Objectives: Understanding the role of Self-Help Group (SHG) in light of the evolving dynamics of sex work needs to be delved into to strategize HIV interventions among FSWs in India. This paper aims to study the HIV program outcome among the FSWs associated with SHGs and FSWs not associated with SHGs in Thane, Maharashtra. Study Design: This cross-sectional study was undertaken from the Behavioral Tracking Survey (BTS) conducted among 503 FSWs in Thane in 2015. Two-stage probability based conventional sampling was done for selection of brothel and bar based FSWs, while Time Location Cluster (TLC) sampling was done for home, lodge and street based sex workers. Methods: Bivariate and multivariate logistic regression were performed to compare and contrast between FSWs associated with SHG and those not associated with SHG with respect to the utilization of HIV related services by them. “Condom use”, “consistent condom use”, “contact with peer-educators”, “counseling sessions” and “HIV testing” were chosen as indicators on HIV service utilization. Results: 8% (38) of FSWs are registered with SHG; 92% aged ≥25 years, 47% illiterate, and 71% are currently married. The likelihood of utilizing HIV services including, knowledge on HIV/AIDS and its mode of transmission (OR: 5.54; CI: 1.87 - 16.60; p < 0.05), accessed drop-in Centre (OR: 6.53; CI: 2.15 - 19.88; p < 0.10), heard about joint health camps (OR: 4.71; CI: 2.12 - 10.46); p < 0.05), negotiated or stood up against police/broker/local goonda/clients (OR: 2.26; CI: 1.08 - 4.73; p < 0.05), turned away clients when they refused to use condom during sex (OR: 3.76; CI: 1.27 - 11.15; p < 0.05) and heard of ART (OR; 4.55; CI: 2.18 - 9.48; p < 0.01) were higher among FSWs associated with SHG in comparison to FSWs not associated with SHG. Conclusions: Considering the improved HIV program outcomes among FSWs associated with SHG, HIV interventions among FSWs could consider facilitating the formation of SHGs with FSWs as one of the key strategies to empower the community for ensuring better program outcomes.
Poverty, gender inequalities and social marginalization continue to be a major challenge globally to HIV prevention efforts particularly among key populations. Current literature indicates that economic insecurity of women and their dependence on men increase their vulnerability to HIV by limiting their agency to negotiate the conditions for safer sex [
Self-Help Groups (SHGs) in India, is conceived as a strategy to bring together women from socially under privileged section of the society and empower them with information and opportunities for economic securities. SHGs comprise of members who share the same local context, life situation or crisis. Members provide emotional support to one another, learn new ways to cope, discover strategies for improving the well-being of their children, and overall help other members while helping themselves. SHG members who share common shame and stigma can come together, without judging, or to provide an “instant identity” and community [
In developing countries, the studies emphasize the importance of SHGs in empowering FSWs and in reduction the risk & vulnerability to STI/HIV [
In India, Maharashtra ranks among the top four states with 0.37% of HIV prevalence among adults aged 15 - 49 years, higher than the national average of 0.26% [
This paper analyses the role of SHG as a structural intervention strategies in empowering FSWs in addition to improving the key HIV program outcomes, including, but not limited to, awareness, access to HIV/STI testing, treatment services and condom usage.
Study Design and Participants: This was a cross-sectional study, drawn from Behavioral Tracking Survey (BTS), conducted in Thane district of Maharashtra, India, during September-October, 2015. Non-Government Organizations (NGOs); working in developmental activities, including health and non-health, predominantly, without making any financial profit have been the forerunners in India, in creating awareness on HIV from the initial stages of this epidemic and gradually implemented HIV prevention activities among HIV associated High Risk Groups (HRGs). Twelve NGOs implementing HIV prevention services to FSWs in Thane, prior to April 2014, were considered for development of sampling frame for the study; and facilitating the recruitment of study population in Thane.
The sampling frame (FSW sites) was developed by accessing information on the hotspots (geographical area), where there is significant concentration of HRGs are found [
Outcome Variables: Considering the level of exposure to intervention may vary widely in existing literature, self-reported data were collected using a questionnaire on exposure to HIV/AIDS and its mode of transmission, Knowledge on modes of prevention of HIV/AIDS, contacted by outreach worker to provide STI/HIV/AIDS information, received condom from NGO/TI, visited drop-in center, received counselling from a TI on STI, HIV, condom use and safe sex practices, visited NGO clinic/ TI-doctor for routine medical checkup and counselling for STIs, heard any health camp where individual from different typologies or different health provider assemble, received/accessed any services from joint health camp in last 12 months, number of times visited health camp in the last 12 months, has turned away clients when they refused to use condom during sex, negotiated or stood up against police/broker/local goonda/client and heard of ART.
