women
of reproductive age [1]. Sex workers face heightened behavioral
risk for HIV infection due to high numbers of sex partners and
frequent sexual encounters. This risk is exacerbated by social and
structural factors, including stigma, poverty, sexual and physical
violence [2–4], as well as inequitable laws and policies, police
brutality, and lack of non-discriminatory healthcare services [5,6].
In part due to the high HIV burden experienced by sex workers,
recent mathematical models suggest that scaling up comprehensive
community-based empowerment interventions among sex workers
could avert significant numbers of new HIV infections not only
among sex worker populations, but also among other reproduc-
tive-aged populations [7]. Evidence from HIV prevention
interventions among sex workers in India [8–15], Brazil [16,17],
and the Dominican Republic [18] suggests that community
empowerment can be an effective tool for reducing HIV-related
risk and enacting social- and structural-level changes that alter
HIV-related risk environments [19]. For example, the Avahan
Initiative in India included interventions such as drop-in centers,
peer education, sex-worker friendly health services, stakeholder
advocacy, and formation of organizations led by and with sex
workers to facilitate program ownership [20]. Avahan promoted
social cohesion among sex workers, creating the potential for
collective action, and worked to increase the acceptance of sex
workers in the general community by facilitating social participa-
tion [21] through activities such as workshops bringing together
police and sex workers [22].
Embedded within community empowerment models is the
concept of social capital. Social capital concerns the connectedness
of individuals between and within groups [23]. It encompasses the
inherent value of social relationships and the material and social
resources these relationships bring [23]. Robert Putnam, a
prominent social capital theorist, has defined social capital as
"the networks, norms, and social trust that facilitate co-operation
for mutual benefit" [24]. According to Putnam, there are two main
types of social capital: bonding, which refers to intra-group
relationships, and bridging, which refers to inter-group interac-
tions [24]. Although the current study involves two social capital
constructs—social cohesion and social participation—we use the
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term social capital with caution as definitions vary and can be
conceptually different [25]. In this study, social cohesion refers to
mutual aid, trust, and solidarity present among sex workers and
reflects bonding social capital. Social participation, which aligns
with bridging social capital, refers to involvement in community
groups outside of sex worker relationships, reflecting their
inclusion in the larger society. A theoretical framework of social
capital and HIV-related risk among sex workers is presented in
Figure 1.
Extensive research has examined relationships between social
capital and health [26-29], and social capital has been identified as
a social-level factor influencing HIV vulnerability [30]. In general,
public health outcomes tend to improve when social capital
measures are high [31]. However, findings show these relation-
ships are complex, especially in regards to HIV. For example,
studies have found that HIV-associated risks can be positively or
negatively associated with social capital, depending on the age and
gender of the individual and the types of social ties maintained
[32,33]. Social capital may be especially important to disadvan-
taged groups, such as sex workers, because it increases access to
material and social resources that would otherwise be denied to
this socially excluded population [34]. However, little research has
been conducted on social capital and HIV-related risk among
female sex workers in sub-Saharan Africa [32].
HIV and Sex Work in Swaziland
Swaziland has the world’s highest HIV prevalence with an
estimated 26% of adults aged 15–49 living with HIV [35]. The
2009 Modes of Transmission Study reports that heterosexual
transmission accounts for the majority of HIV infections in
Swaziland and sex work is a minor driver of the epidemic;
however, it also acknowledges that little information is known
about this hidden population [36]. A literature review revealed
only two peer-reviewed studies conducted on sex workers in
Swaziland [37,38]. Although sex work is not criminalized in
Swaziland, activities related to sex work, such as the solicitation
and procurement of sex in public, are illegal [39], which makes
conducting research among this population difficult yet essential to
understanding factors shaping their HIV-related risk.
A situational analysis of sex work in Swaziland conducted in
2007 found that the majority of sex workers were young (below
age 30) and most reported engaging in sex work due to poverty
and lack of economic opportunities. Sex workers in Swaziland also
reported experiencing high levels of violence, including violence
perpetrated by clients and police, and lacked access to non-
discriminatory health services, such as family planning services
and testing for HIV and sexually transmitted infections [40].
Another study characterized both rural and urban sex work in
Swaziland, highlighting that many sex workers are migratory and
follow clients to ‘‘hot spots’’ depending on the season or time of
month [41]. Sex workers in Swaziland are not brothel-based and
obtain clients directly, either on the street or by being ‘‘on call’’
[41]. Street-based sex workers face heightened vulnerability to
violence as the location of sex varies by client and includes isolated
places where sex workers can be beaten, gang raped, or robbed
[4]. Cohesion among street-based sex workers could help prevent
violence and encourage behavior change, such as through
Figure 1. Theoretical framework of social capital and HIV-related risk among female sex workers in Swaziland.
doi:10.1371/journal.pone.0087527.g001
Social Capital and HIV Risk among Sex Workers
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collective agreements that no one will service a client without
condoms. However, literature relating to the social context of sex
work in Swaziland, including the social relationships that sex
workers have with each other, is scarce. Given the potential
importance of social factors, such as social cohesion and social
participation, in reducing HIV-related risk and supporting
community empowerment, this is a critically understudied area.
