Community Mobilization and Empowerment of Female Sex Workers in Karnataka State,South India: Associations With HIV and Sexually Transmitted Infection Risk

Objectives. We examined the impact of community mobilization (CM) on the empowerment, risk behaviors, and prevalence of HIV and sexually transmitted infection in female sex workers (FSWs) in Karnataka, India.Methods. We conducted behavioral–biological surveys in 2008 and 2011 in 4 districts of Karnataka, India. We defined exposure to CM as low, medium (attended nongovernmental organization meeting or drop-in centre), or high (member of collective or peer group). We used regression analyses to explore whether exposure to CM was associated with the preceding outcomes. Pathway analyses explored the degree to which effects could be attributable to CM.Results. By the final survey, FSWs with high CM exposure were more likely to have been tested for HIV (adjusted odd ratio [AOR] = 25.13; 95% confidence interval [CI] = 13.07, 48.34) and to have used a condom at last sex with occasional clients (AOR = 4.74; 95% CI =  2.17, 10.37), repeat clients (AOR = 4.29; 95% CI = 2.24, 8.20), and regular partners (AOR = 2.80; 95% CI = 1.43, 5.45) than FSWs with low CM exposure. They were also less likely to be infected with gonorrhea or chlamydia (AOR = 0.53; 95% CI = 0.31, 0.87). Pathway analyses suggested CM acted above and beyond peer education; reduction in gonorrhea or chlamydia was attributable to CM.Conclusions. CM is a central part of HIV prevention programming among FSWs, empowering them to better negotiate condom use and access services, as well as address other concerns in their lives.HIV prevention strategies with female sex workers (FSWs) have traditionally relied on individual behavior change, involving peer educators, condom promotion, and provision of sexual health services.1,2 Over the past decade, there has been a growing recognition that HIV epidemics are “socially and culturally produced,”3 and that psychosocial and community-level processes underlie an individual’s ability to adopt safer sexual behaviors. This has influenced approaches to HIV prevention, with more attention being paid to structural and social factors (such as violence, stigma, and poverty) that shape individual-level risk behaviors (e.g., condom use) and interventions that are targeted toward contextual factors in the HIV risk environment.4–8Among FSW populations, community mobilization (CM) has been endorsed as one of the structural interventions that improve the risk environment, with it''s effectiveness in addressing health and social issues of poor and marginalized populations largely explained through “empowerment.”9–12 Such programs have been recognized in the Joint United Nations Programme on HIV/AIDS investment framework, which includes CM as a critical enabler to core programs.13 In contrast to peer education, which usually involves peers meeting FSWs in the field, talking to them about the program, about difficulties they are facing in their lives, about the importance of condom use, and about the clinics and drop-in centers and other program activities, CM involves bringing together FSWs of various typologies who are scattered and hidden across rural areas and towns through mobilization, participation, and empowerment processes, to provide them with the space and the opportunity to act together, to fight injustices against them, and to campaign for their rights. Thus, whereas peer education can be a fairly “top down” approach, CM is designed to be an inclusive process that is initiated and sustained by the community to bring about the changes they desire (e.g., reduction in violence) through the process of empowerment. Empowerment can be defined as “the processes by which those who have been denied the ability to make choices (disempowered) acquire such an ability.”14^(p437) Most empowerment approaches recognize a dynamic interplay between gaining internal skills and overcoming external barriers, often drawing upon a conceptual framework that distinguishes “power within” (for example, self-confidence or critical thinking skills that contribute to individual agency), “power to” (for example, the ability to make individual decisions that determine and demonstrate such agency), and “power with” (communal decisions, such as group solidarity or collective action, which acknowledge that positive change may often be effected by individuals working together, rather than alone).9,15,16 In the context of sex work, the principles of social solidarity and CM seek to shift the burden of safer sex negotiation from being solely that of an individual FSW to a concept that is collectively shared and owned by the SW community, by acknowledging the dynamics and inequalities between a FSW and her client