FORD study- revised research design (draft copy)
COMMUNITY LED INTERVENTIONS FOR HIV PREVENTION AMONG FEMALE SEX WORKERS OF
RAJAHMUNDRY, ANDHRA PRADESH
Executive Summary:
In India, women accounted for 2 million of 5.2 million estimated cases of people living with
HIV/AIDS – constituting 39 % of all HIV infections. The trajectory of HIV/ AIDS clearly
demonstrates that gender inequality fuels the epidemic 3.. Recent estimates indicate that HIV
prevalence among sex workers in the country ranges from 10 percent to 70 percent 5. Sex
workers are vulnerable to HIV not only because of their occupation but because of the violence,
discrimination and disempowerment that marks their lives. In India, very few HIV prevention
programs on sex workers focus on empowerment model and there is not much research on the
impact of these interventions on the HIV risk behaviours of these communities. A strong need to
research and document the implications of empowerment among sex workers and its impact on
HIV risk in their lives
Goal and objectives:
The goal of the study is to assess and validate the effectiveness of Community led strategies in
reducing the risk behaviour of female sex workers to HIV and the specific objectives are:




Identify and understand the vulnerabilities of female sex workers and how these vulnerabilities
increase their risk to HIV
To identify the program interventions aimed at addressing the vulnerabilities of sex workers to HIV
To measure the degree of empowerment among the sex workers
To study the correlation between empowerment and HIV risk behavior among sex workers
Methodology:
Using a cross-sectional study design, about 240 active female sex workers, aged 18 years and above will
be quantitatively interviewed from the CARE SAKSHAM mandals in Rajahmundry, East Godavari District
of Andhra Pradesh. In addition, 10 Focus group discussions and 20 In-depth Interviews with sex workers
and 10 Key Informant Interviews with major stakeholders will be conducted, using qualitative techniques.
Ethical consent from the sex workers will be taken using a two stage consent process
Expected outcomes:
The research helps to understand the linkages between the vulnerabilities of sex workers, their impact on
the empowerment and HIV risk which could otherwise not be trapped by any impact inquiry research. It is
also expected to yield case studies on the success of the empowerment models on reducing the risk
behaviours related to HIV among the sex worker community.
Problem Statement
An estimated 38.6 million [33.4 million–46.0 million] people worldwide were living with HIV in 2005. An
estimated 4.1 million [3.4 million–6.2 million] became newly infected with HIV and an estimated 2.8 million
[2.4 million–3.3 million] lost their lives to AIDS. Latest estimates show some 8.3 million. [5.7 million–12.5
million] people (2.4 million among adult women [1.5 million–3.8 million]) were living with HIV in Asia at the
end of 2005 in which, more than two-thirds of them are from India1. National adult HIV prevalence in India
is approximately 0.36%, which corresponds to an estimated 2 million to 3.1 million people living with HIV
in the country2. Most HIV infections (more than 80% of reported AIDS cases are due to unprotected
heterosexual intercourse, and a significant proportion of them are in women (NACO, 2005). In India,
women accounted for 2 million of 5.2 million estimated cases of people living with HIV/AIDS – constituting
39 % of all HIV infections. The trajectory of HIV/ AIDS clearly demonstrates that gender inequality fuels
the epidemic3
HIV risk can be defined as the probability of an individual becoming infected by
HIV either through his or her own actions, knowingly or not, or via another person’s actions
Vulnerability to HIV reflects an individual’s or community’s inability to control their risk of HIV
infection 4. While data does suggest that HIV prevalence levels are declining among sex workers
in the southern states, overall prevalence levels among this group continue to be high.. The
unfortunate fact is that vulnerability among women is mounting all over the world. Sex workers
are most vulnerable and at-risk of contracting HIV infection because of high rates of partner
change, low condom use and increased susceptibility to sexually transmitted infections (STIs).
Recent estimates indicate that HIV prevalence among sex workers in the country ranges from 10
percent to 70 percent 5. Sex workers are vulnerable to HIV not only because of their occupation