Therefore, the aim of this study was to examine the relationship
between social capital constructs, including social cohesion and
social participation, and HIV-related risk among female sex
workers in Swaziland.
Methods
Setting, study design, and participants
Women in Swaziland aged 18 years or older who reported
exchanging sex for money, favors, or goods in the past twelve
months were eligible to participate in the study. All participants
provided informed consent prior to completing the questionnaire
and serological testing. Oral consent scripts were used in lieu of
signed consent forms to further ensure anonymity, protection of
confidentiality, and security of participants. This ensured that in
case consent forms were lost, no personal information or disclosure
of sex work would take place. The study was implemented as a
joint effort between the Swaziland government, Johns Hopkins
University, and PSI Swaziland. Ethical approval for this study was
granted by the Swaziland Scientific and Ethics Committee and the
Johns Hopkins Bloomberg School of Public Health Institutional
Review Board.
The sample size (n = 324) was calculated based on the ability to
detect significant differences in HIV prevalence among partici-
pants with higher reported protective behaviors related to HIV,
such as consistent condom use with paying partners (alpha = 0.05,
power = 0.80).
Participants were recruited using respondent-driven sampling
(RDS), which is a peer-driven chain referral sampling technique
that approximates a random sample by mathematically controlling
for inherent biases, including network size and homophily (the
tendency of participants to recruit individuals who are similar to
themselves) [42,43]. To initiate the chain referral process, ‘‘seeds’’
were identified during formative research. Seeds were members of
the sex worker community with diverse socio-demographic
characteristics who were motivated to participate in the study
and willing to recruit others in their social network. Three seeds
were selected to begin the referral process and additional pre-
selected seeds were brought into the study when accrual slowed.
Each seed, and each subsequent participant who agreed to recruit
other participants, was given referral cards with a 2-week
expiration date to distribute to eligible members of their social
network. Each recruiter could recruit a maximum of three
participants. Upon survey completion, each participant was
reimbursed for their time and travel to the study site, ranging
from the equivalent of US
$7-$23. Recruiters were also provided
the equivalent of US
$2.50 for every eligible participant who
participated in the study. Recruiter-recruit relationships were
tracked using linked card numbers.
Data collection and survey measures
Data collection took place from July-November 2011. All
participants completed a structured survey administered by a
trained interviewer lasting approximately 1 hour in a private office
setting. The survey could be completed in English or siSwati
depending on the participant’s preference. Participants were asked
questions relating to their social network (ascertained by asking
how many different people a participant knew personally who
were sex workers); socio-demographics; exposure to human rights
violations; HIV-related knowledge, attitudes, and risk behaviors;
condom negotiation skills; reproductive healthcare; and aspects of
social capital, including social cohesion and social participation.
Following completion of the survey, participants were tested for
HIV by trained nurse counselors using rapid tests conducted on
blood samples obtained via finger stick after providing informed
consent. Unigold
TM
(Trinity Biotech) and Determine HIV 1H
(Inverness Medical) were used as the preliminary screening and
confirmatory HIV tests, respectively. Those who tested positive for
HIV were given referrals to seek additional care and treatment
through local health facilities.
Social capital
Social cohesion was measured using a scale developed by
Lippman, Kerrigan, and colleagues for use among sex worker
populations in Brazil [17,44]. Items comprising the scale were
pilot-tested in Swaziland prior to survey implementation but
required little change as questions asked about social situations,
such as relying on colleagues for money or a ride to the hospital,
that are applicable across populations. Participants were asked to
rate their agreement or disagreement with statements relating to
mutual aid, support, and trust among sex workers. Exploratory
factor analysis (EFA) using polychoric correlations was used to
determine unidimensionality within the social cohesion scale, and
Cronbach’s alpha was used to assess the internal consistency [45].
Two of the 11 items were removed from the scale due to exhibiting
low correlations with the other items and low factor loadings
(below 0.3) in EFA. The remaining 9 items exhibited acceptable
internal consistency (a = 0.76) and are listed in Table 1. For
analysis the items were summed to create a scale with scores
ranging from 0 to 27; scores were dichotomized at the median (16)
for ease of interpretation, with 0–16 signaling low social cohesion
and 16.1–27 signaling high social cohesion. Dichotomizing social
capital scales is a technique previously employed by researchers
examining associations between HIV and social capital [32].
Social participation was measured by asking participants about
their involvement in groups outside their sex worker network,
including church or religious groups, clubs (e.g., sports, student
groups, women’s clubs), cultural activities (e.g., dance, music), and
community activities. Participants were scored based on the
intensity of their involvement (0 = do not participate, 1 = member,
2 = active member, and 3 = group leader). This assessment is
similar to the method for measuring structural social capital in the
World Bank’s Social Capital Tool [46], which has also been used
to measure social participation among sex worker populations in
Brazil [17,44]. Categories of social participation were adapted to
the Swazi context prior to implementation. Due to the skewed
distribution of data for this construct (mean score = 1.6 on a 16-
point scale), a social participation index was generated by
summing participants’ involvement across the various groups
(‘‘0’’ for no involvement and ‘‘1’’ for any involvement) for analysis.
Scores on the social participation index could range from 0 (no
social participation) to 4 (participation in all types of social
involvement). The median score on the social participation index
was 1, and scores were dichotomized at the median (0 = score of 0
or 1; 1 = score .1) for ease of interpretation and due to the
skewed distribution of the data.
