Program Science and Sex Work:
Challenges and Opportunities
James Blanchard, MD, MPH, PhD
Professor and Director
Centre for Global Public Health
University of Manitoba
Program Science
• Definition:
– “Promoting collaboration and integration between
programs and science to improve the ways programs
are designed, implemented and evaluated to
accelerate and increase health impact”
• Focuses on multiple levels:
– Strategic – population focus, resource allocation
– Implementation – effectiveness of intervention mix
– Management / evaluation – scaling up, monitoring,
optimizing implementation
Why Focus on Sex Work?
• Sex workers among the most vulnerable groups
• Key to the HIV and STI transmission dynamics in
many world regions
• A key focus of HIV prevention strategies in many
countries and regions
• Sex work is highly diverse and changing rapidly in
many contexts
• Still much room for improvement in the coverage
and quality of programs for sex workers
• Sex work is complex…
Why is more “science” needed?
Key Program Questions
Planning and Initiation Phase
Relative size and distribution of
SW population?
Priority, Scale and Macro planning
Contribution to transmission
dynamics?
Implementation Phase
Outreach models? Prioritization?
Client interventions? Migration?
Mix of interventions components
Structural interventions?
Prioritization of new FSWs?
Implementation and Consolidation
Phase
Economies of scale? Optimal
coverage? Phases of programs?
Optimal management processes
Public vs. private sector? Role of
CBOs?
Planning and Initiation Phase
• Few studies that directly measure the relative size of
the FSW and/or client population:
– Issues in definition
– Inconsistent methods (direct vs. indirect)
• Few studies characterize the distribution of FSWs:
– By typology (no accepted classification)
– Urban / rural
• Relative size of the client population is usually
unknown:
– Problems with direct measurement
• Relative contribution of FSW to the overall epidemic is
difficult to assess without these basic parameters
Pakistan
Size of Key Sub-Populations, By City, 2005
16,000
Sub-Population Size
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Karachi
Lahore
FSW
MSW
Faisalabad
Hijra
IDU
Multan
Pakistan – Relative Size of FSW Population, per
1000 Adult Men
12
10
8
6
4
2
0
Pakistan – Sexual Partnerships for Key Populations
in Different Cities
Partners per Month, Thousands
Estimated Total Number of Sex Partnerships per Month,
x 1,000
700
653
600
500
400
300
200
219 200
192
107
100
10 22
0
Karachi
31 16 25
Lahore
FSW
Faisalabad
MSW
Hijra
25 21
Multan
Distribution of FSWs in Karachi and Lahore by
Main Solicitation Location, 2005
Karachi
Lahore
1%
3%
22%
49%
50%
Public Places
Public Places
Home/KK
Home/KK
Brothel
Brothel
75%
Implementation: Beyond the Basics –
Understanding Risk and Vulnerability
• What are the highest risk contexts?
• When does HIV transmission occur?
• Who are the highest risk partners?
“Payana” Research Project*
• Based on the mapping data, 142 villages with large number of migrant
FSWs were selected from the 3 B districts (Belgaum, Bagalkot,
Bijapur)
• The target sample size was 1,500 (900-1000 non-migrants and 500600 migrants)
• We recruited a cohort of 1,564 women (645 migrant)
• All the migrant women in the villages were selected; for the nonmigrants FSWs, a target was set for each taluka proportionate to the
size of the estimated non-migrant FSWs population
• Retention rate of cohort members was >95%
• Data collection via in-person interviews at baseline and 3, 9 and 15
months
• Qualitative component to look in-depth at key issues
* Funded through Avahan
Main destinations of migrant FSWs
- The most common destinations are Pune,
Sangli, Bombay and Bhiwandi (80%),
followed by Kolhapur, Miraj and Karad.
- Bijapur FSWs go to Bombay, Pune and
Bhiwandi.
- Belgaum FSWs go to Pune, Sangli and
Bombay and to a smaller extent to Miraj
and Goa.
- Bagalkot FSWs go to Pune, Sangli,
Bhiwandi and Bombay, but also to
Kolhapur, Karad and Miraj.
