How to reduce attrition among community healthcare workers essential to HIV prevention programmes among female sex-workers

Peer outreach work as economic activity: implications for HIV prevention interventions among female sex workers.

George A, Blankenship KM. PLoS One. 2015 Mar 16;10(3):e0119729. doi: 10.1371/journal.pone.0119729. eCollection 2015.

Female sex workers (FSWs) who work as peer outreach workers in HIV prevention programs are drawn from poor socio-economic groups and consider outreach work, among other things, as an economic activity. Yet, while successful HIV prevention outcomes by such programs are attributed in part to the work of peers who have dense relations with FSW communities, there is scant discussion of the economic implications for FSWs of their work as peers. Using observational data obtained from an HIV prevention intervention for FSWs in south India, we examined the economic benefits and costs to peers of doing outreach work and their implications for sex workers' economic security. We found that peers considered their payment incommensurate with their workload, experienced long delays receiving compensation, and at times had to advance money from their pockets to do their assigned peer outreach work. For the intervention these conditions resulted in peer attrition and difficulties in recruitment of new peer workers. We discuss the implications of these findings for uptake of services, and the possibility of reaching desired HIV outcomes. Inadequate and irregular compensation to peers and inadequate budgetary outlays to perform their community-based outreach work could weaken peers' relationships with FSW community members, undermine the effectiveness of peer-mediated HIV prevention programs and invalidate arguments for the use of peers.

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Editor’s notes: Many HIV prevention programmes among female sex worker populations recruit female sex workers to act as community health workers. Community health workers act as a bridge between health services and the community, tailoring activities to the local context and encouraging community ownership of programmes. Evidence suggests that female sex workers acting as community health workers can be critical to maximising benefit from HIV prevention programmes. They also provide a network for social and legal advocacy among female sex workers. Yet despite their importance to programmes, attrition among community health workers is often high and little research has been done to investigate why this might be. This paper gathers data from India and finds that an HIV prevention programme paid community health workers much less than they could have earned through sex-work, while the large workload meant they spent far more time on outreach activities than they were paid for. This encouraged attrition of the community health worker workforce, which could have substantially reduced the impact of the HIV prevention programme. The authors suggest that the importance of community health workers to programmes should be reflected by providing sufficient payment for outreach work. Although this study was carried out among a female sex worker population, these findings are relevant anywhere community health workers are used to deliver programmes elsewhere. Furthermore, other research has suggested that an important motivation for community health workers to take on work is to reduce their economic vulnerability. If programmes pay community health workers too little, or unreliably, they can actually increase the economic vulnerability of the very people they are seeking to protect.

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