Collective action, which is defined as any action aiming to
improve a group’s condition [47], has been described as both an
output measure of social capital and an important proxy for
assessing social capital itself [48]. In this study, collective action
was treated as an outcome variable as it was hypothesized that
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having high social cohesion and/or social participation could lead
to collective action, including engagement in activities related to
HIV prevention. Collective action was measured through two
questions asking about participation within the past 12 months in:
1) meetings, marches, rallies, or gatherings to promote the rights of
sex workers, or 2) talks or meetings related to HIV/AIDS with
other sex workers.
HIV-related risk
Behavioral HIV-related risk was measured by asking partici-
pants about condom use during vaginal and anal sex with different
partner types, including new clients, regular clients, and non-
paying partners. New clients were defined as paying clients with
whom participants had had sex once or twice. Regular clients were
defined as those with whom participants had had sex at least three
times and who pay for sex. Non-paying partners included sexual
partners of participants, such as husbands and boyfriends, who do
not pay for sex.
For purposes of this study, consistent condom use was defined as
reporting condom use in all sex acts in the past week with all
partners, which was measured by constructing a ratio of the
reported number of protected sex acts to all sex acts reported in
the previous week. ‘‘Always’’ condom use in the past 30 days
versus some or no condom use was also measured for new clients,
regular clients, and non-paying partners. Although this study
measured ‘‘always’’ condom use in both anal and vaginal sex,
results in this analysis were restricted to condom use during vaginal
sex as approximately 65% of the study population reported no
engagement in anal sex. Prior HIV testing was measured by asking
participants whether they had received an HIV test in the past 12
months.
Additionally, several factors relating to violence and social
discrimination were included as outcome variables since previous
Table 1. Measurement of social capital constructs and outcome variables.
Items in scale/index
Properties
Mean (sd) Alpha
Exposure Variables
Social Cohesion (scale) 16.0 (5.2) 0.76
You can count on your sex worker colleagues if you need to borrow money.
You can count on your sex worker colleagues to accompany you to the doctor or hospital.
You can count on your sex worker colleagues if you need to talk about your problems.
You can count on your sex worker colleagues if you need somewhere to stay.
You can count on your sex worker colleagues to help deal with violent or difficult client.
You can count on your sex worker colleagues to help you find other clients.
You can count on your sex worker colleagues to support the use of condoms.
The group of sex workers with whom you work is an integrated group.
You can trust the majority of other sex workers working in your area.
(Response Choices: strongly agree, mostly agree, mostly disagree, or strongly disagree)
Social Participation (index) 1.4 (1.1) n/a
Participation in the following groups:
1. Affiliations with church or religious groups
2. Affiliations with clubs
3. Cultural activities
4. Community activities
Participation was coded as ‘‘0’’ for no involvement and ‘‘1’’ for any involvement (being a member, active member, or
leader of a specific social group)
Outcome Variables
Consistent condom
use
Consistency defined by having the number of reported protected sex acts (condom worn for entire duration of sex)
equal to the number of all sex acts in the past week for all sex partners (vaginal or anal sex)
‘‘Always’’ condom
use
Reported separately for: a) new clients, b) regular clients, and c) non-paying partners during vaginal sex. ‘‘Always’’
condom use vs. condom use reported never, rarely, sometimes, most of the time, or ‘‘don’t know’’
HIV testing Have you been tested for HIV in the last 12 months?
HIV prevalence HIV testing was offered to all study participants during data collection
Social discrimination Have you ever felt rejected by your friends as a result of you selling sex?
Have you ever felt afraid to seek healthcare services as a result of you selling sex?
Have you ever felt that the police refused protection as a result of you selling sex?
Have you ever felt any verbal and physical harassment as a result of you selling sex?
Have you ever been beaten up as a result of you selling sex?
Collective action In the past 12 months, have you participated in: 1) A meeting, march, rally, or gathering to promote the rights of sex
workers? Or 2) Any talks or meetings related to HIV/AIDS with other sex workers?
doi:10.1371/journal.pone.0087527.t001
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research has shown that violence, including physical, sexual, and
emotional violence, is associated with elevated HIV risk, especially
among female sex workers [49,50]. Social discrimination outcomes
included reported rejection by friends, reported refusal of
protection from police, feeling afraid to seek health services,
reported verbal or physical abuse, and having been beaten up due
to sex work. All exposure and outcome variables are defined in
Table 1.
Analysis
All analyses were conducted using Stata version 11. Cross-
sectional data were used to assess the relationship between HIV-
related outcomes and social capital constructs, including social
cohesion and social participation. Chi square tests were performed
to assess differences in the dichotomized social cohesion and social
participation scores across socio-demographic characteristics.
To account for biases inherent in RDS data collection,
including recruiting patterns and network size, data were weighted
based on population estimates of the outcome variable in all
analyses. Univariate logistic regression analyses were performed on
HIV-related outcome variables to assess associations with social
cohesion and social participation. For analyses where either social
cohesion or social participation were associated with the outcome
at p#0.1, multivariate regressions were conducted to assess the
impact of the relationship when controlling for age, income,
education, marital status, and geographic region of residence in
addition to the RDS weights, which were identified a priori as
potential confounders between social capital and HIV-related
variables.