- Dark red arrows - over 30% of FSWs
- Red arrows - 21 to 30% of FSWs
- Orange - 11 to 20% of FSWs
- Green - 5 to 10% of FSWs
Migration/mobility and Client Volume
6
5.7
Clients per day (mean)
5
4
2.9
3
At Origin
At Destination
2
1.6
1.9
1.8
1
0
Local
Mobile
Migrant
Consistent condom use at origin
100
90
80
92
85
85
76
70
Percent
81
63
60
With occasional client
50
With regular client
40
30
31
With non-paying partner
22
20
15
10
0
Local
Mobile
Migrant
Consistent condom use at destination
100
90
80
99
91
95
75
70
60
With occasional client
50
50
With regular client
40
With non-paying partner
30
25
20
10
0
Mobile
Migrant
HIV Prevalence among FSWs in 4 Districts in
Karnataka by Duration in Sex Work
HIV Prevalence (%)
35
30
25
20
Baseline
15
Round 2
10
5
0
0-1
2 to 4
4 to 9
Duration in Sex Work
10+
Period, Cohort Analysis of sex work
patterns in the first year of sex work
• Data collected at the 9 month interview from
migrant FSWs
• Asked focused questions to gather information
about sex work during their first year of sex work
• Stratified by year of entering sex work:
–
–
–
–
Before 1993 (n=163)
1993-1999 (n=315)
2000-2004 (n=297)
2005-2008 (n=101)
Practiced Sex Work Within / Outside the Village
of Origin During the First Year of SW
80
71.5
70
Percent
60
56.3
49.9
50
40
61.6
59.8
48.9
39.9
39
Within Village
30
Outside Village
20
10
0
Before 1993
1993-99
2000-4
Period of Entering Sex Work
2005-8
Proportion of FSWs reporting that condoms were
available during the first year of sex work
80
70.3
70
58.5
Percent
60
50
43.7
1993-99
40
2000-4
30
2005-8
23.2
20
10
Before 1993
16.2
18.8
17.6
6.7
0
At Origin
At Destination
Proportion of FSWs reporting that found it easy to use
condoms with clients within the first year
80
73.4
70
62.8
Percent
60
50
43.5
Before 1993
1993-99
40
2000-4
29.7
30
2005-8
20.5
20
11.4
10
8.9
1.3
0
At Origin
At Destination
Proportion of FSWs Reporting NEVER Using a
Condom During the First Year of Sex Work
100
90
92.6
81.6
78
80
Percent
70
68.4
63.4
60
Before 1993
46.8
50
1993-99
2000-4
40
2005-8
26.4
30
20
15.6
10
0
At Origin
At Destination
Program Implications
• Although well-established, the program is “too
late”:
– Much of the HIV incidence occurs in the first year or
two, prior to program involvement
• Programs are less effective at increasing condom
use early in sex work at the origin
– At origin, early sex work is “home-based” and often
hidden
– At destination, early sex work is usually in brothels,
with better established condom programming
What about clients?
• Programs are usually generic and
indiscriminant in focus and vague in coverage
• Relative importance of client programs varies:
– General power dynamics between FSWs and
clients
• Relative importance of clients, regular clients
and other partners is seldom known
HIV prevalence (%) among FSW clients
in 6 districts of Karnataka
16
14
13.4
HIV prevalence (%)
12
10
8
6.2
6
6.0
5.4
4
2.6
2.4
2
0
Bagalkot
Belgaum
Bellary
Bangalore
Mysore
Shimoga
Mysore 1 11
Bangalore
Urban
13
Shimoga
Bellary
30
21
17
31
19
16
42
21
13 8
50%
1
2-3
4-5
6-9
7
11 5
42
0%
71
16 5
18
23
Total
39
56
29
Belgaum
11 10
31
19
Bagalkot
37
45
22
5
20
100%
10+
Number of FSWs
visited by clients
in the past 6
months
Bagalkot – clients and lovers
• Many of the sexual partners of FSWs in
Bagalkot are “regular”
• In addition, many of the FSWs have one or
more “lovers”, many of whom also have
multiple FSW partners
• Possibly dense concurrent networks
contributing to high HIV prevalence among
clients and FSWs in Bagalkot
Additional considerations for
transmission dynamics
• Client-FSW partnering patterns:
– Client “share” distribution (i.e. client clustering)
– Overlapping of client-FSW networks
• Higher in brothel and street settings?
• Low in home-based and similar settings?
Sex Work System Properties:
Client-Sex Worker Mixing Patterns
Ghani and Aral.
J Infect Dis 2005.
Network
Isolation
Network
Clustering
Even Client
Distribution
Client
Clustering
Implications for Transmission Dynamics
Network
Isolation
Network
Clustering
Even Client
Distribution
Client
Clustering
Lorenz Curve of the Distribution of Clients Among
Female Sex Workers (FSWs) in 8 Cities of Pakistan
Cumulative Proportion of Clients
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0
0.1
0.2
0.3 0.4 0.5 0.6 0.7 0.8
Cumulative Proportion of FSWs
0.9
1
Results: Distribution of Client Volume Among FSWs
in 8 Cities of Pakistan
Gini
Coefficient
Percentage of Clients
Among Top 20% of FSWs
Faisalabad
0.22
32%
Multan
0.22
32%
Peshawar
0.25
35%
Sukkur
0.32
37%
Quetta
0.35
39%
Karachi
0.45
49%
Lahore
0.47
53%
Hyderabad
0.50
56%
City
Questions to ponder…
• Why doesn’t Sri Lanka have an HIV epidemic
among FSWs?
– Relatively high per capita FSW population
– No circumcision
– Programs rudimentary
• What is the likely trajectory of FSW epidemics in
different parts of China?
• What is the relative contribution of FSW
networks to HIV epidemics in Africa?
– East and Sub-Saharan? South? West?
Program Science and Sex Work – What
Might be Needed?
• Coherent description of what knowledge is
needed for programs:
– According to the phase of the program planning and
implementation cycle
– Identifying “fixed” (i.e. generalizable) and “variable”
knowledge components
• A conceptual framework to guide research
questions that can be applied
• Consistency of program-embedded research
across contexts to address key conceptual and
knowledge gaps
Macro-Level Societal Context
• Socio-cultural milieu
• Demography
• Economy
• Geography
• Political / legal
FSW characteristics
• population size
• socio-demographics
• economic status
Interactive influences
Sex Work Organization
• Locations / venues
• Locus of control
• FSW-Client interfaces
FSWs
Clients
Aggregate properties
Structural patterns
• Client volume
• Condom use
• Duration in SW
• FSW-Client partnering
• Network structures
• Cohort effects
Transmission dynamics
and epidemic trajectory
Client characteristics
• population size
• socio-demographics
• economic status
Thank you