The current study, based on a cross-sectional behavioral survey of mobile FSWs in four states, documents the high degree of congruence between the reported recent (prior) condom use behavior with occasional clients and self-perceived HIV risk at the time of survey. The association between reported condom use behavior with regular clients or non-paying partners and self-perceived HIV risk is either weak or not significant. These findings indicate that FSWs perceive their risk of acquiring HIV mainly on the basis of whether or not they used condoms consistently with occasional clients rather than condom use behavior with regular clients and non-paying partners. In fact, FSWs who either did not have sex with non-paying partners in one week prior to the survey or used condoms inconsistently with non-paying partners perceived themselves to be at a lower risk of acquiring HIV at the time of survey.
The study findings also show that several other risky behaviors are related to high self-perceived risk of HIV, e.g., experience of STI symptoms in the last six months, continuing sex while experiencing STI symptoms, and the use of alcohol before sex. The observed association between inconsistent condom use with occasional clients and perceived high HIV risk is not explained by their joint relationships with the experience of STI symptoms, alcohol use, and other covariates. Incorporating experience of STI symptoms increases the accuracy of personal HIV risk assessment from 63% to 80%. While STI symptoms have poor specificity among women in general, their experience of such symptoms may indicate the outcome of prior inconsistent condom use. In turn the appearance of STI symptoms among FSWs can be used as a marker for diagnosing and treating STIs as well as reinforcing the message of consistent condom use in all sexual encounters.
Furthermore, the apparent inaccurate perception of high HIV risk among about 7% of FSWs who reported using condoms consistently with occasional clients could simply be a reflection of their perception of high HIV risk associated with their profession. It is possible that this perception has not been modified to low risk with the adoption of consistent condom use. Alternatively, some of these FSWs may not have understood the behavioural communication messages and internalized the links between inconsistent condom use and high HIV risk or may be over-reporting both consistent condom use as well as their HIV risk perception. Nevertheless, the inaccurate perception of high HIV risk by those who reported consistent condom use is not important for controlling the spread of HIV, particularly if they actually used condoms consistently. The critical group of FSWs which should be the focus for controlling the spread of HIV is the 12% who perceived themselves to be at low risk of acquiring HIV even though they reported inconsistent condom use with occasional clients.
However, the finding regarding the congruence between inconsistent condom use during sex with occasional clients and high perceived HIV risk perhaps indicates the success of HIV prevention programs in communicating the HIV risk associated with unprotected sex with occasional clients. This finding is supported by the fact that consistent condom use in sex with occasional clients is high. However, the findings of this study also suggest that education programs may not have adequately emphasized the importance of using condoms consistently in all sexual encounters, especially in sex with regular clients and non-paying partners.
The finding that the variance in the degree of self-perceived HIV risk across districts is not explained by the factors included in the study suggests that there are some important unmeasured individual and district-level contextual factors that have not been included in this study. These may, for example, include the prevalence of STI/HIV and the availability of condoms and STI/HIV treatment in the district, and an individual’s knowledge of peers with STIs, and especially HIV, and knowledge of the probability of HIV transmission during any single unprotected sexual encounter. Differences in these individual and contextual factors would also contribute to the important differences observed among states in the degree of self-perceived risk of HIV. In addition, these state-level differences may reflect differences in the type and nature of sex work and the differential effects of HIV prevention programs, particularly behavioral change communication using IEC materials or peer educators. However, the omission of unmeasured contextual factors at the district and state levels may not be important because these two clustering variables accounted for only 13% of the variance in the self-perceived risk of HIV.
The finding that differences across states are greater than differences across districts may indicate the effect of large variations in HIV prevalence across states. Recent data show that HIV prevalence among FSWs in the southern states of India has begun to decline or stabilize in places where effective interventions have been in place for several years . However, due to differences in intensity and geographic coverage of these interventions, changes in the behaviors of high risk population groups, inconsistent condom use, and HIV prevalence continues to be high in selected districts of some of these states.
The finding that perceived level of HIV risk among FSWs differ by states suggest that the peer education programs in these states have been successful to different degrees, which may itself reflect the differences in the nature of sex work across these states. Therefore, these programs need to modify their message and the content of interaction between peer educators and FSWs. The FSWs from Maharashtra perceive themselves to be at the lowest HIV risk; those from Andhra Pradesh perceive to be at the highest HIV risk; and those from Karnataka and Tamil Nadu are in between the other two states. These differences suggest that the peer education programs in Maharashtra may have been more successful than other states. The emphasis in Karnataka could be on finding ways to enable FSWs to shift from inconsistent to consistent condom use with occasional clients. In Andhra Pradesh and Tamil Nadu, there is a need to reinforce the link between consistent condom use with occasional clients and low HIV risk.