However, there is no consensus in the field about how RDS data
should be treated in multivariate analysis [51], particularly
because traditional weighing methods can produce incorrect
standard errors [52]. Therefore, sensitivity analyses were per-
formed in which data were left completely unadjusted and then
adjusted using network size as a confounding variable, which is a
technique previously used for conducting multivariate logistic
regression analyses with RDS data [53]. As the sensitivity analyses
showed no significant difference in associations, analyses using
weighted RDS data were employed for all subsequent analyses.
Additionally, analyses were performed with and without ‘‘seed’’
data because seeds were non-randomly selected. As no significant
differences in associations were detected, data from seeds
remained in the analysis.
Results
Study population
Data were collected from 325 female sex workers, including
data from nine non-randomly selected seeds. The median age of
participants was 25 (inter-quartile range [IQR] 21–30). About half
of participants (n = 175) had completed some secondary or high
school. Out of 317 participants with a confirmed HIV test result,
70.6% (223/317) tested HIV positive. Over 54% of participants
(176/322) reported being told they were HIV positive by a
healthcare provider sometime before participating in the study.
Most participants were single and had never been married (285/
321). Table 2 contains socio-demographic characteristics of the
sample. Marital status was associated with social cohesion in that
participants who had ever cohabitated with a sexual partner (e.g.,
married, widowed, or divorced) experienced lower levels of social
cohesion compared to participants who were single/never married
(p = 0.05).
Social capital among sex workers
Social cohesion scores among sex workers were relatively high.
On a 27 point scale, the mean and median score was 16 (range 0–
27). Over 60% of sex workers agreed or strongly agreed they could
turn to sex workers with whom they work if they needed money, a
ride to the hospital, someone to discuss their problems with, or
help with a difficult client. However, only 37% of participants
(120/321) agreed with statement, ‘‘You can trust the majority of
other sex workers working in your area.’’
Social participation was generally low. On a four point scale,
the median score was 1 (range 0–4). No social participation was
reported by 21% of participants (67/318). Affiliation with a church
or religious group was the most commonly reported form of social
participation with 61% reporting such involvement (197/323).
Regarding collective action, 54% (172/320) reported attending
a talk or meeting relating to HIV with other sex workers in the
past 12 months, but only 34% (111/324) reported attending a
meeting, march, rally, or gathering in the past 12 months to
promote the rights of sex workers.
Associations between social coh esion and HIV-related
risk
Table 3 presents results from logistic regression analyses
examining social cohesion and HIV-related behaviors and risk
factors. In univariate and multivariate analysis, social cohesion was
significantly associated with consistent condom use in the past
week with all partners (adjusted odds ratio [AOR] = 2.25, 95%
confidence interval [CI]: 1.30–3.90). However, there were no
associations found between social cohesion and ‘‘always’’ condom
use with new partners, regular partners, or non-paying partners.
Social cohesion was also associated with fewer reports of social
discrimination, including reported refusal of police protection
(AOR = 0.53, 95% CI: 0.31–0.90) and reported rejection by
friends due to sex work (AOR = 0.52, 95% CI: 0.32–0.84). Social
cohesion also trended towards being inversely associated with
feeling afraid to seek services due to selling sex (AOR = 0.67, 95%
CI: 0.41–1.08, p = 0.10), but results were not significant. Having
high levels of social cohesion was significantly associated with one
measure of collective action: participating in meetings to promote
sex worker rights (AOR = 2.33, 95% CI: 1.37–3.94).
Associations between social participation and HIV-
related risk
Associations between social participation and HIV-related
behaviors and risk factors are presented in Table 4. In both
univariate and multivariate regressions, being tested for HIV in
the previous 12 months was significantly associated with having
high levels of social participation (AOR = 2.39, 95% CI: 1.36–
4.02). When the analysis excluded HIV-infected participants who
did not test for HIV in the past 12 months but had previously been
told by a healthcare provider that they were HIV infected (n = 27),
the association between social participation and prior testing
remained significant (AOR = 1.99, 95% 1.02–3.86, p = 0.04).
Additionally, reporting ‘‘always’’ condom use with non-paying
partners was associated with social participation (AOR = 1.99,
95% CI = 1.13–3.51), although social participation was not
significantly associated with any other condom use measure.
Participants with high levels of social participation had a 45%
reduction in odds of reporting experiencing verbal or physical
harassment as a result of selling sex compared to those with low
levels of participation (AOR = 0.55, 95% CI: 0.33–0.91). Social
participation, like social cohesion, was significantly associated with
collective action. Compared to participants with low levels of
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social participation, participants with high levels of social
participation had over twice the odds of participating in meetings
to promote sex worker rights (AOR = 2.26, 95% CI: 1.35–3.78).
Discussion
Given the HIV prevalence among this sample of female sex
workers was almost three times the general population prevalence
in Swaziland, developing HIV prevention activities for this
population is critical. Associations between social capital constructs
and HIV-related risk factors found in this study demonstrate that
including social capital enhancement in HIV prevention inter-
ventions for sex workers in Swaziland could be beneficial. For
example, we found that having high levels of social cohesion was
associated with increased consistent condom use among sex
workers and their sexual partners and was negatively associated
with certain aspects of social discrimination. Having high levels of
social participation was associated with consistent condom use
between sex workers and their non-paying partners and with being
tested for HIV in the previous year, and was associated with fewer
reports of verbal or physical harassment. Both social cohesion and
social participation were associated with participating in collective
action with other sex workers.
