Intimate relationships of Devadasi sex workers in South India: An exploration of risks of HIV/STI transmission

Intimate Relationships and HIV Infection Risks Among Shan Female Sex Workers From Myanmar in Chiang Mai, Thailand: A Qualitative Study

This study aimed to investigate HIV risks among female sex workers (FSWs) who were from the Shan ethnic group, and how they relate to complex relationships with inconsistent condom use. The study was conducted using in-depth interviews with 17 Shan FSWs (aged 18-45 years old) in Chiang Mai. Intimate relationships between participants and regular clients/steady partners were found to facilitate inconsistent condom use. Participating Shan FSWs sustained intimacy with regular clients not only for economic ends but also for emotional support. Gender norms and male power dominated condom use decision making. Some participants lacked proper HIV preventive knowledge regarding condom breakage and HIV risks. Effective intervention and proper HIV preventive practices should address these intimate contexts. Capacity building among women would assist FSWs to make choices that protect them from HIV/STDs infections. Couples-based HIV interventions addressing emotional intimacy is an urgent need for HIV communication and service delivery in Thailand.

Violence and Mental Health Among Gender-Diverse Individuals Enrolled in a Human Immunodeficiency Virus Program in Karnataka, South India

Purpose: Gender-diverse individuals in India face considerable discrimination, stigma, and violence. There is a dearth of published literature describing experiences of violence among this population and potential links to mental health.

Methods: A questionnaire was administered to 282 study participants, 18 years of age and older, who self-identified as hijra, kothi, double decker, or bisexual and were actively enrolled in a local HIV prevention program in Bangalore, India in 2012. Responses were used to calculate a composite depression/anxiety score. Associations between sociodemographic characteristics and experiences of physical and sexual violence in the previous six months were tested and differences in depression/anxiety score based on experiences of violence were explored.

Results: Recent physical violence was common among study participants and was reported among 46% of nirvan (emasculated) hijras (transgender), 42% of akwa (not emasculated) hijras, and 25% of kothis (feminine acting males). Rape in the previous year was particularly common among akwa hijras (39%). Factors associated with being raped included younger age, less education, and employment in basti (blessings), sex work, chela (disciple of hijra guru), or at a community-based organization. Kothis had the highest depression/anxiety score. No significant difference in depression/anxiety score based on recent history of physical violence or rape was found.

Conclusions: Physical violence and poor mental health are common among gender-diverse individuals in Bangalore, Karnataka. There is a need for services that cater to the unique mental health needs of gender-diverse individuals in India, following rights-based approaches that address the underlying roots of oppression they encounter.

Media, nationalism, and the body: Exploring masculinities, male partner violence, and HIV vulnerability among female sex workers in northern Karnataka, India

Public health and media discourses on men and HIV prevention in India have largely focused on changing knowledge, attitudes and risk behaviour pertaining to condom use and safe sex. Little attempt has been made towards intervening in areas such as masculinity, dominant gender norms and intimate partner violence (IPV) that have been shown to have a direct link to HIV prevalence. In this paper, drawing on findings from an ethnographic study in northern Karnataka (India), we show how socio-political and communicative contexts influence and perpetuate violent behaviours by men in intimate relationships with female sex workers (FSW). We argue that constructions of masculinity, the stereotypes of which are reinforced through contemporary media, and movies, are intricately linked with processes of nationalism and play out in forms of chauvinism among working-class men. Violence, celebrated through various patriarchal discourses, legitimises and reinforces gender ideals that govern the private lives of men and their female intimate partners. This study provides a complex and nuanced understanding of structural factors that lead to IPV against FSWs and offers implications for HIV intervention planning in the region and beyond.

