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.     

Is viral E6 oncoprotein a viable target? A critical analysis in the context of cervical cancer

An understanding of the pathology of cervical cancer (CC) mediated by E6/E7 oncoproteins of high-risk human papillomavirus (HPV) was developed by late 80's. But if we look at the present scenario, not a single drug could be developed to inhibit these oncoproteins and in turn, be used specifically for the treatment of CC. The readers are advised not to presume the “viability of E6 protein” as mentioned in the title relates to just druggability of E6. The viability aspect will cover almost everything a researcher should know to develop E6 inhibitors until the preclinical stage. Herein, we have analysed the achievements and shortcomings of the scientific community in the last four decades in targeting HPV E6 against CC. Role of all HPV proteins has been briefly described for better perspective with a little detailed discussion of the role of E6. We have reviewed the articles from 1985 onward, reporting in vitro inhibition of E6. Recently, many computational studies have reported potent E6 inhibitors and these have also been reviewed. Subsequently, a critical analysis has been reported to cover the in vitro assay protocols and in vivo models to develop E6 inhibitors. A paragraph has been devoted to the role of public policy to fight CC employing vaccines and whether the vaccine against HPV has quenched the zeal to develop drugs against it. The review concludes with the challenges and the way forward.     

青年人群腰椎骨密度及标准差对骨质疏松检出率的影响：多中心、大样本分析

背景: 不同地区骨峰值和标准差不同，对骨质疏松诊断率有较大影响。探讨建立一完整数据库为中国人骨质疏松诊断准确性提供依据。 目的：探讨青年人腰椎骨密度和标准差正常参考值影响骨质疏松症检出率的程度。 设计、时间及地点：调查分析，于1997-01/1999-12分别在北京、上海、广州、南京、嘉兴和成都市完成。 对象：采用前瞻性及回顾性方法对全国6个中心骨密度参考数据库中11 418人进行调查统计分析；男3 666人，女7 752人；年龄20岁~90岁；分别来自北京(2 385人)、广州(1 178人)、上海(1 404人)、南京(2 938人)、成都(1 425人)、嘉兴(2 088人),受试者来源于社区调查、健康体检和健康志愿者。 方法：用GE-Lunar公司的DXA仪测量骨密度，调查全国6个中心11 418人L2~L4腰椎后前位和髋部骨密度，建立了骨密度参考数据库。6个中心的仪器内部精度0.3%~0.7%，仪器间的精度1.1%。 主要观察指标：①6个中心不同年龄组腰椎骨密度分布。②青年人群骨密度及其标准差值对骨质疏松症检出率的影响。 结果：中国汉族女性以腰椎进行骨质疏松症诊断的青年人群的骨密度和标准差值，6个中心，最大差值分别为0.098 g/cm2和0.027 g/cm2。用6个中心及总体各自的青年人平均骨密度和标准差值为参考标准，对同一人群计算T-score和获得的骨质疏松症检出率不相同；发现青年人平均骨密度每变化0.01 g/cm2，则骨质疏松症检出率变化1.6%(呈正相关)，其标准差值每变化 0.01 g/cm2，则骨质疏松症检出率变化4%(呈负相关)。 结论：青年人平均骨密度和标准差值不同引起骨质疏松症检出率也不相同。为了让不同中心的骨质疏松症检出率有可比性,建议同一个类型的骨密度仪,同一个种族,同一个地区用一个设计较完善大样本的参考数据库,以其青年人正常参考值计算T-score。     

Effectiveness and Safety of Topical Under-eye Serum in Patients with Periorbital Hyperpigmentation: An Open-label Single Arm Prospective Study

ObjectiveWe sought to determine the efficacy and safety of a topical under-eye serum (Melalumin™; Menarini India Pvt Ltd.) in patients with periorbital hyperpigmentation (POH).MethodsIn this prospective, open-label single-arm study, 90 patients aged 18 to 55 years with Grade I to IV pigmentary POH, were given the under-eye serum for three months. Follow-up visits were scheduled at one, two and three months from baseline. Effectiveness was evaluated by two independent dermatologists using a skin colorimeter (Dermacatch) and dermoscopy (FotoFinder Systems, Inc., Medical Imaging Systems; Columbia, Maryland), as well as global photographs and patient-reported satisfaction ratings (excellent, very good, good, not satisfied). Adverse events were recorded. The colorimeter values were evaluated using the paired T test and the single-mean T test was used for dermoscopy and global clinical photographs.ResultsOf the 90 patients included, 85 completed the study. Significant reductions in colorimeter values were noted in both melanin (from 708 to 621) and erythema (from 450 to 417) over three months (p<0.05). Mean improvement in dermoscopic assessment was 48.41 percent; Most (n=73/85; 85.88%) patients achieved >25-percent improvement; over one-third (n=31/85; 36.47%) showed >50-percent improvement. Global photographs improved by 49.47 percent; most (n=75/85; 88.24%) patients showed >25-percent improvement, over one-third (n=38/85; 44.71%) showed >50-percent improvement. Patient satisfaction levels were high (Excellent: 16 [18.82%]; Very good: 38 [44.71%]); Good: 26 [30.59%]; Not satisfied: 5 [5.88%]). No adverse events were noted.ConclusionThis study demonstrates safety and effectiveness of the studied under-eye serum in patients with pigmentary POH. In addition to clinical improvements noted by the investigators, significant improvements were also noted in colorimeter values, dermoscopy results, and global photographs. Patients exhibited high satisfaction levels with treatment outcomes. No safety concerns were noted.     

非肿瘤性肩关节损伤与人工肩关节置换

目的:分析假体的选择与手术操作技术对非肿瘤性肩关节损伤人工肩关节置换术治疗的影响。方法:选择2001-04/2006-10在上海长征医院、西藏军区总医院、扬州第一人民医院等进行肩关节置换术患者33例。肱骨急性近端粉碎性骨折28例:行单极人工肩关节置换术17例,双极人工肩关节置换术1例,全肩关节置换术3例。肱骨头缺血坏死2例、骨性关节炎3例,均行全肩关节置换术。术后9个月时22例患者参加随访,18个月时17例参加随访,30个月时5例参加随访。结果:33例患者均进入结果分析。①1例肱骨假体留置过长致肩关节上举运动痛、静止不痛,翻修术后缓解。其余32例完全不疼。②术后患者上举85°～130°,平均(98.7±6.0)°,外旋17°～36°,平均(30.0±5.7)°。内旋75°～101°,平均(82.5±4.8)°。③患者假体置位较好,除1例肱骨假体未完全插入髓腔,翻修后正常。④材料与组织的生物相容性能:符合美国FDA及欧洲CE标准。结论:针对患者的具体情况选用合适的人工肩关节假体,术中假体固定方法的选择以及术后外固定材料的佩戴对肩袖功能有重要影响。