Interestingly, on the social cohesion scale, reported trust among
sex workers in a particular area was relatively low while feelings of
mutual aid were generally high. This difference could be a
consequence of question wording (as the ‘‘trust’’ question asked
about ‘‘sex workers working in your area’’ and the ‘‘mutual aid’’
questions asked about ‘‘sex workers with whom you work’’), but it
could also provide insight into the nature of sex work in Swaziland.
Research among sex workers in South Africa similarly found
limited trust between sex workers due to circumstances such as
competition for clients, but acts of support, such as visiting each
other in the hospital or borrowing money, were common [54].
Other studies among sex workers have found that building
cohesion can be challenging not only due to lack of trust but also
due to heterogeneity between sex workers[55], lack of common
identity [56], frequent migration and high turn-over rates [57],and
not wanting to be openly identify as a sex worker [55]. Despite
these challenges, interventions aiming to improve cohesion found
that over time, cohesion was built by allowing sex workers the
space and time to come together to share problems and develop
collective solutions [56] and by having sex workers advise on
intervention development and implementation to develop a sense
of community and ownership [21,58].
The association between high levels of social cohesion and
consistent condom use found in this study is consistent with
Table 2. Socio-demographic characteristics of the sample by levels of social cohesion and social participation.
Social Cohesion Social Participation
Demographic characteristic N (%) High N Low N High N Low N
Study Population (total) 325 142 159
Age (in years) 0.96 0.43
,21 64 (19.7) 30 30 31 30
21–24 82 (25.2) 35 39 37 45
25–29 91 (28.0) 39 47 45 44
30+ 88 (27.1) 38 43 34 52
Education 0.89 0.22
Primary or lower 106 (32.6) 45 51 44 60
Some secondary 175 (53.9) 79 85 87 85
Completed secondary or higher 44 (13.5) 18 23 16 26
Marital Status 0.05 0.10
Ever cohabited 36 (11.2) 11 24 12 24
Single/Never married 285 (88.8) 129 135 133 145
Region of residence 0.68 0.19
Hhohho 102 (31.4) 40 53 49 48
Manzini 159 (48.9) 71 77 64 95
Shiwelweni 57 (17.5) 28 25 31 25
Lubombo 6 (1.8) 3 3 2 3
Income (in Emalangeni) 0.09 0.08
0–450 85 (26.2) 32 46 43 39
451–800 93 (28.6) 45 38 46 46
801–1300 63 (19.4) 33 26 30 32
1300+ 84 (25.8) 32 49 28 54
HIV status 0.56 0.60
Uninfected 94 (29.7) 30 49 45 47
Infected 223 (70.3) 99 107 100 119
doi:10.1371/journal.pone.0087527.t002
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Table 3. Associations of social cohesion and HIV-related outcomes.
Social Cohesion n(%) Unadjusted
a
Adjusted
b
Outcome varia ble n High Low OR (95% CI) P value AOR (95% CI) P value
Behavioral
Consistent condom use- all partners 278 99/135 (73.3) 80/143 (55.9) 2.17 (1.30–3.60) 0.003 2.25 (1.30–3.90) 0.004
‘‘Always’’ condom use- new clients 280 101/133 (75.9) 106/147 (72.1) 1.22 (0.71–2.09) 0.47 -----
‘‘Always’’ condom use- regular clients 291 68/138 (49.3) 70/153 (45.8) 1.15 (0.72–1.83) 0.55 -----
‘‘Always’’ condom use- non-paying partners 267 42/127 (33.1) 44/140 (31.4) 1.08 (0.64–1.81) 0.76 -----
Tested for HIV in previous year 300 108/142 (76.1) 114/158 (72.2) 1.23 (0.73–2.07) 0.44 -----
Biological
HIV-infected 294 99/138 (71.7) 107/156 (68.6) 1.16 (0.70–1.93) 0.56 -----
Social Discrimination/Violence
Afraid to seek health services 301 56/142 (34.4) 78/159 (49.1) 0.67 (0.43–1.07) 0.10 0.67 (0.41–1.08) 0.10
Felt rejected by friends 318 63/142 (44.4) 97/159 (61.0) 0.51 (0.32–0.81) 0.004 0.52 (0.32–0.84) 0.008
Was refused police protection 300 59/141 (41.8) 91/159 (57.2) 0.54 (0.34–0.85) 0.009 0.53 (0.31–0.90) 0.02
Verbal/physical harassment 301 84/142 (59.2) 102/159 (64.2) 0.81 (0.51–1.29) 0.36 -----
Beaten up due to selling sex 299 49/140 (35.0) 65/159 (26.4) 0.78 (0.49–1.25) 0.30 -----
Collective Action
Participated in meeting to promote sex worker
rights
301 59/142 (41.6) 42/159 (26.4) 1.98 (1.22–3.23) 0.006 2.33 (1.37–3.94) 0.006
Participated in meeting about HIV/AIDS
with other sex workers
314 87/142 (61.3) 77/157 (49.0) 1.64 (1.03–2.61) 0.04 1.61 (0.96–2.68) 0.07
a
Univariate analyses adjusted for RDS weights based on estimated population proportions of outcome variable.
b
Adjusted for age, income, education, marital status, and region in addition to RDS weights.
doi:10.1371/journal.pone.0087527.t003
Table 4. Associations of social participation and HIV-related outcomes.
