Social cohesion, social participation, and HIV related risk among female sex

workers in Swaziland

Virginia FonnerJohns Hopkins Bloomberg School of Public Health

July 3, 2013

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Background• Sex workers are disproportionately affected by HIV• Research and interventions among sex workers are lacking in

Swaziland• Social capital can potentially reduce HIV vulnerabilities by:

– Facilitating internal group-related mutual aid and support– Providing access to social and material resources

• Social capital is related to community empowerment, an intervention strategy recommended by WHO and endorsed by sex workers

• The concept of social capital is notoriously difficult to define and operationalize

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Conceptual Framework

Social Cohesion (mutual aid, trust, and solidarity among

sex workers)

Social Participation(engagement in community activities

outside of sex work)

Access to social and material resourcesCommunity support Social acceptanceCollective action

Communication/negotiation skillsHIV knowledge/awareness

Self-efficacy

Behavior change

Impact on structural and environmental

context

SOCIAL CAPITAL

Reduced vulnerability to

HIV

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Study Objective• Assess relationships between social cohesion, social

participation, and HIV-related risk among female sex workers in Swaziland

• HIV-related risk assessed through:– Behavioral outcomes (ex: condom use)– Biological outcomes (ex: HIV serostatus)– Social discrimination and exposure to violence– Collective action

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Methods• Cross-sectional survey among women in Swaziland who

reported selling sex in the past year• 325 women recruited using respondent-driven sampling• Social cohesion: 9-item scale (α= 0.76) • Social participation: 4-item index accounting for levels of

participation in various social groups• Both social capital constructs were dichotomized for analysis• Logistic regression used to asses relationships of social

capital constructs and HIV-related risk

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Results

Outcome aOR*95% Confidence Interval

Consistent condom use in past week 2.10 1.26-3.51

Reported refusal of police protection 0.56 0.35-0.90

Participating in meetings to promote sex worker rights 2.02 1.23-3.32

Outcome aOR* 95% Confidence Interval

Received HIV test in previous year 2.27 1.31-3.92

Condom use with non-paying partners 1.72 1.03-2.88

Reported verbal or physical harassment 0.58 0.36-0.94

Social CohesionMedian score: 16 (range: 0-27)

Results(comparing high vs. low levels of cohesion)

Social ParticipationMedian score: 1 (range: 0-7)

Results(comparing high vs. low levels of participation)

* Adjusted for age, income, education, marital status, region, and RDS weights based on estimated population proportions of outcome variables.. Odds ratios compare participants with high vs. low social cohesion/participation.

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Conclusions High levels of social cohesion and social participation

are associated with protective behaviors related to HIV. More research is needed to understand the social context

of female sex workers in Swaziland, such as the extent to which sex workers are willing and able to collectivize and how sex workers are portrayed and treated by the larger community.

Building social capital could potentially improve access to resources, enhance social support, and change HIV-related behaviors among this population.

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The USAID | Project SEARCH, Task Order No.2, is funded by the U.S. Agency for International Development under Contract No. GHH-I-00-07-00032-00, beginning September 30, 2008, and supported by the President’s Emergency Plan for AIDS Relief. The Research to Prevention (R2P) Project is led by the Johns Hopkins Center for Global Health and managed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP).

Acknowledgements: Co-Authors: Deanna Kerrigan, Zandile Mnisi, Sosthenes

Ketende, Caitlin Kennedy, Stefan BaralPartners: Swaziland National AIDS Program, USAID, PSI

Swaziland, Rock of Hope, JHU/R2PAll study participants