Addressing vulnerabilities of female sex workers in an HIV prevention intervention in Mumbai and Thane: experiences from the Aastha project

Background: It is important for targeted interventions to consider vulnerabilities of female sex workers (FSWs) such as poverty, work-related mobility, and literacy, for effective human immunodeficiency virus (HIV) prevention. This paper describes and examines the association of the Aastha HIV/sexually transmitted infection (STI) prevention project in Mumbai and Thane, India, on the relationship between vulnerability and behavioral outcomes. Materials and methods: Data were drawn from the Behavioural Tracking Survey, a cross-sectional behavioral study conducted in 2010 with 2,431 FSWs recruited in Mumbai and Thane. The key independent measures used were program exposure and "vulnerability index", a composite index of literacy, factors of dependence (alternative livelihood options, current debt, and children), and aspects of sex work (mobility and duration in sex work). Dependent measures included service uptake, self-confidence, self-identity, and individual agency. Logistic regression analysis was used to examine the study objectives. Results: Of the analytical sample of 2,431 FSWs, 1,295 (53.3%) were categorized as highly vulnerable. Highly vulnerable FSWs who were associated with the Aastha program for more than a year were more likely to have accessed crisis-response services in the past 6 months (adjusted odds ratio [AOR] 2.2, 95% confidence interval [CI] 1.4-3.6; P < 0.001), to have visited a clinic to get a checkup for STI symptoms (AOR 2.4, 95% CI 1.2-4.8; P < 0.015), not to be ashamed to disclose identity as an FSW to health workers (AOR 2.1, 95% CI 1.2-3.5; P < 0.008), and to be confident in supporting a fellow FSW in crisis (AOR 1.7, 95% CI 1.0-2.8, P < 0.033) compared to those less vulnerable with similar exposure to the Aastha program. Conclusion: It is critical for HIV/STI interventions to consider vulnerabilities of FSWs at project inception and address them with focused strategies, including a segmented service-delivery model and community involvement, in order to strengthen the structural response to HIV prevention.