Social Participation n(%) Unadjusted
a
Adjusted
b
Outcome varia ble n High Low OR (95% CI) P value AOR (95% CI) P value
Behavioral
Consistent condom use- all partners 294 86/135 (63.7) 103/159 (64.8) 0.95 (0.60–1.54) 0.85 -----
‘‘Always’’ condom use- new clients 294 101/133 (75.94) 117/161 (72.7) 1.19 (0.70–2.02) 0.53 -----
‘‘Always’’ condom use- regular clients 306 70/142 (49.3) 78/164 (47.6) 1.07 (0.68–1.68) 0.76 -----
‘‘Always’’ condom use- non-paying partners 279 53/132 (40.2) 41/147 (27.9) 1.73 (1.05–2.87) 0.03 1.99 (1.13–3.51) 0.04
Tested for HIV in previous year 317 121/147 (82.3) 117/170 (68.8) 2.11 (1.23–3.61) 0.007 2.39 (1.36–4.02) 0.003
Biological
HIV-infected 311 100/145 (70.0) 119/166 (71.7) 0.88 (0.54–1.43) 0.60 -----
Social Discrimination/Violence
Afraid to seek health services 318 63/147 (42.9) 78/171 (45.6) 0.89 (0.57–1.40) 0.62 -----
Felt rejected by friends 318 78/147 (53.1) 89/171 (52.1) 1.04 (0.67–1.62) 0.86 -----
Was refused police protection 317 67/146 (45.9) 91/171 (53.2) 0.75 (0.48–1.16) 0.20 -----
Verbal/physical harassment 318 79/147 (53.7) 115/171 (67.2) 0.57 (0.36–0.89) 0.02 0.55 (0.33–0.91) 0.02
Beaten up due to selling sex 315 51/146 (34.9) 73/169 (43.2) 0.71 (0.45–1.12) 0.14 -----
Collective Action
Participated in meeting to promote sex worker
rights
318 64/147 (43.5) 46/171 (26.9) 2.09 (1.31–3.36) 0.002 2.26 (1.35–3.78) 0.002
Participated in meeting about HIV/AIDS with
other sex workers
314 85/145 (58.6) 83/169 (49.1) 1.47 (0.94–2.30) 0.09 1.31 (0.79–2.17) 0.30
a
Univariate analyses adjusted for RDS weights based on estimated population proportions of outcome variable.
b
Adjusted for age, income, education, marital status, and region in addition to RDS weights.
doi:10.1371/journal.pone.0087527.t004
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Page 7
previous research that has examined these variables longitudinally.
The Sonagachi Project from Kolkata, India, which sought to
reduce HIV risk for sex workers through promoting group
solidarity, fostering empowerment, and increasing access to social
and material resources, has led to significant increases in condom
use among sex workers [10]. However, social cohesion was not
directly measured in the Sonagachi Project. A replication of this
intervention in West Bengal also led to increases in consistent
condom use [59], as have several other interventions focusing on
community mobilization and collectivization of sex workers in
India [9,60] and on community solidarity in the Dominican
Republic [18] and Brazil [17]. The negative association of social
cohesion and refusal of police protection found in this study is
consistent with results from interventions in India, such as the
Avahan initiative, which demonstrated that groups of sex workers
can collectively confront and change police practices towards sex
workers, resulting in safer and healthier work environments
[22,61].
The association between social participation and ‘‘always’’
condom use with non-paying partners is noteworthy as condom
use among sex workers has been found to be lower in partnerships
with high relationship intimacy and trust [62]. Having sexual
relationships with non-paying partners is linked to social partic-
ipation in that both involve making connections with the larger
community beyond the world of sex work, which could explain
why social participation was related to condom use with non-
paying partners but not with new or regular clients in this study.
The significant association between social participation and
previous HIV testing has not been reported in other studies with
sex workers, but research with other high risk populations has
found that acceptability of HIV testing was associated with having
prosocial network characteristics [63], and that having a small
social network was associated with not being tested for HIV [64].
As global testing rates remain low, further research about the
influence of social networks and social participation on HIV
testing could generate important insights for increasing uptake of
HIV testing, particularly among population groups at heightened
risk for HIV infection.
Other research has demonstrated that the type of social
participation influences the relationship to HIV risk. For example,
a study from South Africa found that participation in savings clubs
was associated with risky sexual behavior among female members
and with being HIV infected among male members [33]. Prior
research has shown that the value of participating in certain social
groups is dependent on characteristics of the group, such as how
well the group functions, relationships among group members, and
the group’s purpose, which could all contribute to how protective
or harmful group membership is in relation to HIV [65]. In this
study, social participation was examined collectively, but in further
research it would be beneficial to look at associations by
participation in different group types and their function. The
IMAGE study, which involved microfinance and group health
education components for women in South Africa, provides an
innovative model for interventions striving to improve economic
opportunities for disadvantaged groups while simultaneously
creating channels for social participation and fostering social
cohesion [32].
