Background: Between 2014 and 2017, a program aimed at reducing HIV risk and promoting safe sex sought to work through addressing social and economic vulnerabilities and strengthening community-led organizations (COs) of female sex workers (FSWs). This study examines if the program was effective by studying the relationship between the strengthening of COs, vulnerability reduction and sustaining of HIV risk behavior among FSWs.
Methods: We used a panel data of 2085 FSWs selected from 38 COs across five states of India. The longitudinal data were collected both at CO and individual level in 2015 and 2017. Measures of governance, project management, financial management, program monitoring, advocacy and networking, and resource mobilization were used to assess organizational strength. Individual-level data were used to measure financial security (FS), social welfare security (SWS), socio-legal security (SLS), and safe sex behavior. Bivariate and multivariable regression models were fitted to examine the change in various outcomes from round 1 to round 2. Multivariable regression with an interaction term was used to assess the effect of program indicators on the change in outcomes.
Results: Significant improvement was noted in the strength of COs (up by 27 percentage point [pp]), FS (32 pp), SWS (34 pp) and SLS (27) from Round 1 to Round 2. The improvement in strength of COs led to improvement in FS (3 times), SWS (2 times) and SLS (3 times) among FSWs. The multivariable analysis further showed that improvement in FS contributed to sustained safe sex behavior among FSWs whereas SWS and SLS had a negligible effect on sustaining safe sex behavior. A positive outlier analysis of those who demonstrated sustained safe sex behavior shows that sustained behavior was positively associated with membership in self-help groups, high self-efficacy, and self-confidence, solicitation in street and brothels.
Conclusions: The vulnerability reduction program was successful in sustaining the safe sex behavior among FSWs by strengthening COs and addressing socio-economic vulnerabilities faced by FSWs. Moreover, the improvement in the financial condition of FSWs is key to sustaining behavior. Therefore, going forward interventions should focus on empowering FSWs economically can help in adopting safe sex behavior.