University of Manitoba (Reza-Paul, Lorway, O’Brien, Jain), Ashodaya Samiti (Bhagya, Fathima, Venukumar, Raviprakash, Baer), McGill University Health Centre (Lazarus), World Health Organization (Steen)
"Structural interventions have the capacity to improve the outcomes of HIV/AIDS interventions by changing the social, economic, political or environmental factors that determine risk and vulnerability."
This case study of an intervention that mobilised sex workers to lead an HIV prevention response that addressed violence in their daily lives draws on ethnographic research and project monitoring data from a community-led structural intervention in Mysore, India, implemented by Ashodaya Samithi. [Footnotes have been removed throughout by the editor.] Because violence faced by sex workers has been identified as a major contributor to HIV vulnerability, Mysore sex workers adopted structural interventions to address occupational hazards, including violence. "Although the sex worker-led response to violence is the focus of this paper, it rests on the premise that collectivization processes and transformations in sex workers’ relationships with local health services are a critical prerequisite of effective HIV prevention, as discussed elsewhere in the literature. This case study highlights the positive outcomes of anti-violence work resulting from the community-led intervention using ethnographic field work, qualitative findings and programme monitoring data."
In 2006, 70 sexual life histories of sex workers were recorded. Then, in 2008, 46 in-depth qualitative interviews were conducted with sex workers (20 female, 14 male), as well as 12 key informant interviews with community leaders, police officers, brokers, boyfriends and lodge owners, and 2 focus group discussions with female and male sex workers. Baseline data on violence was obtained from a community-based monitoring system developed by the community in 2004 and enhanced over time with feedback from the field. From the data analysis, "a four-stage framework of community empowerment was devised: (i) Engagement; (ii) Involvement; (iii) Ownership; and (iv) Sustainability. Using this four-stage framework, temporal associations were explored between changes in monitored violence-related outcomes, specific community actions, and stages of community development."
Incidents of violence decreased from the baseline by 84% over 5 years. "Violence by police and anti-social elements, initially most common, decreased substantially after a safe space was established for sex workers to meet and crisis management and advocacy were initiated with different stakeholders. Violence by clients, decreased after working with lodge owners to improve safety. However, initial increases in intimate partner violence were reported, and may be explained by two factors: (i) increased willingness to report such incidents; and (ii) increased violence as a reaction to sex workers’ growing empowerment. Trafficking was addressed through the establishment of a self-regulatory board (SRB). The community's progressive response to violence was enabled by advancing community mobilization, ensuring community ownership of the intervention, and shifting structural vulnerabilities, whereby sex workers increasingly engaged key actors in support of a more enabling environment."
"It was found that Ashodaya's community-led response to violence followed a progression whereby action taken at multiple levels proved highly synergistic and effective in confronting structural violence and addressing its root causes. The community's progressive response to violence was made possible by three changing factors in the context of the intervention: sex workers’ mobilization strengthened their collective agency; the intervention integrated mechanisms to build ownership of the intervention among sex workers, resulting in stronger self-efficacy for services including crisis response; and sex workers’ engagement with key actors to build a more enabling environment reduced stigma, discrimination and violence....In conclusion, the community-led approach was a prerequisite for the development of the structural intervention. Building capacity of the community was critical so that they could exert their positional power and have collective bargaining power. Such capacity-building should be integral to targeted interventions and therefore, should be adequately budgeted for. As policy makers globally and in India endeavour to make HIV prevention a viable prospect in a concentrated epidemic, this case study shows that it can only be successful if community-driven structural interventions are undertaken."
Indian Journal of Medical Research 2012 January; 135(1): 98-106, accessed June 3 2013. Image credit: Moneycontrol website