Limitations
This study has several limitations. Firstly, since this is a cross-
sectional study, causation and temporality between exposure and
outcomes cannot be determined. Additionally, this study utilized
respondent-driven sampling methods. While RDS has led to
important breakthroughs for sampling hard to reach populations,
questions remain about biases introduced by purposeful seed
selection and preferential referral patterns of subsequent recruits
[66]. There is also a lack of consensus about how to treat RDS
data in multivariate regression analysis [51]. It is possible that
using RDS led to a more homogeneous population of sex workers
than currently exists in Swaziland. For example, previous research
suggests that transactional sex is common in rural areas of
Swaziland, but that the nature of the exchange is based more on
‘‘neighborliness’’ (i.e., helping out a neighbor in need of money or
food by exchanging sex) than sex work [41]. This study focused
more on ‘‘open’’ sex workers operating in urban and peri-urban
areas.
Most questions analyzed in this study came from self-reported
behaviors, such as condom use, which introduces social desirability
and reporting bias. Additionally, this study measured complex
social capital constructs with a social cohesion scale and a social
participation index that have not undergone extensive reliability
and validity testing and may not be applicable to other
populations. Social capital is a social phenomenon and is therefore
a characteristic of a group and not just a single individual [67];
however, in this study social capital was measured on an individual
basis. Although this is a common way to measure social capital,
there are debates in the field about the utility of using individual
measurement as a proxy for this ecological concept [68].
Additionally this study focused on social participation and social
cohesion as exogenous exposure variables and did not explore the
personal and environmental factors that may facilitate or hinder
an individual’s propensity for social engagement.
Conclusion
Few studies have examined the social context of sex work in sub-
Saharan Africa, and we identified only two HIV prevention
interventions targeting sex workers in this region that sought to
address social and structural factors related to HIV [69,70]. Most
research on social capital- and community empowerment-based
interventions for sex workers has been conducted in areas of the
world, such as South Asia, where sex work is largely establishment-
based. This feature may facilitate interventions aimed at increasing
social cohesion and participation as establishments may be easy
ways to bring together sex workers into functioning groups. Sex
work in sub-Saharan Africa often involves non-establishment
based sex work [71], presenting an additional challenge for
implementing HIV prevention interventions for sex workers in
these settings.
Results from this study demonstrate that the social context of
sex work matters. Findings suggest that higher levels of social
cohesion and social participation are associated with protective
behaviors, including condom use and HIV testing, and are
inversely associated with HIV-related risk factors, such as
experiencing social discrimination and violence. However, more
needs to be understood about the social context of female sex
workers in Swaziland, such as the extent to which sex workers are
willing and able to collectivize and advocate for rights and how sex
workers are portrayed and treated by the larger community.
Answering these questions is critical to understanding how
community-based empowerment interventions, which could
include components related to building social capital among sex
workers and between sex workers and the larger community, can
be implemented in this setting. Given recent evidence that scaling-
up comprehensive community-based empowerment interventions
is a cost-effective way to prevent a substantial number of new
infections, especially in places with high rates of HIV infection [7],
Social Capital and HIV Risk among Sex Workers
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Page 8
a better understanding of these relationships is important not only
for the sex worker community, but also for the general population.
Acknowledgments
We thank all staff members, Community Advisory Board members,
government officials, and participants for their hard work and involvement
in the project. We would also like to thank the project coordinators, Darrin
Adams and Rebecca Fielding-Miller, and the non-governmental organi-
zation, Lidvwala Lelitsemba, for all of their efforts and dedication.
Author Contributions
Conceived and designed the experiments: VF DK ZM CK SB. Performed
the experiments: VF DK CK SB ZM. Analyzed the data: VF SK.
Contributed reagents/materials/analysis tools: VF DK SB SK ZM. Wrote
the paper: VF DK CK SK.
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Transmitted Infections 82: iii18–iii25.
Social Capital and HIV Risk among Sex Workers
PLOS ONE | www.plosone.org 10 January 2014 | Volume 9 | Issue 1 | e87527
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    • "Fourth and last, a study by Fonner and colleagues (Fonner et al., 2014), defines social cohesion as part of social capital, labeling it " bonding social capital " . They measure social cohesion with an 11-item scale with questions about individual perceptions of group processes. "
    [Show abstract] [Hide abstract] ABSTRACT: Among various social factors associated with health behavior and disease, social cohesion has not captured the imagination of public health researchers as much as social capital as evidenced by the subsuming of social cohesion into social capital and the numerous studies analyzing social capital and the comparatively fewer articles analyzing social cohesion and health. In this paper we provide a brief overview of the evolution of the conceptualization of social capital and social cohesion and we use philosopher Erich Fromm’s distinction between “having” and “being” to understand the current research focus on capital over cohesion. We argue that social capital is related to having while social cohesion is related to being and that an emphasis on social capital leads to individualizing tendencies that are antithetical to cohesion. We provide examples drawn from the literature where this conflation of social capital and cohesion results in non-concordant definitions and subsequent operationalization of these constructs. Beyond semantics, the practical implication of focusing on “having” vs. “being” include an emphasis on understanding how to normalize groups and populations rather than providing those groups space for empowerment and agency leading to health.