Covariate Variables: The primary variable of interest was “are you a member of self-help group (No, Yes)”, however we also include others variables as the potential
confounders. Like, age (<25 years and >=25 years), education (Illiterate, Primary, Secondary and Upper-secondary and more), marital status (Never, Married, currently married and widowed/Divorced/Separated), source of income other than sex (No, Yes), age at first sexual intercourse (<20 years, >=20 years), age at first selling sex work (<20 years, >=20 years) , number of occasional clients (clients who came to you only once or a few times more but you do not remember their face or do not know them) in seven days , ever had physical or sexual violence (No, Yes) were considered.
Data were manually entered in CSPro 6.1 software and were cross-checked for duplication. Descriptive statistics of socio-demographic profile of the study participants were calculated using STATA 13. Bivariate analysis was carried out to understand the proportion of SHG against Non-SHG FSWs by selected background characteristics. Chi squire was used to test the significant difference among SHG and Non-SHG by selected characteristics. In addition to that difference between means was assessed using Wilcoxon Mann-Whitney Test. All test were two sided and a p-value of <0.05 was considered statistically significant. Multiple logistic regression was performed to assess the role of SHG on HIV prevention. The significant association between HIV/AIDS related services and SHG was further considered for adjusted multiple logistic regression.
The mean age of the study participants is 30 (SD = 6.0) years, while FSWs associated with SHG was 32 (SD = 5.5) years significantly (p = 0.031) higher than the mean age of FSWs not associated with SHGs. The participating FSWs were predominantly bar-based, followed by home, street and brothel based. Among the sub-typology, FSWs associated with SHG majority are predominantly street-based, while bar-based FSWs are representing higher in the group than not associated with SHG. It was observed more than 40 percent of them were illiterates in both the groups and majority of them in both the groups are currently married. In
Across both the groups >80% of them had reported their first sexual activity at a younger age, <20 years, while >=80% of them had got into sex trade after 20 years of their age. The mean number of occasional and regular clients and the mean number of sexual acts are observed to be within a range of 5 - 6 in both the groups.
Total (mean/%) | SHG (mean/%) | Non-SHG (mean/%) | P value (chi-squire test/Wilcoxon Mann-Whitney Test) | |
---|---|---|---|---|
N | 492 | 38 | 454 | |
Age of respondent | ||||
Mean age in years (SD) | 30.0 (6.0) | 32.0 (5.5) | 29.8 (6.99) | 0.031 |
<25 years | 15.7 | 7.9 | 16.7 | |
>=25 years | 84.3 | 92.1 | 83.3 | |
Sub-typology | ||||
Brothel | 11.43 | 13.16 | 11.28 | 0.000 |
Bar | 52.45 | 15.79 | 55.53 | |
Street | 14.29 | 42.11 | 11.95 | |
Home | 21.84 | 28.95 | 21.24 | |
Education of respondent | ||||
Illiterate | 44.5 | 47.4 | 44.3 | 0.889 |
Primary | 17.9 | 13.2 | 18.3 | |
Secondary | 14.8 | 15.8 | 14.8 | |
Upper-secondary & more | 22.8 | 23.7 | 22.7 | |
Marital status | ||||
Never married | 11.2 | 2.6 | 11.9 | 0.204 |
Currently married | 67.1 | 71.1 | 66.7 | |
Widowed/Divorced/Separated | 21.8 | 26.3 | 21.4 | |
Source of income other than sex | 63.8 | 31.6 | 66.5 | 0.000 |
Age at first sexual intercourse | ||||
< 20 years | 83.7 | 89.5 | 83.3 | 0.319 |
>=20 years | 16.3 | 10.5 | 16.7 | |
Age at first sex work | ||||
< 20 years | 19.1 | 10.5 | 19.8 | 0.161 |
>=20 years | 80.9 | 89.5 | 80.2 | |
Mean no. of occasional client in last seven days(SD) | 5.3 (5.3) | 5.9 (9.5) | 5.2 (4.9) | 0.390 |
Mean no. of sex with occasional client in last seven days (SD) | 5.4 (4.5) | 6.1 (9.5) | 5.3 (3.9) | 0.277 |
Mean no. of regular client in last seven days (SD) | 5.6 (5.4) | 5.0 (3.1) | 5.7 (5.6) | 0.890 |
Mean no. of sex with regular client in last seven days (SD) | 5.9 (4.9) | 5.3 (3.4) | 6.0 (5.1) | 0.603 |
Ever had physical violence | 8.5 | 5.3 | 8.8 | 0.452 |
Condom use with occasional clients | 97.8 | 100.0 | 97.6 | 0.332 |
Condom use with regular clients | 96.1 | 100.0 | 95.8 | 0.198 |
Exposure to program | 97.4 | 100.0 | 97.1 | 0.290 |
Note: SD standard deviation.