Love, power, resilience and vulnerability: relationship dynamics between female sex workers in Ghana and their intimate partners

Little is known about female sex workers' daily lives or emotional relationships. Using relational-cultural theory, this study explored the relationship dynamics between sex workers and their intimate partners in Kumasi, Ghana. We collected qualitative data from 37 male intimate partners through 24 in-depth interviews and two focus group discussions (FGDs) with 13 male partners. We also conducted three FGDs with 20 women involved in sex work. Relationships between sex workers and their intimate partners were mutual, reciprocal and transactional. Male partners provided protection for financial support, a place to sleep and intimacy. Both men and women described their relationships in terms of friendship, love and a hopeful future. Women were reluctant to quit sex work because they depended on it for income. Most respondents did not use condoms in these romantic relationships, citing trust, love, faithfulness and commitment. Both men and women described high levels of violence in their relationships. The context of sex work heightens vulnerability but also appears to facilitate resilience and creative coping strategies. The relational dynamics between sex workers and their intimate partners in Ghana merit further exploration to examine the extent to which women involved in sex work hold and exert power within these relationships.

Education, poverty and "purity" in the context of adolescent girls' secondary school retention and dropout: A qualitative study from Karnataka, southern India

BACKGROUND

Gender-related norms and poverty remain important structural barriers to secondary school attendance among adolescent girls in southern India. We analyse how gender norms interact with family deprivation and dynamics to result in girls dropping out of school; we identify the main facilitators of school retention and changes to gender socialisation.

METHODS

Longitudinal qualitative case studies with 36 girls were nested within a cluster randomized trial to evaluate the Samata intervention targeting adolescent girls in Bagalkote and Vijayapura districts in northern Karnataka. We used two rounds of in-depth interviews, conducted in 2014 at a time when respondents were in 8th standard at the age of 13 to 14 and sixteen months later. We combined thematic and narrative analyses.

RESULTS

Our study found that poverty and socioeconomic realities at the household level strongly affect conformity with discriminatory gender practices such as restricting girls' mobility. The value placed on education by parents clearly differentiates the regular school goers from those frequently absent and others who dropped out. With active encouragement of the girls' educational and career aspirations, parents engendered the girl's agency to communicate openly both at home and at school, allowing subtle changes to gender performance while resisting the pressure of social sanctions. In contrast, where educational aspirations were weak, parents invested more intensely in enforcing correct performance of gender, prioritising her well-being by aiming to secure her future in a good marriage. Among poorer families, girls' domestic duties came at the cost of schooling with concerns about protecting her sexual purity predominating.

CONCLUSIONS

In contexts where a strong gender ideology of virginity before marriage rules, subtle shifts in harmful gender practices are possible. Interventions aiming to improve education need to target the most deprived families, focussing on trust building through open communication.

A community-based qualitative study on the experience and understandings of intimate partner violence and HIV vulnerability from the perspectives of female sex workers and male intimate partners in North Karnataka state, India

Background

Research has increasingly documented the important role that violence by clients and the police play in exacerbating HIV vulnerability for women in sex work. However few studies have examined violence in the intimate relationships of women in sex work, or drawn on community partnerships to explore the social dynamics involved. A community-based participatory research study was undertaken by community and academic partners leading intimate partner violence (IPV) and HIV prevention programs in Bagalkot district, Karnataka state, India. The purpose was to explore the experience and understandings of intimate partner violence and HIV/AIDS among women in sex work and their intimate partners in Bagalkot that would inform both theory and practice.

Methods

A community-based, interpretive qualitative methodology was used. Data was collected between July and October 2014 through in-depth interviews with 38 participants, including 10 couples, 13 individual female sex workers, and 5 individual male intimate partners. Purposive sampling was done to maximize variation on socio-demographic characteristics. Thematic content analysis was conducted through coding and categorization for each interview question in NVivo 10.0, followed by collaborative analysis to answer the research questions.

Results

The results showed that an array of interrelated, multi-level factors underlay the widespread acceptance and perpetuation of violence and lack of condom use in participants’ intimate relationships. These included individual expectations that justified violence and reflected societal gender norms, compounded by stigma, legal and economic constraints relating to sex work. The results demonstrate that structural vulnerability to IPV and HIV must be addressed not only on the individual and relationship levels to resolve relevant triggers of violence and lack of condom use, but also the societal-level to address gender norms and socio-economic constraints among women in sex work and their partners.