    No preview · Article · May 2016 · Social Science & Medicine
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    • "Social cohesion, a key component and marker of community empowerment , has significantly reduced unprotected sex among SWs with both their paying and non-paying partners in Brazil, Swaziland, and the Dominican Republic (Fonner et al., 2014; Kerrigan et al., 2006; Lippman et al., 2010 ) and emerging research in Canada suggests that social cohesion has a direct protective effect on client condom refusal (Argento et al., in press). These findings suggest that interventions that increase community connectedness and agency may enhance communication and negotiation skills with partners, leading to higher condom use and overall better health outcomes for SWs and their intimate partners (Fonner et al., 2014; Lippman et al., 2010; Robertson et al., 2014 ). As intimate partnerships often provide a sense of stability and emotional support for SWs, promoting condom use may not be all that desirable or realistic , even where planning to have children is not a factor. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Despite high HIV burden among sex workers (SWs) globally, and relatively high prevalence of client condom use, research on potential HIV/STI risk pathways of intimate partnerships is limited. This study investigated partner/dyad-level factors associated with inconsistent condom use among SWs with intimate partners in Vancouver, Canada. Methods: Baseline data (2010-2013) were drawn from a community-based prospective cohort of women SWs. Multivariable generalized estimating equations logistic regression examined dyad-level factors associated with inconsistent condom use (<100% in last six months) with up to three male intimate partners per SW. Adjusted odds ratios and 95% confidence intervals were reported (AOR[95%CI]). Results: Overall, 369 SWs reported having at least one intimate partner, with 70.1% reporting inconsistent condom use. Median length of partnerships was 1.8 years, with longer duration linked to inconsistent condom use. In multivariable analysis, dyad factors significantly associated with increased odds of inconsistent condom use included: having a cohabiting (5.43[2.53-11.66]) or non-cohabiting intimate partner (2.15[1.11-4.19]) (versus casual partner), providing drugs (3.04[1.47-6.30]) or financial support to an intimate partner (2.46[1.05-5.74]), physical intimate partner violence (2.20[1.17-4.12]), and an intimate partner providing physical safety (2.08[1.11-3.91]); non-injection drug use was associated with a 68% reduced odds (0.32[0.17-0.60]). Conclusions: Our study highlights the complex role of dyad-level factors in shaping sexual and drug-related HIV/STI risk pathways for SWs from intimate partners. Couple and gender-focused interventions efforts are needed to reduce HIV/STI risks to SWs through intimate partnerships. This research supports further calls for integrated violence and HIV prevention within broader sexual/reproductive health efforts for SWs.
    Full-text · Article · Oct 2015 · Drug and alcohol dependence
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    • "In South Africa, threats of violence from clients and violence from nonpaying partners have been cited by FSW as barriers to condom use (Stadler & Delany, 2006; Varga, 1997). Social cohesion among FSW in Swaziland, including being able to count on FSW colleagues to support the use of condoms, was found to be positively related to consistent condom use with all clients and partners in the past week (Fonner et al., 2014). There is a need to better characterize prevention strategies among FSW to inform increasing investments in targeted HIV and STI prevention programs for the FSW population globally (Kerrigan et al., 2013). "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives. This study examined correlates of condom use among 248 female sex workers (FSW) in The Gambia. Methods. Between July and August 2011, FSW in The Gambia who were older than 16 years of age, the age of consent in The Gambia, were recruited for the study using venue-based sampling and snowball sampling, beginning with seeds who were established clients with the Network of AIDS Services Organizations. To be eligible, FSW must have reported selling sex for money, favors, or goods in the past 12 months. Bivariate and multivariate logistic regressions were used to determine associations and the relative odds of the independent variables with condom use. Four different condom use dependent variables were used: consistent condom use in the past six months during vaginal or anal sex with all clients and partners; consistent condom use in the past month during vaginal sex with new clients; consistent condom use in the past month during vaginal sex with nonpaying partners (including boyfriends, husbands, or casual sexual partners); and condom use at last vaginal or anal sex with a nonpaying partner. Results. Many FSW (67.34%, n = 167) reported it was not at all difficult to negotiate condom use with clients in all applicable situations, and these FSW were more likely to report consistent condom use with all clients and partners in the past 6 months (aOR 3.47, 95% CI [1.70–7.07]) compared to those perceiving any difficulty in condom negotiation. In addition, FSW were more likely to report using condoms in the past month with new clients (aOR 8.04, 95% CI [2.11–30.65]) and in the past month with nonpaying partners (aOR 2.93, 95% CI [1.09–7.89]) if they had been tested for HIV in the past year. Women who bought all their condoms were less likely than those who received all of their condoms for free (aOR 0.38, 95% CI [0.15–0.97]) to have used a condom at last vaginal or anal sex with a nonpaying partner. Conclusions. HIV and sexually transmitted infection (STI) prevention interventions for FSW should aim to improve condom negotiation self-efficacy since women who report less difficulty negotiating condom use are more likely to use condoms with clients. Interventions should also be aimed at structural issues such as increasing access to free condoms and HIV testing since these were positively associated with condom use among FSW.
    Full-text · Article · Aug 2015 · PeerJ
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