We found strong evidence of a reduction in the proportion of FSWs who reported violence at follow-up compared with baseline, following the implementation of a multi-layered violence intervention as part of a wider HIV prevention program. In addition, we found that FSWs who reported experiencing violence in the past year were less likely to report using condoms with their clients, were more likely to be infected with gonorrhea, and were less likely to have accessed the HIV prevention services than FSWs who did not report violence.
There is growing recognition of the impact of physical and sexual violence on the mental and physical health of women, including HIV infection [3
], and studies with non-sex workers have reported reductions in violence within intimate partnerships as part of broader HIV intervention programs [34
]. However, although several studies have reported violence against marginalised groups such as sex workers [10
], to our knowledge, this is the first study to report on a multi-layered strategy to address violence against sex workers, as part of HIV prevention programming. Consistent with studies from elsewhere, data from our IBBA surveys suggest that FSWs who reported being beaten or raped in the past year were more likely to be infected with gonorrhea than FSWs who did not [22
]. The possible mechanisms through which violence can enhance vulnerability to STIs are multiple and complex, and are likely to be both direct (for example, having unprotected forced intercourse with more risky partners, or being in unsafe situations for negotiating condom use) [10
]; and indirect (for example depression resulting from victimisation may reduce motivation to access HIV intervention services or negotiate condom use) [2
]. Indeed, similar to findings from elsewhere, FSWs in our study who reported violence in the previous year were less likely to have been contacted by a peer educator or to have accessed the project sexual health clinics, and were much less likely to report using condoms with their clients [10
]. In addition to increased knowledge and awareness of sexual risk leading to increase condom use following participation in an HIV prevention program, the conversion of a hostile environment to a more facilitative enabling environment for sex work has been reported elsewhere as a contributing factor to improved condom use [39
]. Furthermore, reducing violence can translate into sex workers accessing services more easily, as well as carrying condoms without fear of their being used as evidence of sex work. In addition, working in an environment less threatened by violence supports FSWs to make choices based on their own volition [20
As this study was evaluating a violence intervention program which has been implemented throughout Karnataka state, it was not possible for us to include a control group for comparison. With unlinked cross-sectional survey data such as these, and without a control group, it is always possible that the findings presented here represent natural trends over time and are independent of the violence intervention efforts. However, the strength and consistency of the associations across virtually all districts surveyed suggests that this is unlikely. Moreover, when we stratified participants in the IBBA surveys according to length of exposure to the HIV intervention program, violence in the preceding year was negatively associated with increasing duration of program exposure. Another limitation of the study is that it was not possible to separate out the impact on violence of individual aspects of the program, such as the policy level advocacy vs. the crisis response program vs. the police officer training vs. increasing access to social entitlements. Future qualitative and policy-oriented research would be important to undertake in the future to address this issue. Another important issue to address is program cost. It has recently been reported that the median cost per female sex worker registered in the first two years of Avahan programs in four south India states (including Karnataka) was $53, which is comparable to that of similar programs elsewhere [40
]. Future work should examine the proportion of costs attributable to the components of the program directed at violence reduction.
Rates of reported violence were very high, and were much higher in the PBS compared with the IBBA, likely reflecting social desirability bias in the face-to-face interviews, and highlighting the importance of using alternative survey methods when collecting information on sensitive behaviours [6
]. The elevated rates of reported violence in the 2007 PBS survey compared with the 2006 PBS survey may have reflected increased violence during this time period, as perpetrators tried to re-assert their power [20
]. Alternatively, it may be that women became more comfortable with reporting violence, and more understanding of the nature of violence, and so were more likely to report it. In any case, reported violence in 2008 in the PBS was significantly lower than either of the preceding years across 12 of the 13 districts surveyed. Discussions with FSWs suggest that violence may have been under-reported [2
], particularly in the baseline surveys, not least because at this time many sex workers did not consider sexual or physical violence by their intimate partners as being untoward events. Furthermore, the definition of violence used in this study was quite narrow, and thus may not have captured all violence, leading to further under-reporting. Baseline surveys were conducted 8-16 months after program initiation, by which time levels of violence may have already started to reduce, and thus the reductions in violence may have been underestimated; unfortunately, it is difficult to undertake cross-sectional surveys such as these among sex worker communities until prevention programs are underway and trust with the community is well established.
Embedding a violence intervention program such as this one within a broader HIV prevention framework has several challenges. Dealing with violence directly may conflict with power structures which are responsible for violence, and can perhaps, in the short term, put FSWs at increased risk of harm. The relationships among violence, FSWs and the perpetrators of violence are complex, with perpetrators (such as police, lovers and pimps) having the potential to act as protectors, as well as purveyors of violence [17
]. The routine transfer of police personnel and the highly mobile nature of FSW populations suggest that in order for reductions in violence to be sustained, training of police personnel and legal empowerment training need to be ongoing.