but because of the violence, discrimination and disempowerment that marks their lives. Structural
forces, in the form of gender inequality, rights violation, discrimination and stigma coupled with
low levels of education, poverty and lack of communal support make sex workers particularly
vulnerable to HIV. These factors prevent women from taking the necessary steps to safeguard
their health and therefore act as barriers to the effective and sustainable prevention of HIV.
Researchers, leaders, activists, and NGO actors worldwide have all come to support the notion
that the feminization of the AIDS crisis is being fueled by the unequal power dynamics in
women’s lives. Hence women empowerment through development initiatives should be ensured
to keep HIV/AIDS in bay. In India, very few HIV prevention interventions on sex workers are built
on empowerment model and there is hardly any evidence on how these empowerment models
have resulted in prevention of HIV risk behavior among the sex worker community. In the light of
these facts, there appears a strong need to research and document the implications of
empowerment among sex workers and study its impact on HIV risk in their lives
Study Rationale:
There is not much data on the linkage between empowerment and HIV risk behaviour. While technical
HIV prevention efforts focus on condom distribution, HIV education, awareness generation and provision
of clinical services, these steps alone are increasingly recognized as sufficient 6. Very few programs have
empowerment as key intervention. Therefore it is difficult to conduct research on the empowerment efforts
and its contribution to reduction in the risk towards HIV. In India, CARE India is successfully conducting
SAKSHAM program which is based on the community based empowerment approach. It works to
address these structural forces and decreases the sex workers’ vulnerability to HIV through strategies of
personal and collective it therefore gives a good opportunity to research on the role of such
empowerment interventions on understanding the impact on sex workers’ vulnerabilities and their HIV
risk.
The Saksham Project
CARE India is implementing a capacity building initiative through its program on HIV and AIDS,
‘Strengthening Awareness, Knowledge and Skill for HIV/AIDS Management’ (SAKSHAM), funded by the
Bill and Melinda Gates Foundation’s India AIDS Initiative – AVAHAN. The goal of the program is
prevention of HIV/AIDS through an empowered community of female sex workers.
The basic understanding of the project is that Sex workers are vulnerable to HIV for a variety of reasons.
This is because of the violence, discrimination, and disempowerment that mark their lives. This is further
accentuated by the fact that the occupation itself is stigmatized and the structure of the sex trade in
general is discriminatory. It was recognized that unless there is a broader strategy to deal with the above,
it might not be possible to prevent the spread of HIV. CARE India utilizes a community-based
empowerment approach (CLSI) to reduce risk behavior to HIV among sex workers. The program brings
sex workers together to collectively (through Community Based Organizations) address the challenges
they face, demand the rights they deserve, and address the structural forces of gender inequity, stigma,
and rights violations that have a bearing on risk behavior to HIV.
Goal
To assess and validate the effectiveness of Community led strategies in reducing the risk
behaviour of female sex workers to HIV
Research hypothesis
The research is built on the hypothesis
 that increased empowerment among female sex workers reduces their vulnerabilities
 that increased empowerment through community led strategies among female sex workers enable
them to protect themselves from the risks of HIV
Objectives
1. Identify and understand the vulnerabilities of female sex workers and how these
vulnerabilities increase their risk to HIV
Sub-Objectives
 To identify the vulnerabilities of female sex workers to HIV
 To identify the factors that shape the vulnerabilities among sex workers
 To understand the vulnerabilities and coping mechanisms of HIV positive sex workers
 To explore the impact of the vulnerabilities on HIV/AIDS risks among sex workers
2. To identify the program interventions aimed at addressing the vulnerabilities of sex workers
to HIV
3. To measure the degree of empowerment among the sex workers
Sub-objectives

