Experience of violence and adverse reproductive health outcomes, HIV risks among mobile female sex workers in India

Abstract

BackgroundFemale sex workers (FSWs) are a population sub-group most affected by the HIV epidemic in India and elsewhere. Despite research and programmatic attention to FSWs, little is known regarding sex workers' reproductive health and HIV risk in relation to their experiences of violence. This paper therefore aims to understand the linkages between violence and the reproductive health and HIV risks among a group of mobile FSWs in India.MethodsData are drawn from a cross-sectional behavioural survey conducted in 22 districts from four high HIV prevalence states (Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu) in India between September 2007 and July 2008. The survey sample included 5,498 FSWs who had moved to at least two different places for sex work in the past two years, and are classified as mobile FSWs in the current study. Analyses calculated the prevalence of past year experiences of violence; and adjusted logistic regression models examined the association between violence and reproductive health and HIV risks after controlling for background characteristics and program exposure.ResultsApproximately one-third of the total mobile FSWs (30.5%, n = 1,676) reported experiencing violence at least once in the past year; 11% reported experiencing physical violence, and 19.5% reported experiencing sexual violence. Results indicate that FSWs who had experienced any violence (physical or sexual) were significantly more likely to be vulnerable to both reproductive health and HIV risks. For example, FSWs who experienced violence were more likely than those who did not experience violence to have experienced a higher number of pregnancies (adjusted odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.0-1.6), ever experienced pregnancy loss (adjusted OR = 1.4, 95% CI = 1.2-1.6), ever experienced forced termination of pregnancy (adjusted OR = 2.4, 95% CI = 2.0-2.7), experienced multiple forced termination of pregnancies (adjusted OR = 2.2, 95% CI = 1.7-2.8), and practice inconsistent condom use currently (adjusted OR = 1.97, 95% CI: 1.4-2.0). Among FSWs who experienced violence, those who experienced sexual violence were more likely than those who had experienced physical violence to report inconsistent condom use (adjusted OR = 1.8, 95% CI: 1.4-2.3), and experience STI symptoms (adjusted OR = 1.3, 95% CI: 1.1-1.7).ConclusionThe pervasiveness of violence and its association with reproductive health and HIV risk highlights that the abuse in general is an important determinant for reproductive health risks; and sexual violence is significantly associated with HIV risks among those who experienced violence. Existing community mobilization programs that have primarily focused on empowering FSWs should broaden their efforts to promote reproductive health in addition to the prevention of HIV among all FSWs, with particular emphasis on FSWs who experienced violence.

Gender-Based Violence among Married Women in Debre Tabor Town, Northwest Ethiopia: A Qualitative Study

“…Almost all the participants explained that gender-based violence increases the risk of different adverse reproductive outcomes, such as unwanted pregnancy, abortion, miscarriage, still birth, HIV/AIDS and fistula among married women. This finding is consistent with a study conducted in India, where women who were victims of genderbased violence experienced increased risks of multiple forced terminations of pregnancies 30 . The association between gender-based violence and adverse reproductive health outcomes might be that women who are physically and sexually violated have limited access to contraception which leads to unwanted pregnancies and usually ends up in abortion.…”

“…This corroborates the already established link between alcohol and violence. Different studies have documented that many men who abuse alcohol have been violent to female partners and are perpetrators of domestic violence 30,32 . Almost all the participants explained that gender-based violence increases the risk of different adverse reproductive outcomes, such as unwanted pregnancy, abortion, miscarriage, still birth, HIV/AIDS and fistula among married women.…”

Intimate partner violence against female sex workers in Mombasa, Kenya

“…Moreover, inequitable gender norms, criminalisation and stigmatisation of sex work contribute not only to their increased risk of IPV, but also to the challenges female sex workers encounter for harm reduction, as they are less likely to seek or receive assistance from violent situations (Ratinthorn et al 2009;Beattie et al 2010;Decker et al 2010;Mbonye et al 2012;Shannon et al 2012). Female sex workers also are at increased risk for adverse reproductive health outcomes, including sexually transmitted infections and unintended pregnancies (Swain et al 2011). A recent meta-analysis of 102 articles from studies conducted in 50 countries revealed that female sex workers have much greater risk of HIV infection than women who do not engage in sex work (OR 13.5; 95% CI 10.0 -18.1) (Baral et al 2012).…”

Fertility-related research needs among women at the margins

“…These risks include violence perpetrated against sex workers, high HIV prevalence and sustained antenatal exposure to HIV and other STIs, and limited engagement in healthcare services, which may collectively have deleterious effects on pregnancy outcomes. [64][65][66][67][68] Yet, fertility-related evidence has focused predominantly on the incidence of pregnancy among sex workers and their unmet contraceptive needs. [69][70][71] Continued efforts to integrate emergency contraception into sex worker-friendly services, and measurement of the impact of these services on unsafe abortions would help to expand the evidence base.…”