and the owners, pimps, and madams of sex establishments where sex workers work.17The Sonagachi program in Kolkata in east India provided one of the first examples of a rights-based HIV prevention program for FSWs, focusing on the mobilization and empowerment of brothel-based sex workers, as well as engagement with power structures,12,18–20 with data suggesting that HIV prevalence remained much lower in this setting compared with FSWs elsewhere in India.19 More recently, a growing body of evidence has suggested that organizing FSWs into support groups and community-based organizations can help the community to collectively challenge factors contributing to their vulnerability, such as stigma, discrimination, poverty, housing instability, violence, and harassment.21–31 However, although studies have reported strong associations between CM and collective power, uptake of sexually transmitted infection (STI) services, and consistent condom use with clients,11,17,32–35 there remains a paucity of data examining the impact of CM on biological (HIV or STI) outcomes.India has an estimated 2.4 million people living with HIV.36 Karnataka state in south India has the fourth highest HIV prevalence in the country. HIV is predominantly transmitted heterosexually, with the prevalence of HIV previously exceeding 1% in the general population, and a prevalence of more than 30% among FSWs in some districts.37,38 Before 2003, there was little HIV prevention programming in Karnataka. The Karnataka Health Promotion Trust was established in 2003 as part of the India Avahan initiative, funded by the Bill & Melinda Gates foundation.39,40 The program aimed to slow the HIV epidemic by rapidly scaling up targeted HIV prevention programs, reaching more than 60 000 FSWs and 20 000 men who have sex with men and transgenders in 20 of the 30 districts in the state.Community mobilization and the empowerment of FSWs formed a core part of HIV prevention programming in Karnataka (Figure 1).21,29–31 The process of mobilization and empowerment was gradual, with later phases of the program building on previous phases, and each activity contributing to the mobilization of SWs. For example, in the early phase of the project, peer educators were recruited from the FSW community. FSWs were brought together, and safe drop-in centers were created to respond to FSWs’ need for somewhere safe to rest, dress up, and meet friends. The program organized events and meetings for FSWs together with clinical services in these drop-in centers. These services included the provision of the “gray pack,” which was supplied every 3 to 6 months for the periodic presumptive treatment of gonorrhea and Chlamydia (containing 1 g azithromycin and 400 mg cefixime). These drop-in centers, in turn, helped attract more SWs, which resulted in the centers becoming a space where FSWs could meet each other and share their experiences, which helped create a sense of solidarity. The program then worked to support and develop critical thinking among the FSW community, providing a forum where FSWs could discuss the difficulties in their lives and reflect on how they could work together to address the challenges they faced.Open in a separate windowFIGURE 1—Community mobilization activities of Karnataka Health Promotion Trust: Karnataka, India, 2003–2014.Note. DIC = drop-in center; FSW = female sex worker; STI = sexually transmitted infection.In the intensive phases of the program (2006–2008), FSWs built on their sense of solidarity and started to undertake collective action, working with policymakers, the police, government officials, human rights lawyers, and the media to address issues of stigma, discrimination, violence, and social inequity.21,31 This, in turn, gave birth to collectivization and the formation of community-based institutions, such as peer groups or collectives. In the maintenance phase (2008–2013), FSW community-based organizations were formed to enable the process of handing over ownership of the Avahan program to FSWs and to the state government by 2013, which is now complete.41A detailed analysis of the impact of Avahan on HIV and risk behavior has been conducted, and suggests that the combination HIV program had a significant impact on HIV prevalence in Karnataka.42 However, a key policy debate, especially given current resource constraints, has been whether it is necessary to include CM, collectivization, and empowerment components in FSW HIV prevention programming, which can be costly and time-consuming. Therefore, we examined the impact of CM on HIV and STI prevalence, HIV risk behaviors, and collective and individual power among FSWs in Karnataka, using secondary analyses of data from 2 rounds of behavioral–biological surveys conducted with FSWs in 2008 and 2011.     