Self-help group | Non-self-help group | P value (based on chi-squire test and Wilcoxon Mann-Whitney Test) | Odds Ratio | 95% CI | |
---|---|---|---|---|---|
Knowledge on HIV/AIDS and its mode of transmission | 94.7 | 74.6 | 0.005 | 5.572** | (1.870 - 16.000) |
Knowledge on modes of prevention of HIV/AIDS | 94.7 | 90.9 | 0.562 | $ | |
Contacted by outreach worker to provide STI/HIV/AIDS information | 94.7 | 92.3 | 1.000 | $ | |
Received condom from NGO/TI | 100.0 | 93.4 | 0.154 | $ | |
Accessed drop in center | 97.4 | 78.2 | 0.003 | 6.534* | (2.148 - 19.879) |
Received counseling from a TI on STI, HIV, condom use and safe sex practices | 94.7 | 85.7 | 0.142 | $ | |
Accessed NGO Clinic/TI-doctor for routine medical checkup and counselling for STIs | 79.0 | 72.6 | 0.451 | $ | |
Heard about Joint Health Camp (JHC) | 26.3 | 10.4 | 0.003 | 4.710*** | (2.122 - 10.458) |
Have you accessed any services from JHC in last 12 months | 95.8 | 89.3 | 0.322 | $ | |
Mean number of times visited health camp in the last 12 months (SD) | 3.3 (2.3) | 2.8 (1.8) | 0.490 | $ | |
Have you turned away clients when they refused to use condom during sex | 88.9 | 66.8 | 0.006 | 3.762* | (1.269 - 11.152) |
Negotiated or stood up against police/broker/local goonda/client | 39.47 | 20.28 | 0.006 | 2.264* | (1.083 - 4.734) |
Have you heard of ART | 55.3 | 20.0 | 0.000 | 4.548*** | (2.181 - 9.482) |
Note: Controlled variables in logistic regression-age of respondent, education, marital status, source of income other than sex; *** p < 0.01, ** p < 0.05, * p < 0.1; OR: Odds Ratio; Only those variables which are significant in bi-variate are considered in multivariate analysis; $: insignificant in bivariate table so these indicators are not consider for logistic regression and CI: Confidence Interval.
and/or negotiated against police/broker/local goons/atrocities of clients. The odds of the above discussed indicators observed to >2.3 times than FSWs not associated with SHGs.
The study was able to show the need for FSWs to be engaged in SHGs, which could facilitate in empowering the community, especially in case of turning away clients when they refuse to use condoms and stood up against police/brokers/local goonda. A key observation of this study is that this study has higher (52%) representation of bar-based FSWs, rather than the brothel-based, home-based and street-based FSWs [
The study has significantly observed that FSWs have the multiple sources of income, including, but not limited to, selling vegetables or flower, daily labourer, domestic help, working in bar, work in massage parlor and beauty parlor is high (66.5% against 31.6%) among the FSWs not associated with SHGs. This observation should be interpreted with the sub-typology of FSWs, as it has shown significant association, but which specific typology had greater association; could not be observed due to less representation of FSWs in SHGs in the cohort sample.
With regard to program exposure and subsequent outcome, our study showed consistent findings with the literature available [
This self-reported survey has its in-built limitation such as recall bias. As this is a cross-sectional study by design, causal relationship is not possible. Since the distribution of sub-typologies was not representative among FSWs associated with SHG, analysis by sub-typologies could not be considered. These results however provide an evidence for the role of SHG among specific sub-typologies of FSWs in Thane, India in improving HIV program outcomes.
The finding has been warranting the TIs role in reaching out to the FSWs not associated with SHGs, more rigorously, to ensure favorable HIV program outcomes. In addition, TIs could also consider facilitating FSWs across typologies to get associated with SHGs, which can enhance the self-esteem of the community and make them less vulnerable to HIV.
Written consent was collected from the participants. The study protocol and the tools were approved by the Manipal University Ethic Committee (MUEC/12/2015 on August 08, 2015).
The United State Agency for International Development (USAID) funded this research through the HIV/AIDS Partnership: Impact through Prevention, Private Sector and Evidence-based Programming (PIPPSE) managed by Public Health Foundation of India (PHFI). The author thanks Debasish Chowdhury, Program Manager, PIPPSE, PHFI and Dr. Roopa Shivashankar, Sr. Research Associate, PHFI for their inputs in finalization of the manuscript. Finally we thank the FSWs community for their participation in the study.
Yadav, A., Sakthivel, S.P., Tayyaba, S., Shah, U. and Agarwal, A. (2016) Female Sex Workers and Their Association with Self-Help Groups in Thane, Maharashtra, India: A Comparative Analysis in the Context of HIV Program Outcome. World Journal of AIDS, 6, 186-196. http://dx.doi.org/10.4236/wja.2016.64021