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Risk reduction and perceived collective efficacy and community support among female sex workers in Tamil Nadu and Maharashtra, India: the importance of context
  1. Mohua Guha1,
  2. Angela Baschieri2,
  3. Shalini Bharat1,
  4. Tarun Bhatnagar3,
  5. Suvarna Sanjay Sane4,
  6. Sheela V Godbole4,
  7. Saravanamurthy P S5,
  8. Mandar Keshav Mainkar4,
  9. Joseph Williams5,
  10. Martine Collumbien2
  1. 1Centre for Health & Social Sciences, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India
  2. 2Department for Population Studies, London School of Hygiene and Tropical Medicine, London, UK
  3. 3National Institute of Epidemiology (ICMR), Chennai, India
  4. 4National AIDS Research Institute (ICMR), Pune, India
  5. 5Chartered Voluntary Health Services, Chennai, India
  1. Correspondence to Martine Collumbien, Department for Population Studies, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK; martine.collumbien{at}


Background Empowering sex workers to mobilise and influence the structural context that obstructs risk reduction efforts is now seen an essential component of successful HIV prevention programmes. However, success depends on local programme environments and history.

Methods The authors analysed data from the Integrated Behavioural and Biological Assessment Round I cross-sectional survey among female sex workers in Tamil Nadu and Maharashtra. The authors used propensity score matching to estimate the impact of participation in intervention activities on reduction of risk (consistent condom use) and vulnerability (perceived collective efficacy and community support).

Results Background levels of risk and vulnerability as well as intervention impact varied widely across the different settings. The effect size ATT of attending meetings/trainings on consistent condom use was as high as 21% in Tamil Nadu (outside of Chennai) where overall use was lowest at 51%. Overall, levels of perceived collective efficacy were low at the time of the survey; perceived community support was high in Tamil Nadu and especially in Chennai (93%) contrasting with 33% in Mumbai. Consistent with previous research, the context of Mumbai seems least conducive to vulnerability reduction, yet self-help groups had a significant impact on consistent condom use (ATT=10%) and were significantly associated with higher collective efficacy (ATT=31%).

Conclusions Significant risk reduction can be achieved by large-scale female sex worker interventions, but the impact depends on the history of programming, the complexity of the context in which sex work happens and pre-existing levels of support sex workers perceive from their peers.

  • HIV
  • developing country
  • sexual health
  • social science
  • public health
  • communicable diseases
  • epidemiology
  • health behaviour
  • statistics
  • biostatistics
  • meta-analysis
  • AIDS
  • alcohol
  • access to health care
  • cancer: cervix
  • communicable diseases
  • health impact assessment
  • sexually transmitted disease
  • family planning
  • reproductive health

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  • Funding Bill and Melinda Gates Foundation grant no. OPP1006842. Providing salary money for evaluation.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by the National AIDS Research Institute (ICMR) and the National Institute of Epidemiology (ICMR).

  • Provenance and peer review Commissioned; externally peer reviewed.

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