Kerrigan DL, Fonner VA, Stromdahl S, Kennedy CE. Community empowerment among female sex workers is an effective HIV prevention intervention: a systematic review of the peer-reviewed evidence from low- and middle-income countries. AIDS Behav. 2013 Jul;17(6):1926-40.
To systematically review the evidence for community empowerment interventions for preventing HIV infection in female sex workers (FSW) in low- and middle-income countries (LMIC).
Randomized controlled trials (RCTs) and observational studies in which there was a control group or comparator that did not receive the intervention (including pre-post studies). Studies had to have been published in a peer-reviewed journal between January 1, 1990 and the search date of October 15, 2010.
FSW in LMIC.
Intervention (Predictor Variable)
Community empowerment interventions, defined as structural interventions designed to address and improve social, political and material conditions for FSW. The authors used Wallerstein's definition(1) of community empowerment interventions to identify eligible articles: "a social- action process that promotes the participation of people, organizations, and communities towards the goals of increased individual and community control, political efficacy, improved quality of community life, and social justice."
HIV infection; other sexually transmitted infections (STIs); condom use.
A range of relevant keywords was used to search PubMed, CINAHL, EMBASE, PsycINFO and Sociological Abstracts. There were no restrictions on language. The date range of the searches was from January 1, 1990 to the search date of October 15, 2010. Reference lists of all included studies were reviewed, and the reviewers contacted experts working in the field. The reviewers also had access to a World Health Organization (WHO) database of articles on HIV and sex workers.
One reviewer screened all titles and abstracts and selected those eligible for full-text consideration. Two reviewers working independently examined the full-text articles and determined those that met the review's inclusion criteria. Data from included studies were abstracted by two reviewers working independently. The reviewers used the Cochrane Collaboration's tool for assessing risk of bias in the RCT,(2) and an eight-point "rigor scale" for assessing methodological quality in the observational studies.(3)
After removing duplicates, 4,318 references were identified. Seventy-two full-text articles were assessed for eligibility. Ten studies (including one RCT) were included in the review. Seven studies were from India, two were from Brazil and one was from the Dominican Republic.
Most interventions included such key components as promoting community cohesion and collective agency to solve shared health-related challenges, including protecting FSW and their partners from HIV infection. Many interventions also focused on the process of challenging social structures external to the FSW community, including engaging police, sex work establishment owners and managers, health care facilities and other key stakeholders. All studies included explicit community empowerment and social mobilization activities as well as community-led peer education, condom distribution and the promotion of periodic STI screening.
HIV infection. Three observational studies from India examined the outcome of incident HIV infection, though only two proved data relevant to an intervention. Data from the third study were excluded from analysis. Combining data from two studies with an average of 2.5 years follow-up, community empowerment interventions significantly protected FSW from incident HIV infection (odds ratio [OR] = 0.837, 95% confidence interval [CI] 0.71 to 0.99).
STI infection. Six observational studies measured STI infection. In a Brazilian study, combined chlamydia and gonorrhea prevalence was lower 12 months after the intervention (crude OR=0.51, 95% CI 0.26 to 0.99). Meta-analysis of data from four Indian studies found that community empowerment was significantly associated with lower gonorrhea prevalence (OR=0.66, 95% CI 0.47 to 0.90) and marginally with lower chlamydia prevalence (OR=0.77, 95% CI 0.54 to 1.11). Combined data from three studies showed a non-significant decrease in the prevalence of high-titer syphilis (OR=0.36, 95% CI 0.17 to 1.75).
