Background As evidence has revealed the role of broader political, economic and local environmental factors in shaping HIV epidemic transmission patterns, new approaches have emerged that move beyond addressing individual risk behaviour to addressing the structural forces that condition risk. Within this context, Community-Led Structural Interventions (CLSI) aimed at reducing sex workers' vulnerability have demonstrated successes in reducing STI and HIV transmission in India.
Methods A comprehensive CLSI, know as Ashodaya Samithi, was initiated in the South Indian district of Mysore. Established in 2004 by the India AIDS Initiative (Avahan), Ashodaya is funded through the Bill and Melinda Gates Foundation and implemented by Karnataka Health Promotion Trust. Four-years into its inception, the project lays claim to significant successes. The collective has reported a reduction in STIs, an increase in condom use, and the mobilisation of 1500 sex workers. Our research describes and analyzes sex workers' participation as it unfurled across various phases of collectivisation. Qualitative, community-based research methodologies were utilised including; 40 open-ended interviews, participant observations and focus groups. Drawing upon these findings we explored how a community of sex workers came to develop the ability to recognise, challenge and significantly alter an array of unequal power relations that shape HIV vulnerability in their everyday lives.
Results Our research demonstrates the promise CLSI projects hold for preventing the spread of HIV. Ashodaya's success depends on its ability to set new community norms, create a safer working environment, improve stakeholder relationships, and provide a supportive network. The interrelated processes of mobilisation, collectivisation, sex-worker identity, and political action, which transformed day-to-day vulnerability to HIV for Mysore sex workers demonstrates how complex HIV prevention remains.
Conclusions Findings from the Ashodaya collective offer valuable lessons for public health practice. The Ashodaya collective demonstrates how CLSI strategies can be employed to help transform the very vulnerabilities that endanger health and sustain STI and HIV transmission. The collective provides an example of the positive impact of CLSIs and provides evidence for strategies that steer away from individual or education based public health programs, to those that engage with structural inequities.
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