Non-paying partnerships and its association with HIV risk behavior, program exposure and service utilization among female sex workers in India

Abstract

BackgroundIn India, HIV prevention programs have focused on female sex workers’ (FSWs’) sexual practices vis-à-vis commercial partners leading to important gains in HIV prevention. However, it has become apparent that further progress is contingent on a better understanding of FSWs’ sexual risks in the context of their relationships with non-paying partners. In this paper, we explored the association between FSWs’ non-paying partner status, including cohabitation and HIV risk behaviors, program exposure and utilization of program services.MethodsWe used data from the cross-sectional Integrated Behavioral and Biological Assessment (IBBA) survey (2009–2010) conducted among 8,107 FSWs in three high priority states of India- Maharashtra, Andhra Pradesh and Tamil Nadu. Multiple logistic regression was used to examine the association between non-paying partner and cohabitation status of FSWs with HIV risk behaviors, program exposure and utilization of program services.ResultsFSWs reporting a non-paying partner were more likely to be exposed to and utilize HIV prevention resources than those who did not have a non-paying partner. Analyses revealed that FSWs reporting a non-cohabiting non-paying partner were more likely to be exposed to HIV prevention programs (adjusted OR: 1.7, 95% CI: 1.3 – 2.1), attend meetings (adjusted OR: 1.5, 95% CI: 1.2 – 1.8), and visit a sexually transmitted infections clinic at least twice in the last six months (adjusted OR: 1.6, 95% CI: 1.3 – 1.9) as compared to those reporting no non-paying partner. That said, FSWs with a non-paying partner rarely used condoms consistently and were more vulnerable to HIV infection because of being street-based (p < 0.001) and in debt (p < 0.001).ConclusionFSWs with cohabiting partners were more likely to be exposed to HIV prevention program and utilize services, suggesting that this program was successful in reaching vulnerable groups. However, this subgroup was unlikely to use condoms consistently with their non-paying partners and was more vulnerable, being street based and in debt. The next generation of HIV prevention interventions in India should focus on addressing relationship factors like risk communication and condom negotiation, including specific vulnerabilities like indebtedness and street based solicitation among women in sex work.

The role of dyad-level factors in shaping sexual and drug-related HIV/STI risks among sex workers with intimate partners

“…Analogous to intimate partnerships in other contexts, unprotected sex by SWs’ intimate partners is common relative to by clients (Deering et al, 2011; Murray et al, 2007; Travasso et al, 2014), even when SWs are aware of their intimate partner’s drug use and sexual risk behaviors for HIV/STIs (El-Bassel and Wechsberg, 2012; El-Bassel et al, 2010; Pequegnat and Bray, 2012). Moreover, SWs in our study reported that 11.2% of intimate partners had sexual relationships with other SWs and 14.3% had sexual relationships with other non-SW female partners, suggesting complex pathways through which HIV and STIs could potentially be contracted.…”

“…Similarly, a study in India found that between 7–12% of SWs reported inconsistent condom use with occasional clients, while 58–97% reported inconsistent condom use with intimate partners (Travasso et al, 2014). Among SWs in a US study, 56% reported always using condoms with their clients, compared to 32% and 14% with occasional partners and regular partners, respectively (Johnson et al, 2001).…”

Changes in Condom Use Over Time Among Female Sex Workers and Their Male Noncommercial Partners and Clients

“…However, condomless sex with clients may not be the only source of HIV/STI risk for FSWs (Travasso, Mahapatra, Saggurti, & Krishnan, 2014). Many FSWs report having noncommercial male partners (Deering et al, 2011; Hong & Li, 2008; Mishra et al, 2013), with whom condom use is infrequent (Hong & Li, 2008; Travasso et al, 2014; Ulibarri et al, 2012; Voeten, Egesah, Varkevisser, & Habbema, 2007). A study by Lowndes et al (2000) in Benin, Africa found a greater percentage of FSWs’ boyfriends were HIV positive compared to their clients (16.1% vs. 8.5%).…”

Measuring vulnerability among female sex workers in India using a multidimensional framework

“…Only two Indian studies have considered the multi-dimensional nature of vulnerability by creating a composite index of vulnerability. One of these studies considered three factors (solicitation in street-based setting, experience of violence and financial debt) to create a composite measure of vulnerability [ 15 ]. The other study considered six factors (literacy, duration in sex work, mobility for sex work, an additional source of income other than sex work, currently being in debt, and having children) to create an index of vulnerability.…”