Condom use. Nine studies measured condom use. The single RCT, conducted in India, presented results for a statistically significant improvement in condom use in terms of the beta [ß] coefficient (ß=0.345, 95% CI, p=0.002). An observational study in Brazil found marginally signficant improvement for consistent condom used in the preceding 30 days with new clients (OR=1.6, 95% CI 0.90 to 2.80) and with non-paying clients (OR=1.5, 95% CI 0.9 to 2.5). The improvement was significant with regular clients (OR=1.9, 95% CI 1.1 to 3.3). Because of differences in study design, data from the remaining observational studies were combined and analyzed separately from this Brazilian study. In three studies, conducted in India and in the Dominican Republic, community empowerment was associated with significantly higher odds of consistent condom use with new clients (OR=3.04, 95% CI 1.29 to 7.17). In two Indian studies, there was an improvement with regular paying clients (OR=2.2, 95% CI 1.41 to 3.42). In six studies (one in Brazil and five in India), there was a marked improvement in condom use with all clients (OR=5.87, 95% CI 2.88 to 11.94), though heterogeneity among the studies was very high (I2 = 96.18, p< 0.001). In three studies from India, consistent condom use with non-paying partners was not significantly improved (OR=2.52, 95% CI 0.80 to 7.97).
The reviewers conclude that community empowerment interventions were associated with significant improvements in many HIV outcomes. They note that no significant negative associations were documented among any of the outcomes assessed in the review.
The reviewers used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to assess evidence quality.(4) GRADE ranks the quality of evidence on four levels: "high," "moderate," "low" and "very low." Evidence from randomized controlled trials starts at "high," but can be downgraded based on study limitations, inconsistency of results, indirectness of evidence, imprecision or for reporting bias. Evidence from observational studies starts at "low," but can be upgraded if the magnitude of treatment effect is very large, if there is a significant dose-response relation, or if all possible confounders would decrease the magnitude of an apparent treatment effect. Evidence from observational studies can also be downgraded. The reviewers found low to very low quality evidence for all outcomes. The RCT provided only low quality evidence due to very serious limitations in its design.
This was a high quality systematic review. It addresses nearly all points of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist.(5)
The Sonagachi project in Kolkata, India is probably the best-known example of a community empowerment intervention for FSW. This review includes three Sonagachi papers.(6, 7, 8,) It is important to note that no studies were identified from sub-Saharan Africa, the region with the highest HIV burden, nor were any identified from Eastern Europe or Central Asia, regions where the epidemic is growing. Qualitative research among FSW in South Africa found that empowerment in and ownership of HIV prevention interventions was important to them.(9, 10)
Rigorous studies of community empowerment interventions for FSW are needed, particularly in settings with generalized or rapidly growing HIV epidemics.
- Wallerstein N. Powerlessness, empowerment, and health: implications for health promotion programs. Am J Health Promot. 1992; 6:197-205.
- Higgins JPT, Green S (eds). Cochrane Handbook for Systematic Reviews of Interventions. Chichester: Wiley-Blackwell, 2008
- No evaluation of this instrument has yet been published, but it has been used in at least 12 systematic reviews, beginning with this one: Kennedy C, O'Reilly K, Medley A, Sweat M. The impact of HIV treatment on risk behaviour in developing countries: a systematic review. AIDS Care. 2007;19(6):707-20
- Guyatt G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J, Norris S, Falck-Ytter Y,Glasziou P, DeBeer H, Jaeschke R, Rind D, Meerpohl J, Dahm P, Schünemann HJ. GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables. Journal of Clinical Epidemiology 2011 Apr;64(4):383-94.
- Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred Reporting Items for Systematic Reviews and Meta- Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi:10.1371/journal.pmed.1000097
- Jana S, Singh S. Beyond medical model of STD intervention lessons from Sonagachi. Indian J Public Health. 1995;39(3): 125-31. Epub 1995/07/01.
- Jana S, Bandyopadhyay N, Mukherjee S, Dutta N, Basu I, Saha A. STD/HIV intervention with sex workers in West Bengal, India. AIDS. 1998;12(Suppl B):S101-8
- Gangopadhyay DN, Chanda M, Sarkar K, Niyogi SK, Chakraborty S, Saha MK, et al. Evaluation of sexually transmitted diseases/human immunodeficiency virus intervention programs for sex workers in Calcutta, India. Sex Transm Dis. 2005;32(11):680-4.
- Campbell C, Mzaidume Z. Grassroots participation, peer education, and HIV prevention by sex workers in South Africa. Am J Public Health. 2001;91(12):1978-86.
- Cornish F, Campbell C. The social conditions for successful peer education: a comparison of two HIV prevention programs run by sex workers in India and South Africa. Am J Commun Psychol. 2009;44(1-2):123-35.