To identify the indicators of empowerment

To understand the status of empowerment

To understand the sex workers’ attribution for their current level of empowerment.
4. To study the correlation between empowerment and HIV risk behavior among sex workers


To correlate the status of empowerment and level of vulnerabilities
To correlate the status of empowerment with reduced HIV risk behaviour .
Research Design
Using a cross-sectional study design, sex workers from Rajahmundry, the heart of the East Godavari
district of Andhra Pradesh will be covered. The study will employ both qualitative and quantitative data
collection methods
Study site: The study will be conducted in Rajahmundry of East Godavari District where SAKSHAM
program of CARE is being implemented among female sex workers. The program is operational in 10
mandals of East Godavari district.
The universe:
The universe for the study comprises of active female sex workers aged 18 and above. Operating in 10
mandals of East Godavari
Methodology
Sample selection:
The active sex workers for the study will be selected from the existing total of 800 sex workers. Using a
stratified random sampling technique, sex workers will be divided into 4 categories based on their
association with the CBO. There are a total no of 475 sex workers who are involved in the Community
based organizations (CBOs) and 325 sex workers who are non members. The sex workers will be first
randomized depending on their association with the Community based organizations. Again they will be
further stratified under each category based on the type of sex work as brothel based, home- based and
street/highway based. A total no 240 sex workers will be selected from various categories, and the
sample number will be 60 in each category, The detailed sampling classification is given below:
Types
Membership of sex workers in CBOs
–
< 6 months
6 months
years
Brothel based
20
20
20
20
Street based/ Highway
based
20
20
20
20
Home based
20
20
20
20
Total
60
60
60
60
Grand Total
1.5
Non CBO SW
> 1.5 years
240
Rationale for the sampling design
As the CBO formation is the key strategy for empowerment, stratifying the sample based on CBO
membership was considered.
Data Collection:
The study will employ both qualitative and quantitative data collection methods simultaneously to
understand the impact of the empowerment on reducing the risks of HIV
1. Interviews with sex workers: Using a structured questionnaire, about 240 sex workers aged 18
years and above and belonging to different categories will be selected and interviewed. Their
selection will be based on their involvement in the CBO as described in the sampling. The aim is to
identify and understand their vulnerabilities, factors shaping these vulnerabilities, their impact on HIV,
whether programs have been able to address their vulnerabilities, their level of empowerment, impact
of empowerment on their HIV risk behavior. The detailed questionnaire is given in Annexure. A
stratified random sampling will be carried out based on their involvement in CBOs
2. Focus Group Discussions with sex workers: 10 focus group discussions will be held with different
categories of sex workers, depending on their involvement in CBOs. Each group would consist of 10 15 community members. The groups for FGD will be homogeneous and would be based on the
typology. The aim is to understand their perceptions about empowerment, and how SAKSHAM’s
empowerment framework helped them empower and study the dimensions of empowerment.
Guidelines for the Focus Group are given in Annexure
3. In-depth Interviews with empowered sex workers: About 20 sex workers, who have been rated for
their empowerment, using the self esteem tool will be selected and interviewed using qualitative
interview guidelines. The aim of this exercise is to establish case studies on the impact of
empowerment on their lives and also reduction in HIV risk behavior. Guidelines for In-depth
Interviews are given in annexure
4. Key Informant Interviews with stakeholders: About 10 Qualitative interviews will be conducted
with major stakeholders., like police, representative from legal cell, women activists, district health
officials etc. The main aim is to understand how the attitudes of these stakeholders towards sex
workers have been changed over a period of time and how they have contributed to the structural
changes in the lives of sex workers, to enable them access more social support , enhance their
negotiation with the general community. Also this will strengthen and support the research data
obtained from the sex workers community as to how empowerment has contributed to their increased
quality of life. The detailed guidelines for the KII are given in Annexure
Ethical Procedures:
Initial Ethical approval for conducting the study on sex workers will be sought from the standing ethical
committee.(Program Management Committee). 1. The study design and the ethical guidelines which will
be followed during the study will be discussed with the PMC and written consent for conducting the study
will be obtained. Following this, an ethical approval will also be sought from the Institutional Review Board
of CARE Atlanta.
Written informed consent will be obtained from study participants. Interviews will be conducted at a site
identified by the respondent as convenient for them and that ensure privacy and confidentiality. The study
will ensure the respondents privacy and confidentiality through a coding process. The consent forms is
given in annexure
Research Interviewers:
The research team will comprise of 2 social science post graduates who will be used for qualitative data
collection and 3 field researchers from the community will be engaged in data collection .
Risks and Benefits
Participants will be explained about the risks and benefits of participating in the study. The risks to
participants in this study would include sharing of their identity as sex worker . However, this information
will be kept confidential and not be shared with anyone outside the research team.
1
Program management Committee is a standing ethical committee constituted of Sex Workers and the project staff.
The participants will also be explained that while the study may not benefit them directly, but it may
benefit them and others in the future. Their opinions and experiences will be very helpful to develop policy
platforms that aim at reducing women’s vulnerability to HIV
Study time frame
The study will be completed in 6 months from October 2007 till April 2008 as indicated below:
Activities
Oct
Global research
meeting
design
Nov
Dec
Jan
Feb
Mar
X
Refine global research
framework
to
country
context,-preparation
of
research design
X
Identify numerators/field
researchers
X
X
Training for numerators,
/field researchers
X
Begin
collection
X
X
On-going research
X
X
X
Preliminary analysis of
research; documentation
of promising programs
and best practices
X
X
X
X
X
X
X
research-Data
Analysis of data
April
Draft country report
X
X
Dissemination of findings
at local level
X
X
References:
1. 2006 report on the Global AIDS Epidemic. UNAIDS. 2006. Ch.2: PP,8,23, 25
2. 2.5 million People in India living with HIV, according to new estimates.UNAIDS Press release. 6
July 2007.
3. http://www.unifem.org.in/PDF/HIV/nacobro.pdf"
4. HIV Infection in Women. NIAID Fact sheet. May 2006
5. M. Nag, Prostitution and AIDS in India: Anthropological Perspectives. Economic and Political
Weekly, 36 (42), 2001: 4025-30.
6. Helweg –Larsen,M.Social Psychological perspective on the role of knowledge about AIDS in
AIDS prevention. Current Directions in Psychological Science. Vol 6, (2).1997, pp 23-6