1. Evaluation of Community Mobilization and Empowerment in Relation to HIV Prevention Programming among Female Sex Workers in Karnataka State, South India World Bank Human Development Network Meeting, Washington, D.C., October 5-6, 2011 H.L. Mohan, A. Blanchard, M. Shahmanesh, R. Prakash, S. Isac, B.M. Ramesh, P. Bhattacharjee, S. Moses, JF Blanchard University of Manitoba and Karnataka Health Promotion Trust H.L. Mohan, A. Blanchard, M. Shahmanesh, R. Prakash, S. Isac, B.M. Ramesh, P. Bhattacharjee, S. Moses, JF Blanchard University of Manitoba and Karnataka Health Promotion Trust

2. Why Evaluate Community Mobilization in Female Sex Workers? Empowerment as a means to improve health FSWs specific vulnerability –Power imbalances that disadvantage FSWs Individual: Low self esteem (internalised stigma) Community: Violence and coercion (stigma & discrimination) Societal: limited social, economic and political capital (poverty, low literacy, and no legal status) –Social exclusion Gender, class/caste, sex work taboo and ambiguity of legal status –Lead to HIV vulnerability

3. Aim and Objectives Aim: Document and evaluate the role of community mobilization and empowerment programs for HIV prevention among FSWs Objectives: –Develop an integrated empowerment framework to describe the models of community-based activities among FSWs –Explore the impact of the community response on access to programs and services, and to STI/HIV outcomes. –Explore the impact of the community response on social transformation. –Explore the pathways between community-based mobilization, empowerment, and health outcomes.

4. Context The University of Manitoba (UM) and the Karnataka Health Promotion Trust (KHPT) have been implementing HIV prevention programs for FSWs in 20 districts of Karnataka state since 2003. Population of the 20 districts 40 million Population of FSW > 60,000 Components of the program –Community mobilization –Peer outreach and education –Condom programming and STI service delivery –Advocacy and building an enabling environment

5. District Coverage of Targeted Intervention Programs in Karnataka 20 Districts: 60,000+ FSWs, 21,000+ MSM UM/KHPTUM/CBO KSAPS/ KHPTKSAPS

6. Power Within Power with Others Power over Resources Socio- demographic variables Sex work organization Program and structural interventions Empowerment Dimensions Power imbalances Social exclusion Vulnerability Disempowering social context Power to Address Conceptual Framework

7. Conceptual Framework Community mobilization is used to address power imbalances, social exclusion and HIV vulnerability Three domains of empowerment of FSWs: –“Power within” – self-esteem, self-confidence and self- efficacy –“Power with” – collective power, defined as collective identity that leads to collective agency –“Power over resources” – access to financial and other social entitlements

8. Main Data Sources Behavioural Tracking Survey (BTS) –Random sample of FSWs in five districts in 2010 (350 FSWs per district) –Used to identify associations with “power with”, “power within” and “power over resources” (Principal Components and Factor Analyses) –Used to identify associations with individual behavioural outcomes Integrated Behavioural and Biological Assessments –Conducted among a random sample of FSWs in 5 different districts; two rounds, 2006-2010, 400 FSWs per district per round –Used to identify associations with individual biological outcomes

9. Top Line Findings from the Multivariate Analysis of “Power” from BTS Lower power generally associated with –Younger age (18-21) –District with poor community-based organisation –Shorter duration of exposure to program –Fewer contacts with program Power within –Greater self efficacy for condom use with regular partners and service utilisation Power with –Greater self efficacy for condom use with clients –Greater autonomy and service utilisation in 3 districts –Reduced violence

10. Levels of Empowerment, By District

11. Levels of “Power Within" and “Power With”, by Time Since First Used Program Services in Belgaum, Gulbarga and Gadag Districts

12. Unadjusted Differences in Outcomes by CBO Membership (BTS)

13. Unadjusted Differences in STI Outcomes by CBO Membership (IBBA)

14. Conclusions 1.The integrated empowerment framework is a useful tool to describe how KHPT’s multifaceted community mobilization models address issues of FSW empowerment (power with, power within and power over) and the disempowering social context. 2.At district level “Power” is associated with strength/intensity of community mobilisation 3.At individual level “Power” is associated with Programme exposure 4.FSWs with greater level of “Power”, show greater self efficacy “power to” use condoms, services and autonomy 5.Membership of CBO (Collective Power) is associated with an enabling environment and reduced sexual risk

15. Acknowledgements Bill & Melinda Gates Foundation University of Manitoba and KHPT Community Mobilization Teams Partner NGOs and CBOs