In all the states, there is a need for messages to focus on the importance of using condoms consistently with regular and non-paying partners to reduce the risk of acquiring HIV. The design and success of these interventions in changing risky behavior with regular clients, especially with non-paying partners, would require a better understanding of why FSWs do not use condoms consistently with these partners and why those who do use condoms consistently still perceive themselves to be at a high HIV risk, and why FSWs who do not have non-paying partners perceive themselves to be at lower HIV risk than those who do. It is possible that FSWs do not use condoms with non-paying partners because of unequal power relationships. The current study suggests that FSWs may have emotional and perhaps security stakes in their relationships with non-paying partners, and may perhaps be in denial mode about the risk associated with inconsistent condom use. In-depth studies are needed on how self-assessment of HIV risk could relate to risky behavior with each type of client/partner and how this relationship could vary across different contexts.
While the current cross-sectional study of mobile FSWs has important implications for further research as well as HIV prevention programs, these results should be interpreted with caution because of a few limitations and methodological issues. First, the results of this study cannot be generalized to the non-mobile FSWs without repeating it for a representative sample of all FSWs. Second, answers to questions about consistent condom use may reflect some normative responses and could over-estimate the extent of consistent condom use. However, reported consistent condom use in last one week in this sample of mobile FSWs was lower than those who reported condom use at last sex with each type of client. Furthermore, the extent of this over-estimation of reported consistent condom use with occasional clients may be much lower than that associated with reported consistent condom use with regular clients and non-paying partners.
Third, obtaining accurate information about self-perceived risk is quite challenging. To begin with, risk is a probabilistic concept and it generally indicates the potential or the probability that an action or activity would lead to an undesirable outcome. Risk assessment or an individual’s perception of risk involves an assessment, based on current knowledge and belief. While the life-time consequences of HIV are quite severe, the probability of acquiring HIV with a single unprotected sexual encounter is quite low. However, no attempt was made in this study to explain to the respondents the concept of risk in terms of its probabilistic nature; the data on the reported self-perceived risk of acquiring HIV is based on only one question asked directly. It did not include references to any time period, e.g., the question did not specify whether the risk referred to the present period or to the future, an obvious recommendation from other studies based on review of literature [44, 45]. Further, the terms low, moderate, and high risk were not explained to the respondents. Thus, the response “moderate” to the question may reflect some ambivalence in risk perception. Future research of this type should explain the concept of risk to participants and include some time reference for assessed risk as well as a follow-up question to ascertain the respondents’ understanding of the term “moderate” risk. Moreover, questions could also be asked about the source of high or low perceived HIV risk , and the perception of risk associated with specific types of risky behavior, e.g., inconsistent condom use with occasional clients, inconsistent condom use with regular clients, and inconsistent condom use with non-paying partners.
Fourth, due to the reciprocal (two way) nature of the relationship between reported risky behavior and perceived HIV risk, these results based on a cross-sectional design do not necessarily imply causation [39, 44, 46]. While causal inference can adequately be drawn from longitudinal studies, the cross-sectional studies are appropriate to explore the relationship between past risky behavior and current risk perception. The cross-sectional studies are not appropriate to explore the effect of risk perception on subsequent changes in risky behavior . In terms of temporal sequence, explanatory variable should precede the outcome variable and we incorporated the presumed temporal sequence between the two events by considering risky behavior for the period (i.e. condom use in the week prior to the survey) preceding the reported perceived HIV risk at interview. Using this approach for a group of FSWs, we demonstrated the expected positive association between reported recent inconsistent condom use with occasional clients and higher self-perceived current HIV risk . Longitudinal studies are especially important to establish causation between self-perceived high HIV risk at time 1 and reduction in subsequent risky behaviors between time 1 and time 2 [45–47]. Moreover, operations research studies are required to assess the impact of interventions on improvements in the accuracy of perceived HIV risk and its affect on the reduction in subsequent risky behavior.
It should be noted that the relationship between risk perception and the adoption of preventive behaviors is fairly complex. Moreover, sustained preventive behavior requires repeated condom use during each sexual encounter and perception of high risk associated with not using a condom during any sexual encounter. Perceived high risk of acquiring HIV associated with unprotected sex may be necessary but it is not a sufficient condition for the adoption of preventive behavior. For example, many FSWs may charge a higher fee for having unprotected sex even though they may be aware of the risk involved . Many other individual and especially contextual factors may be responsible for hindering or facilitating an individual’s decision to use condoms consistently with a client or a partner. Moreover, overall reduction in risky behavior may also happen with changes in societal norms about safe sex and with the implementation of programs focused on changing these norms and sexual practices at the group level, e.g. 100% condom use in Thailand. Nevertheless, motivational messages to reduce risky behavior should incorporate HIV risk associated with inconsistent condom use with all types of clients and partners.