Where does policy end and practice start? Review of a paper on HIV programmes with sex workers.

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“Risk” groups for HIV prevention

A few years ago, colleagues in an NGO asked me to comment on their HIV prevention strategy.  The strategy had a list of priority population groups that the programme would aim to target – these groups were selected based on actual or perceived risk of HIV infection.  One of the groups on the list was “wives of unfaithful men”.

Targeting health programmes towards people who are most affected or most at risk makes sense.  Not only is it more economical, but it also more practical since different types of people have different circumstances and needs.  But an important aspect of targeting is to make sure that the categories being defined are “operational” from the perspective of the people providing the services.  Was the idea that programmes would specifically target women with unfaithful husbands?  How might an outreach worker identify the women in the marketplace whose husbands are unfaithful, so as to focus on them?  Were sexual health clinicians being asked to factor in the likelihood of spousal infidelity when deciding what tests or treatments to prescribe to a married woman who comes to see them with symptoms?  And if “wives of unfaithful men” really were a high-risk group, were programmes also identifying the men and reaching them with sexual health services and advice?

Redefining risk categories – a new study from Karnataka, India

I was reminded of this story when reading a recent research paper, “Devising a female sex work typology using data from Karnataka, India”*.  The authors set out to define a typology for female sex workers that more accurately predicts HIV risk than the typology currently used in India’s National AIDS Control Organisation guidelines.  A more robust typology, that can act as a “predictor” of risk for HIV, would help programmes to discriminate between sex workers at higher and lower risk and prioritise programmes reaching the former, according to the article.

The existing typology classifies female sex workers according to where they solicit sex – because this is seen as the most practical basis for delivering services or outreach.   But the authors of this new study argue that this typology masks differences in risk for HIV, specifically measured by the actual HIV prevalence in each category.  The new classification proposed by the authors is based on a combination of the place of solicitation of sex with the place where sex actually takes place.  Categories include “Brothel to brothel”, “home to home”, “street to home”, “street to rented room “street to lodge” “street to street” and “other” (in each case, the first term represents the place of solicitation and the second the place of sex). 

The authors successfully demonstrate that the newly proposed set of seven categories gives a more complex picture of how risk for HIV – measured by the current level of HIV prevalence – is distributed, when compared to the other typologies in use (which had 4 and 6 categories respectively).  The analysis shows that the category most affected by HIV is the “brothel to brothel” one (34.0%), the lowest is other (11.1%).  The authors also argue that further research might enable the development of even more sensitive categorisations can be developed based on.

How can the findings be used?

While it is true that the study shows clearly that there are bigger variations in HIV prevalence between different categories of sex worker under the new proposed typology, might the comparative statistics might be getting in the way of the bigger picture?  While the odds of HIV infection among the “street to lodge” category may well be nearly 3 times higher than it is for the “other” category, sex workers in the other category are still over 20 times more likely to be HIV positive than women in the general population.  Levels of other STIs in this group are also not negligible, as are levels of condom breakage.  Members of the “other” group were the most likely to have been raped in the past year.  Levels of unwanted pregnancy or of other health problems are not reported.

It isn’t clear that there is a strong justification for focussing on some of the new categories rather than old ones.  Are categories such as “street to home” operational when compared to “street to lodge”?  Can outreach workers or clinicians differentiate between the street-soliciting sex workers based on whether they go home or to a lodge to have sex, and should they?  And are the types of services required by members of each of these new categories demonstrably different from each other? 

On the one hand, while the commitment to understanding context and not providing a one-size-fits-all approach is commendable, it isn’t clear what to do with the findings.  Given how affected all sex workers in the study were by HIV, STIs, and violence, it hardly seems appropriate to focus only on those most at risk.  On the other hand, if the study findings demonstrate that some of the new categories are clearly “underserved” by existing programmes, the findings might help encourage programmers to ensure that this is redressed.  In India there is still a way to go in reaching sex workers with HIV and AIDS programmes: according to India’s most recent HIV report to the UN, coverage of sex workers by essential HIV programmes is only just over 50%.

When does policy stop and practice start?

Epidemiological studies on HIV risk aim to identify who the “most at risk” groups are.  They look at a number of different variables – including actual levels of HIV infection, other STIs, and behaviours that may contribute to risk.  But studies of this kind are inevitably generalisations because in any given population group, there will be subcategories, and eventually individuals, who are at higher or lower risk.  While there may be a temptation to stratify population groups further and further so as to increase the precision of risk categories, might there also be a point at which the increasing numbers of categories make it harder, not easier, to deliver programmes?  This might also be the point at which the analysis is no longer be the job of the researcher, policy maker or programme designer, but of the health care provider or outreach worker – because front line providers should be responding based on what individual clients tell them, not based on what the epidemiological categories are telling them to assume. 

 

* Buzdugan R, Copas A, et al “ (2010) Devising a female sex work typology using data from Karnataka, India”, International Journal of Epidemiology 39 (439-448)

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