Conclusion

The study contributes to a better understanding on the interplay of individual agency and structural forces at a time when researchers and program planners are increasingly pondering how best to address complex and intersecting social and health issues. Ongoing research should assess the generalizability of the results and the effectiveness of structural interventions aiming to reduce IPV and HIV vulnerability in other contexts.

Electronic supplementary material

The online version of this article (10.1186/s12905-018-0554-8) contains supplementary material, which is available to authorized users.

Understanding the Relationship Between Female Sex Workers and Their Intimate Partners: Lessons and Initial Findings From Participatory Research in North Karnataka, South India

While traditional HIV prevention programs with female sex workers (FSWs) in Karnataka, India, have focused on reducing HIV transmission between FSWs and clients through increased condom use, these programs have not fully addressed the transmission risk between FSWs and their nonpaying intimate partners (IPs). Condom use is infrequent and violence is recurrent in these relationships: Furthermore, there is little evidence on the precise nature of FSW–IP relationships. Our study addresses this knowledge gap to inform HIV programs targeted at FSWs. A series of workshops, using participatory tools, was held to explore FSW-IP relationships; 31 FSWs and 37 IPs participated. Three aspects of FSW–IP relationships were examined: how FSWs and IPs understand and interpret their relationships, factors influencing condom use, and the role of violence and its consequences. FSWs wish to be perceived as their IPs’ wives, while IPs expect their FSW partners to accept their dominance in the relationship. Nonuse of condoms signals fidelity and elevates the status of the relationship almost to that of marriage, which helps FSWs enter the category of “good” (married) women. Tolerating and accepting violence in these relationships is normative, as in other marital relationships; IPs justify violence as necessary to establish and maintain their power within the relationship. Both FSWs and IPs value their relationships despite the high degree of risk posed by low condom use and high levels of violence. Implications for program design include addressing current norms around masculinity and gender roles, and improving communication within relationships.

Alcohol use, expectancies and HIV-related sexual risk: a cross-sectional survey of male migrant workers in South India

Male migrant workers (MMWs) in India are vulnerable to developing alcohol-related problems and engaging in unprotected sex, putting them at risk of HIV. Research has shown that alcohol-related expectancies mediate vulnerability to alcoholism. We examined which expectancies were associated with sexual risk and drinking. We surveyed 1085 heterosexual MMWs in two South Indian municipalities, assessing expectancies, sex under the influence, and unprotected sex with female sex workers (FSW) and casual female partners in the prior 30 days. Men more strongly endorsed positive than negative expectancies (t = 53.59, p < .01). In multivariate logistic regression, the expectancy of having more fun helped drive the combination of alcohol and unprotected sex with FSW partners (OR = 1.22, p < .05), whereas the expectancy of better sex helped drive a similar combination with casual partners (OR = 1.24, p < .01). Men concerned about alcohol-induced deficits were less likely to drink with FSW partners (OR = 0.81, p < .01), but more likely to have unprotected sex with them (OR = 1.78, p < .01). To reduce risk, MMWs would benefit from combination prevention approaches that use behavioral strategies to address drinking norms and awareness of risk, while using biomedical strategies to reduce viral transmission when risk does occur.

Meeting the Reproductive Health Needs of Female Key Populations Affected by HIV in Low- and Middle-Income Countries: A Review of the Evidence

Female sex workers and other women at high risk of acquiring HIV have the right to sexual and reproductive health, including the right to determine the number and timing of pregnancies. We conducted a literature review to examine the data that exist regarding the family planning and reproductive health needs of female key populations, the underlying determinants of these populations' vulnerability to poor reproductive health outcomes, and the obstacles they face in accessing high-quality reproductive health services. Findings indicate that female key populations experience high rates of unmet need for family planning and safer conception services, unintended pregnancies, sexual violence, and abortion, and that they practice inconsistent condom use. Restrictive policy environments, stigma and discrimination in health care settings, gender inequality, and economic marginalization restrict access to services and undermine the ability to safely achieve reproductive intentions. We offer recommendations for structural, health system, community, and individual-level interventions that can mitigate the effects of these barriers and improve reproductive health outcomes.

