The Encontros project: a multi-level HIV prevention intervention among sex workers in Brazil

1. The Encontros project: a multi-level HIV prevention intervention among sex workers in Brazil Sheri A. Lippman1,2, Magda Chinaglia3, Angela Donini4, Deanna Kerrigan5, Art Reingold2, Juan Díaz3 1Center for Aids Prevention Studies, University of California, San Francisco; 2Division of Epidemiology, University of California, Berkeley; 3Population Council, Brazil & Reprolatina, Brazil; 4Brazilian Ministry of Health, STI/AIDS Program; 5The Johns Hopkins School of Public Health

2. Changing the Prevention Paradigm • HIV-related behaviors are negotiated within complex and multi-faceted contexts filled with social and economic inequalities • Successful, sustainable prevention requires multi-level strategies aimed at encouraging protective individual behaviors AND transforming the surrounding environment

3. Why modify the social environment? • A sex worker’s safe sex skills are undermined by experiencing gender inequality, stigma and discrimination, and social exclusion. • Encontros aimed to create an environment which enabled healthy behaviors by forging dialogue, trust, and a sense of community among sex workers and by facilitating sex worker participation in public life.

4. Primary Research Question Can a multi-level intervention combining enhanced individual level clinical services, peer-led participatory education and social mobilization activities aimed at modifying the social environment lead to increased condom use and reductions in STIs among sex workers?

5. Corumbá, Central-west Brazil Population: 100,000 + 75,000 tourists/year

6. Multi-Sectoral Partnerships • Non-Governmental Partners: Population Council/ Brazil with the Brazilian Network of Sex Workers and Pathfinder Brazil • Governmental Partners: Federal, State and local STI/AIDS Programs and local Secretary of Health • Academic Partners: University of California, Berkeley, UCSF Center for Aids Prevention Studies, and the Johns Hopkins Bloomberg School of Public Health

7. Intervention: Individual Level • Enhanced clinical services: • STI testing & treatment • VCT for HIV • Gynecological exams • Reproductive health services • Psychological services: • Counseling • Distribution of condoms and educational materials Study venue: Municipal HIV/STI referral center

8. Intervention: Community Level • Collective activities, events, workshops to encourage stigma reduction and participation in public life & engage community on issues of sex work, citizenship, health and human rights: - Peer outreach to mobilize participation - Materials de-stigmatizing sex workers • Support for formation of an association of sex workers • Forging of government/community partnerships

9. Design and Methods • Longitudinal study of 420 female, male and transvestite sex workers over the age of 18 working in Corumbá • 15 month follow up period (every 3 months) • Each data collection visit included administration of a structured questionnaire, STI/HIV prevention counseling, a clinical exam, collection of urine samples for STI testing, and treatment for STI if indicated • Testing for Chlamydia and Gonorrhea was performed on urine specimens using automated PCR technology

10. Exposure Measure • Participation or project exposure: • contact with peer educators and counselors • contact with project educational materials • participation in project-sponsored workshops, activities, and organizations • 20 questionnaire items collectively analyzed and pooled into scores using item response modeling/reliability=.86 • Scores dichotomized into none/low participation or high participation (project exposure) at each visit

11. Measures of Social Environment • Social Cohesion: Perceptions (Likert scale) of mutual aid, trust, support, solidarity and connectedness experienced among sex workers (Alpha=.81 for 13 item measure) • Social Networks: Participation (yes/no) in social and group activities such as church, clubs, neighborhood groups or cultural associations (Alpha=.61 for 7 item measure)

12. Outcome Measures • Incident STI infection (CT & GC) • Consistent condom use in last 30 days with: • New clients • Regular clients • Non-paying partners • Time-ordered exposure and outcome data: • Condom use and STI outcomes in each visit were linked to previous exposure to project activities

13. Data Analysis • Inverse probability weights utilized to account for censoring and non-randomization • Effect of the intervention on each outcome was estimated using generalized estimating equations with robust confidence intervals • Providing estimate of effect while accounting for the non-independence of repeated measures among individuals

14. Results Adjusted ORs (95%CI) for consistent condom use (CCU) in the last 30 days and incident CT/GC infection by participation level * Significant at p=.05; ** at p=.10

15. Results Adjusted beta coefficients (95% CI) for level of social cohesion and participation in social networks by project participation level * Significant at p=.05

16. Sustaining Positive Changes in the Social Environment • Establishment of Sex Worker Association : DASSC • Activities begun under the Encontros initiative have continued under the guidance of DASSC and the municipal health program • Key project services incorporated into municipal health service, including collaboration with peer-educators Dignity, Action, Health, Sexuality, and Citizenship (Dignidade, Ação, Saúde,Sexualidade e Cidadania )

17. Discussion • Few studies have examined the process and impact of interventions aimed at modifying the social environment to reduce HIV-related vulnerability • This study includes longitudinal data, behavioral and biomedical, and statistical tools to mimic a randomized trial • One of first projects to provide evidence that a multi-level intervention can improve perceptions of the social environment, increase consistent condom use and reduce STIs among sex workers

18. Attention to human rights: reduction of stigma and social exclusion among sex workers should be a cornerstone of evidence-based, HIV prevention. • Replication and expansion of findings in randomized controlled trial is warranted; as is research into the social pathways of changes in HIV-related outcomes. Conclusions Without Shame, Girl. You Have a Profession.

19. Acknowledgements • Encontros study advisory committee: Elaine Bortolanza, Roberto Chateaubriand, Magda Chinaglia, Silvia Conceição, Juan Diaz, Angela Donini, Maria Inês Franca, Gisele Brandão Freitas, Kelly Guerra, Mario Sergio Kassar, Carlos Laudari, Gabriela Leite, Sheri Lippman, Kelly Marcon, Laura Murray, Paula de Oliveira, Carmen Pereira, Liliana Pitaluga, Arthur Reingold, Vera Ramos, Telma Regina Santos, Lucia Viana • Institutional partners (Population Council, the Brazilian Ministry of Health, Pathfinder do Brasil, Rede Brasileira de Prostitutas, Mato Grosso do Sul STI/AIDS Program, Corumbá Secretary of Health) • Laboratory coordinator, Iracema Sampaio; Ministry of Health STD/AIDS program representatives: Ivo Brito and Lilian Amaral Inocencio. • Research was supported by Population Council-USAID, Pathfinder do Brasil, and the Brazilian STD/Aids Program, Ministry of Health. The first author received support from Fogarty AIDS International Training and Research Program, University of California, Berkeley.