1. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up Deanna Kerrigan, Caitlin E. Kennedy, Ruth Morgan-Thomas, Sushena Reza-Paul, Peninah Mwangi, Kay Thi Win, Allison McFall, Virginia A. Fonner, Jennifer Butler

2. Background Sex workers’ risk for HIV infection occurs within a context characterized by powerful structural constraints Sex workers are exposed to multiple forms of stigma, discrimination & violence e.g. occupation, HIV, gender Without addressing these factors, the HIV response among sex workers is likely to be limited in its effectiveness

3. Definition Community empowerment- based response to HIV: a process by which sex workers take collective ownership of programs to achieve the most effective HIV outcomes and address social and structural barriers to health & human rights It has been a UNAIDS Best Practice for more than a decade

4. Rationale Evaluations of community empowerment efforts have shown it to be a promising approach to reduce HIV among sex workers Mathematical modeling suggests comprehensive community empowerment efforts among sex workers can significantly reduce HIV incidence among sex workers and the general adult population Despite this encouraging evidence, investment has been limited ≠

5. Methods Comprehensive review of the peer-reviewed and practice- based literature on the implementation, effectiveness, measurement, and barriers and facilitators of a community empowerment responses to HIV among sex workers globally Nested systematic review and meta-analysis (n=30,325 from 22 studies) of the effectiveness of community empowerment on HIV-related outcomes in low- and middle-income countries Four case studies highlighting the structural challenges faced by sex workers across settings and their collective responses to reduce their HIV risk and promote health and human rights

6. Approach Community empowerment is an approach, set within a broader health and human rights framework, which shapes and creates synergy across intervention components (biomedical, behavioural, structural) Cannot be reduced to a specific activity (e.g., a drop-in-center or other “mobilization” activities)

7. Implementation Community empowerment often starts with the promotion of internal social cohesion and ensuring a safe space to gather Mobilization of collective power and action to address the social and structural context of HIV risk Sex worker participation in processes to influence access to material resources

8. Effectiveness Community empowerment among sex workers was significantly associated with improvements in all outcomes in meta-analysis OutcomeCombined odds ratio from meta-analysis 95% confidence interval HIV0.680.52, 0.89 Gonorrhea0.610.46, 0.82 Chlamydia0.740.57, 0.98 High-titre syphilis0.530.41, 0.69 Consistent condom use with: All clients3.272.32, 4.62 New clients3.031.89, 4.86 Regular clients2.902.22, 3.78

9. Measurement Traditional HIV prevention indicators are still being used: Access to clinic, peer educator, educational materials, condoms Only a few specific community empowerment measures exist: Processes of social cohesion & mobilization Changes at the community and structural levels Innovation in measurement needed to document pathways

10. Barriers & Facilitators

11. Case Study: Ashodaya Samithi

12. Conclusions Community empowerment holds significant promise as an effective approach to reduce HIV risk among sex workers  Evidence is consistent and compelling  Integration with combination prevention Findings highlight important challenges associated with expanding community empowerment efforts  Changing the global discourse  Recognition of sex work as work Greater support is needed to enable sex worker groups to more effectively and sustainably overcome barriers identified  Funding for sex worker-led groups  Support for practice-based evidence

13. Acknowledgments Thanks to the following people for their contributions: The sex workers who led and participated in the research and programmatic efforts which are the basis of this analysis The experts and members of the NSWP listserv who responded to our requests for relevant articles and reports Laura Murray for her help developing the Brazil case study Gina Dallabetta for her assistance clarifying information about data from the Avahan project Andrea Blanchard, Kim Blankenship, and Mandar Mainkar for providing additional information about their articles included in the review The editorial and technical team of the Lancet Series, particularly Zena Nyakoojo and Pam Das