MAHILA: a protocol for evaluating a nurse-delivered mHealth intervention for women with HIV and psychosocial risk factors in India

Background

Women living with HIV are vulnerable to a variety of psychosocial barriers that limit access and adherence to treatment. There is little evidence supporting interventions for improving access and treatment adherence among vulnerable groups of women in low- and middle-income countries. The Mobile Phone-BasedApproach forHealthImprovement,Literacy andAdherence (MAHILA) trial is assessing the feasibility, acceptability and preliminary efficacy of a novel, theory-guided mobile health intervention delivered by nurses for enhancing self-care and treatment adherence among HIV-infected women in India.

Methods/Design

Women (n = 120) with HIV infection who screen positive for depressive symptoms and/or other psychosocial vulnerabilities are randomly assigned in equal numbers to one of two treatment arms: treatment as usual plus the mobile phone intervention (experimental group) or treatment as usual (control group). In addition to treatment as usual, the experimental group receives nurse-delivered self-care counselling via mobile phone at fixed intervals over 16 weeks. Outcome measures are collected at baseline and at 4, 12, 24 and 36 weeks post-baseline. Outcomes include antiretroviral treatment adherence, HIV-1 RNA, depressive symptoms, illness perceptions, internalized stigma and quality of life.

Discussion

The MAHILA trial will provide information about how a mobile health counselling intervention delivered by non specialist nurses may improve access to care and support the adherence and clinical outcomes of women with HIV infection living in low- and middle-income countries such as India.

Trial registration

NCT02319330 (First received: July 30, 2014; Last verified: January 2016)

Fertility intentions, power relations and condom use within intimate and other non-paying partnerships of women in sex work in Bagalkot District, South India

This study aimed to: (1) examine the relationship between interpersonal as well as social-demographic, cultural and structural factors, and condom non-use by sex workers' main intimate or other non-paying male sex partners (NPPs), as reported by a sample of sex workers (SWs); and (2) understand HIV/sexually transmitted infections (STIs) risk (e.g., numbers of sexual partners; condom use with different partners) among couples comprised of a sub-set of SWs and their NPPs. Bivariate and multivariable logistic regression was used to identify factors associated with condom non-use at last sex by the main NPP, as reported by SWs. Adjusted odds ratios and 95% confidence intervals are reported (AOR[95%CIs]). Data were drawn from cross-sectional surveys in Bagalkot District, Karnataka State, South India. Responses by SWs whose main NPPs agreed to enrol in the study and the main NPP enroled were linked; these responses by couples (pairs of SWs and NPPs) were examined to assess sexual risk for HIV/STIs. Overall, this study included 257 SWs and 76 NPPs. The data from 67 couples (88.2%) could be linked. In over a quarter of partnerships, at least one (SW or NPP) partner reported having another type of partner besides each other (and clients of SWs). In multivariable analysis, significantly increased odds of condom non-use at last sex with the main NPP were found for the following key factors: planning to have a child with their main NPP (AOR = 3.71[1.44-9.58]); and having decisions about condom use made by their main NPP (AOR = 9.87[4.03-24.16]) or both equally (AOR = 3.18[1.39-7.80]) (versus by the SWs herself). Our study highlights the potential risk for HIV/STI acquisition and transmission between NPPs and SWs, and between NPPs and their non-SWs wives and other sex partners. Study results underscore the need for HIV/STI prevention approaches that incorporate informed decision-making about childbearing and parenting, and empowerment strategies for SWs in the context of their relationships with NPPs.