Neurocognitive Dysfunction in Hematopoietic Cell Transplant Recipients: Expert Review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and Complications and Quality of Life Working Party of the European Society for Blood and Marrow Transplantation

Hematopoietic cell transplantation (HCT) is a potentially curative treatment for children and adults with malignant and nonmalignant diseases. Despite increasing survival rates, long-term morbidity after HCT is substantial. Neurocognitive dysfunction is a serious cause of morbidity, yet little is known about neurocognitive dysfunction after HCT. To address this gap, collaborative efforts of the Center for International Blood and Marrow Transplant Research and the European Society for Blood and Marrow Transplantation undertook an expert review of neurocognitive dysfunction after HCT. In this review we define what constitutes neurocognitive dysfunction, characterize its risk factors and sequelae, describe tools and methods to assess neurocognitive function in HCT recipients, and discuss possible interventions for HCT patients with this condition. This review aims to help clinicians understand the scope of this health-related problem, highlight its impact on well-being of survivors, and help determine factors that may improve identification of patients at risk for declines in cognitive functioning after HCT. In particular, we review strategies for preventing and treating neurocognitive dysfunction in HCT patients. Finally, we highlight the need for well-designed studies to develop and test interventions aimed at preventing and improving neurocognitive dysfunction and its sequelae after HCT.     

Chest wall stabilization using plate fixation

Large defects of the chest wall require stabilization of the remaining thorax to prevent paradoxical movement. A technique of fixation using rib grafts and compression plates is presented.     

Shunt nephritis

Six children with shunt nephritis are reported of whom two did not show complete recovery of renal function. Follow up and outcome in relation to the delay in diagnosis and renal biopsy appearances are discussed.     

Brain activity and language assessment using event-related potentials: development of a clinical protocol

To test the validity of a new computerized task to assess children's receptive vocabulary, event-related potentials (ERPs) were recorded from 56 typically developing children ranging in age from 5 to 12 years. This ERP-computerized vocabulary task does not require a child to give a verbal or motor (i.e. pointing) response. Single pictures, from an existing standardized test of receptive vocabulary, were presented on a computer screen and simultaneously named either correctly (congruent) or incorrectly (incongruent) via a computer. As predicted, the N400 amplitude was found to be significantly higher to the incongruent picture-word pair (i.e. the child knew it was an incorrect pairing) than to the congruent picture-word pair (i.e. the child knew it was a correct pairing). This effect was found for each of the four age groups (5 to 6 years, 7 to 8 years, 9 to 10 years, 11 to 12 years). This task accurately estimated current receptive vocabulary in typically developing children. Although still in the development stage, it may eventually serve as an adjunct to a thorough neurological and neurodevelopmental assessment of some children presenting with moderate to severe cerebral palsy.     

Food label reading and understanding in parts of rural and urban Zimbabwe

Background

Overweight and obesity prevalence is rapidly rising in developing countries. The reading and understanding of nutrition information on food packages has been shown to improve food choices and instill healthy eating habits in individuals.

Objective

The aim of this study was to describe the prevalence of food label usage and understanding among urban and rural adults in Zimbabwe and its association with demographic and socio economic factors.

Methods

A cross sectional study was conducted on 320 adults (147 urban and 173 rural) using a validated questionnaire adapted from previous similar studies. Data were analysed using SPSS-17 statistical software.

Results

A high proportion (77.2%) of the respondents read food labels. Food label reading differed significantly by educational status (p<0.05), employment status (p<0.05) and locality (p<0.05). Only 40.9% of food label readers mostly understood the information on the food labels. More urban shoppers (86.1%) read food labels than their rural counterparts (66.7%). A significant number of participants (80.6%) indicated they would like to be educated on the meaning of food labels and 80.3% preferred the nutrition information on food labels to be simplified.

Conclusion

The study found above average reported reading of nutrition information on food labels with partial understanding. Efforts should be made to determine how all consumers could be made to understand the nutrition information on food labels and use it effectively in decision making.