HIV preventive interventions focused on vulnerable groups such as sex workers have traditionally targeted individual behaviour only, with impediments to success frequently including structural factors beyond the scope of these programmes [5, 6]. In this paper, we have described a structural approach to HIV prevention which sought to change those context-specific social, economic, political and environmental factors determining HIV risk and vulnerability, as part of a large-scale HIV prevention programme in Karnataka state. We focused on addressing structural factors identified by the FSW community as contributing to their HIV vulnerability and, following collectivisation and community mobilisation of FSWs, worked in partnership with policy makers, secondary stakeholders (police, journalists and human rights lawyers), and primary stakeholders (FSWs themselves) to address issues of stigma and discrimination, violence and harassment, and social inequity facing the FSW community.
Previously we have reported significant increases in condom use, reductions in HIV and STI rates and reductions in violence against FSWs in Karnataka [16, 21, 25, 26]. In this study we have reported that the HIV prevention programmes have supported FSWs to re-dress over 90% of reported incidents of violence and harassment against them. In addition, we have presented evidence of widespread FSW mobilisation and collectivisation, substantial increases in the numbers of FSWs gaining access to government social benefits, and substantial changes in the reporting of HIV/AIDS and sex work in district and state level newspapers. The impact of the various components of a structural intervention on reducing HIV vulnerability can be difficult to assess . This is particularly true of structural barriers which are more distal to HIV risk, such as stigma and discrimination of FSWs by the general population, compared with more proximal factors such as sexual violence or micro-environmental factors affecting the conditions and resources of individuals (e.g. living conditions, food availability and education). Elsewhere, studies have demonstrated strong evidence of the detrimental impact on HIV risk of structural factors such as violence [32, 36, 43, 44], poverty [45–47], and stigma and discrimination [48–51]. In addition, some studies have sought to address structural barriers contributing to HIV/STI risk [52, 53], although there have been few studies demonstrating the direct impact of structural interventions on HIV risk among vulnerable populations [11, 12, 54]. Indeed, although the 100% condom programme in Thailand and the Sonagachi programme in Kolkata have both reported reduced or low rates of HIV among their target populations, without a randomised control trial design, it is difficult to directly assess the impact of the structural intervention components of these programmes on HIV prevalence [7, 9, 10, 37, 55].
Although we have presented evidence here suggesting that we are managing to successfully address some of the structural barriers identified as important by the FSW community, it is not possible for us to tease out from the data available, which components of our structural intervention have been most important in contributing to the reductions in HIV/STI rates. We are planning to conduct qualitative and process evaluation studies with FSWs to help in this respect. Evidence from studies elsewhere suggests that increased social capital at both the individual and community level could be important in reducing vulnerability to HIV [56–58]. In addition, evidence from elsewhere suggests that had we focused solely on individual behaviour change and not addressed the context-specific structural barriers contributing to the HIV vulnerability of FSWs, it is unlikely our HIV prevention programming would have been as successful [1, 10, 11].
There were several challenges to implementing this structural intervention, and lessons learned. One lesson is that it is important to develop the vulnerability reduction strategies from programme inception, as risk and vulnerability go hand in hand. In addition, vulnerabilities faced by FSWs are very contextual, and thus the involvement of sex workers in defining the structural drivers or factors causing vulnerability is crucial. For example, we found that while addressing violence was more important for certain FSW typologies and in certain geographic areas, for other FSWs improving social equity was more important. Addressing structural drivers is a long term intervention and requires patience from the donor and the implementer. Furthermore, any structural intervention work comes into direct conflict with power structures, which can sometimes lead to short-term increases in violence, discrimination and inequity. It is important that there is solidarity among the FSW population to be prepared for this, and that the supporting agencies provide maximum support to FSWs during this time. Finally, measuring the success or impact of structural interventions is complex, and the results of these interventions are not always consistent (for example, levels of reported violence can initially increase following a violence intervention due to violent reactions from established power structures, and increasing capability in violence reporting by FSWs) .
There are several limitations to a study such as this one. The absence of a precise baseline profile is a clear limitation, but it was not possible for us to conduct studies with the FSW community until trust had been established and the HIV prevention programme had begun. From our discussions with FSWs it is clear that prior to the programme commencing, no support systems (e.g. crisis management teams) or social entitlements were available to them, and condom availability was low . The lack of cohort data makes it difficult for us to examine changes to individual behaviour over time, or to unpack the impact of the various structural interventions on changes to individual behaviours or STI/HIV rates. In addition, as most of the newspapers in Karnataka are not available online, the tracking of news reports is currently conducted manually, and may be subject to reporting error. Finally, it was beyond the scope of this paper to examine the cost and cost-effectiveness of this structural intervention, but such evaluations of the programme overall have been reported elsewhere, with results suggesting that this HIV prevention programme is not costly compared with other HIV prevention programmes, and that it is cost-effective [59, 60].