Program Science and Sex Work: Challenges and Opportunities

1. Program Science and Sex Work: Challenges and Opportunities James Blanchard, MD, MPH, PhD Professor and Director Centre for Global Public Health University of Manitoba

2. Program Science • Definition: • “Promoting collaboration and integration between programs and science to improve the ways programs are designed, implemented and evaluated to accelerate and increase health impact” • Focuses on multiple levels: • Strategic – population focus, resource allocation • Implementation – effectiveness of intervention mix • Management / evaluation – scaling up, monitoring, optimizing implementation

3. Why Focus on Sex Work? • Sex workers among the most vulnerable groups • Key to the HIV and STI transmission dynamics in many world regions • A key focus of HIV prevention strategies in many countries and regions • Sex work is highly diverse and changing rapidly in many contexts • Still much room for improvement in the coverage and quality of programs for sex workers • Sex work is complex…

4. Why is more “science” needed? Key Program Questions Planning and Initiation Phase Relative size and distribution of SW population? Priority, Scale and Macro planning Contribution to transmission dynamics? Implementation Phase Outreach models? Prioritization? Client interventions? Migration? Mix of interventions components Structural interventions? Prioritization of new FSWs? Implementation and Consolidation Phase Economies of scale? Optimal coverage? Phases of programs? Optimal management processes Public vs. private sector? Role of CBOs?

5. Planning and Initiation Phase • Few studies that directly measure the relative size of the FSW and/or client population: • Issues in definition • Inconsistent methods (direct vs. indirect) • Few studies characterize the distribution of FSWs: • By typology (no accepted classification) • Urban / rural • Relative size of the client population is usually unknown: • Problems with direct measurement • Relative contribution of FSW to the overall epidemic is difficult to assess without these basic parameters

6. Pakistan

7. Pakistan – Relative Size of FSW Population, per 1000 Adult Men

8. Pakistan – Sexual Partnerships for Key Populations in Different Cities

9. Distribution of FSWs in Karachi and Lahore by Main Solicitation Location, 2005

10. Implementation: Beyond the Basics – Understanding Risk and Vulnerability • What are the highest risk contexts? • When does HIV transmission occur? • Who are the highest risk partners?

11. “Payana” Research Project* • Based on the mapping data, 142 villages with large number of migrant FSWs were selected from the 3 B districts (Belgaum, Bagalkot, Bijapur) • The target sample size was 1,500 (900-1000 non-migrants and 500-600 migrants) • We recruited a cohort of 1,564 women (645 migrant) • All the migrant women in the villages were selected; for the non-migrants FSWs, a target was set for each taluka proportionate to the size of the estimated non-migrant FSWs population • Retention rate of cohort members was >95% • Data collection via in-person interviews at baseline and 3, 9 and 15 months • Qualitative component to look in-depth at key issues * Funded through Avahan

12. Main destinations of migrant FSWs • The most common destinations are Pune, Sangli, Bombay and Bhiwandi (80%), followed by Kolhapur, Miraj and Karad. • Bijapur FSWs go to Bombay, Pune and Bhiwandi. • Belgaum FSWs go to Pune, Sangli and Bombay and to a smaller extent to Miraj and Goa. • Bagalkot FSWs go to Pune, Sangli, Bhiwandi and Bombay, but also to Kolhapur, Karad and Miraj. • Dark red arrows - over 30% of FSWs • Red arrows - 21 to 30% of FSWs • Orange - 11 to 20% of FSWs • Green - 5 to 10% of FSWs

13. Migration/mobility and Client Volume

14. Consistent condom use at origin

15. Consistent condom use at destination

16. HIV Prevalence among FSWs in 4 Districts in Karnataka by Duration in Sex Work

17. Period, Cohort Analysis of sex work patterns in the first year of sex work • Data collected at the 9 month interview from migrant FSWs • Asked focused questions to gather information about sex work during their first year of sex work • Stratified by year of entering sex work: • Before 1993 (n=163) • 1993-1999 (n=315) • 2000-2004 (n=297) • 2005-2008 (n=101)

18. Practiced Sex Work Within / Outside the Village of Origin During the First Year of SW

19. Proportion of FSWs reporting that condoms were availableduring the first year of sex work

20. Proportion of FSWs reporting that found it easy to use condoms with clients within the first year

21. Proportion of FSWs Reporting NEVER Using a Condom During the First Year of Sex Work

22. Program Implications • Although well-established, the program is “too late”: • Much of the HIV incidence occurs in the first year or two, prior to program involvement • Programs are less effective at increasing condom use early in sex work at the origin • At origin, early sex work is “home-based” and often hidden • At destination, early sex work is usually in brothels, with better established condom programming

23. What about clients? • Programs are usually generic and indiscriminant in focus and vague in coverage • Relative importance of client programs varies: • General power dynamics between FSWs and clients • Relative importance of clients, regular clients and other partners is seldom known

24. HIV prevalence (%) among FSW clients in 6 districts of Karnataka

25. Number of FSWs visited by clients in the past 6 months

26. Bagalkot – clients and lovers • Many of the sexual partners of FSWs in Bagalkot are “regular” • In addition, many of the FSWs have one or more “lovers”, many of whom also have multiple FSW partners • Possibly dense concurrent networks contributing to high HIV prevalence among clients and FSWs in Bagalkot

27. Additional considerations for transmission dynamics • Client-FSW partnering patterns: • Client “share” distribution (i.e. client clustering) • Overlapping of client-FSW networks • Higher in brothel and street settings? • Low in home-based and similar settings?

28. Ghani and Aral. J Infect Dis 2005. Sex Work System Properties: Client-Sex Worker Mixing Patterns Network Isolation Network Clustering Even Client Distribution Client Clustering

29. Implications for Transmission Dynamics Network Isolation Network Clustering Even Client Distribution Client Clustering

30. Lorenz Curve of the Distribution of Clients Among Female Sex Workers (FSWs) in 8 Cities of Pakistan

31. Results: Distribution of Client Volume Among FSWs in 8 Cities of Pakistan

32. Questions to ponder… • Why doesn’t Sri Lanka have an HIV epidemic among FSWs? • Relatively high per capita FSW population • No circumcision • Programs rudimentary • What is the likely trajectory of FSW epidemics in different parts of China? • What is the relative contribution of FSW networks to HIV epidemics in Africa? • East and Sub-Saharan? South? West?

33. Program Science and Sex Work – What Might be Needed? • Coherent description of what knowledge is needed for programs: • According to the phase of the program planning and implementation cycle • Identifying “fixed” (i.e. generalizable) and “variable” knowledge components • A conceptual framework to guide research questions that can be applied • Consistency of program-embedded research across contexts to address key conceptual and knowledge gaps

34. Macro-Level Societal Context • Socio-cultural milieu • Demography • Economy • Geography • Political / legal • FSW characteristics • population size • socio-demographics • economic status • Client characteristics • population size • socio-demographics • economic status Interactive influences • Sex Work Organization • Locations / venues • Locus of control • FSW-Client interfaces FSWs Clients • Aggregate properties • Client volume • Condom use • Duration in SW • Structural patterns • FSW-Client partnering • Network structures • Cohort effects Transmission dynamics and epidemic trajectory

35. Thank you