Findings from this study indicate that nearly one-third of mobile FSWs in high HIV prevalence states of India experience physical or sexual violence. The experience of violence is associated with increased pregnancies, pregnancy loss, RTI symptoms, inconsistent condom use, STIs symptoms and high perception of HIV risk. Violence victimization in general among FSWs is associated with both reproductive health and HIV risks. However, FSWs who had experienced sexual violence were more likely to report HIV risks than those who experienced only physical violence. These findings indicate that reproductive health risks continue to be a concern among generally abused FSWs and suggest the need for interventions to address the reproductive health needs of FSWs along with existing HIV risk reduction programs.
The reported prevalence of violence among mobile FSWs in this study is consistent with previous research among all FSWs [11, 15] and among women in the general population [7, 19], suggesting that this group of FSWs face a double jeopardy because in addition to being vulnerable to experiencing violence they are also socially stigmatized. As many as one-third of FSWs experience violence; this experience of violence is higher among FSWs who have no formal education, formerly married and those in sex work for more than five years.
Among violence episodes, the most critical - sexual violence-- is experienced to a larger extent than physical violence; this is also true of sex workers in most countries in the Asian region [9, 23, 25]. These results suggest that neither extensive HIV prevention programmatic attention [30, 31] nor the National AIDS Control Policy  have been adequate to reduce violence, particularly to protect FSWs who are the most disadvantaged.
This study is amongst the first to examine the relationship between the experience of violence and reproductive health and HIV risks among mobile FSWs in India, and advances prior work from multiple settings demonstrating that violence victimization is linked to HIV risk behaviors in India and elsewhere [15, 33]. Additionally, the high level of reproductive health risks identified to be associated with violence indicate the need to develop new strategies in intervention programs that will address the adverse reproductive health circumstances of the abused FSWs and the violence. Similarly, the higher levels of inconsistent condom use in sex with clients and symptoms of STI among abused FSWs as compared to FSWs who have not experienced violence points to increased HIV risk among FSWs who face violence. These results are consistent with previous work in other developing countries, which indicate that the threat of physical or sexual violence results in sex workers 'agreeing to have sex without condoms' thus potentially exposing them to HIV infection . Evidence from studies of women in the general population in South Asia too have documented the high rates of intimate partner violence [3, 7] and its impact on the risk of HIV infection.
Prior to this study, the understanding of the effects of violence victimization on FSWs' reproductive health in India was limited. Similar to abused women in the general population, abused FSWs also continue to experience reproductive health and HIV risks and the support systems of FSWs are more limited than those of women in the general population because of the clandestine nature of sex work in India .
Although findings from this study offer important insights into violence victimization among FSWs in India and its association with reproductive health and HIV risks, they must be interpreted in the light of certain study limitations. First, responses to violence victimization, STIs, condom use and reproductive health outcomes are based on self-reports and are therefore vulnerable to significant social desirability and recall biases, and under reporting. The use of experienced research staff linked with training and local support was designed to increase respondents' comfort and reduce social desirability; moreover, the use of short time-frames for recall was designed to reduce recall biases. However, the self-reported symptoms of STI may be an underestimate given that many FSWs with STIs may not experience any symptoms, and some of those reporting symptoms may not actually have an STI . Second, analyses are cross-sectional; thus, causality cannot be assumed in linkages between indicators of reproductive health and violence victimization. Finally, findings are specific to mobile FSWs from four high prevalence states of India, and cannot be generalized to other FSWs within India. Nonetheless, current findings are consistent with those observed in previous cross-national studies of violence victimization among FSWs [11, 37], and advances the knowledge on association between violence and reproductive health and HIV risks in this marginalized and socially stigmatized group.
The pervasiveness of violence among FSWs and its strong association with reproductive health and HIV risks indicates the crucial need for violence prevention interventions among FSWs in India. Findings from this study are timely because the up-scaling of the community mobilization strategy in HIV prevention interventions is underway; this could provide a window of opportunity for these programs to intervene in areas where violence reported to be high as well as to integrate reproductive health services for FSWs within HIV risk reduction programs. Interventions to promote safe sex among FSWs must be part of an overall effort to ensure their safety from contextual risk in terms of sex work vulnerability towards violence and abuse. Empowering and equipping FSWs with self-defense skills to address violence could be another effective strategy. Other strategies to address violence among FSWs could include helping FSWs to identify risky clients, build awareness about their legal rights, assist them to network with collectives, and inform them about how to prevent abuse. Efforts should also focus on FSWs' reproductive health needs, and should integrate family planning education, particularly in sexual relations with non-paying partners or husbands. While major efforts are under way to reduce the risk of FSWs acquiring and transmitting HIV, it is vital that existing interventions are expanded to integrate reproductive health services for FSWs and address violence within such contexts.