Community empowerment and involvement of female sex workers in targeted sexual and reproductive health interventions in Africa: a systematic review

Abstract

BackgroundFemale sex workers (FSWs) experience high levels of sexual and reproductive health (SRH) morbidity, violence and discrimination. Successful SRH interventions for FSWs in India and elsewhere have long prioritised community mobilisation and structural interventions, yet little is known about similar approaches in African settings. We systematically reviewed community empowerment processes within FSW SRH projects in Africa, and assessed them using a framework developed by Ashodaya, an Indian sex worker organisation.MethodsIn November 2012 we searched Medline and Web of Science for studies of FSW health services in Africa, and consulted experts and websites of international organisations. Titles and abstracts were screened to identify studies describing relevant services, using a broad definition of empowerment. Data were extracted on service-delivery models and degree of FSW involvement, and analysed with reference to a four-stage framework developed by Ashodaya. This conceptualises community empowerment as progressing from (1) initial engagement with the sex worker community, to (2) community involvement in targeted activities, to (3) ownership, and finally, (4) sustainability of action beyond the community.ResultsOf 5413 articles screened, 129 were included, describing 42 projects. Targeted services in FSW ‘hotspots’ were generally isolated and limited in coverage and scope, mostly offering only free condoms and STI treatment. Many services were provided as part of research activities and offered via a clinic with associated community outreach. Empowerment processes were usually limited to peer-education (stage 2 of framework). Community mobilisation as an activity in its own right was rarely documented and while most projects successfully engaged communities, few progressed to involvement, community ownership or sustainability. Only a few interventions had evolved to facilitate collective action through formal democratic structures (stage 3). These reported improved sexual negotiating power and community solidarity, and positive behavioural and clinical outcomes. Sustainability of many projects was weakened by disunity within transient communities, variable commitment of programmers, low human resource capacity and general resource limitations.ConclusionsMost FSW SRH projects in Africa implemented participatory processes consistent with only the earliest stages of community empowerment, although isolated projects demonstrate proof of concept for successful empowerment interventions in African settings.

Sexual transactions between long distance truck drivers and female sex workers in South Africa

“…Having a LDTD peer interviewer, a male researcher or a FSW interviewer could have yielded different results, as seen in other studies. [4,22] The FSWs in this study were recruited from the same hotspot and so the study could have missed dynamics of the sex trade taking place in other parts of the N3 highway and other transport routes in South Africa. Thus results from this study are unique to this setting and cannot be generalized to other settings where FSWs engage with LDTDs.…”

“…[2,3] Additional efforts are needed to address the susceptibility of these key and vulnerable populations to new HIV infections and transmissions. [3,4]…”

Behavioural interventions promoting condom use among female sex workers in sub-Saharan Africa: a systematic review

“…Previous systematic reviews which have addressed relevant HIV-related issues globally and within sub-Saharan Africa on FSWs include: sex work, sexual risk factors for HIV and facility-based sexual and reproductive health ; size estimates of the FSW population globally (Vandepitte et al, 2006); sex workers' mobility (Platt et al, 2013); community empowerment approaches (Kerrigan et al, 2013;Moore et al, 2014); sexually transmitted infections (STIs) and their control (Cwikel, Lazer, Press, & Lazer, 2008); impact of interventions on condom use in varied sexual partnerships, that is, youths, married/steady, casual and commercial (Foss, Hossain, Vickerman, & Watts, 2007); and HIV-prevention interventions in low-and middle-income countries in general (Hong & Li, 2008;Shahmanesh, Patel, Mabey, & Cowan, 2008).…”

Correlates of unprotected sex with male clients among female sex workers in 13 Mexican cities

“…These include both individual approaches (e.g., promoting condom use) and structural approaches (e.g., modifying venue-based policies); the latter, along with longer term empowerment approaches, have demonstrated the largest impact on HIV prevention and treatment for FSWs (Blanchard et al, 2013; Kerrigan et al, 2013; Moore et al, 2014). Finally, men and transgender sex workers who carry a high burden of HIV/STI risk have been underrepresented in sex work research in Mexico and other LMIC (Bungay, Oliffe, & Atchison, 2015).…”

“…A similar approach could be implemented in Mexico. Also, peer-based outreach to promote condom distribution among street-based FSWs in LMIC has been shown to be successful in a number of studies (Moore et al, 2014). …”