A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up

A community empowerment-based response to HIV is a process by which sex workers take collective ownership of programs to achieve the most effective HIV outcomes and address social and structural barriers to their overall health and human rights. Community empowerment has increasingly gained recognition as a key approach to addressing HIV among sex workers with its focus on addressing the broader context within which their heightened risk for infection occurs. However, large-scale implementation of community empowerment-based approaches has been limited. We conducted a comprehensive review of community empowerment approaches to addressing HIV among sex workers. Within this effort, we conducted a systematic review and meta-analysis of the effectiveness of community empowerment among sex workers in low- and middle-income countries. The systematic review yielded studies including 30,325 participants; however, evaluations from only 8 projects in 3 countries met the eligibility criteria. In meta-analysis, community empowerment was associated with reductions in HIV (odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.52–0.89), gonorrhea (OR: 0.61; 95% CI: 0.46, 0.82), chlamydia (OR: 0.74; 95% CI: 0.57, 0.98), and high-titre syphilis (OR: 0.53; 95% CI: 0.41, 0.69) and increased consistent condom use with clients (OR: 3.27; 95% CI: 2.32, 4.62). Given the relatively weak study designs and limited geography of the studies, findings do not definitely demonstrate the expected effects of community empowerment across settings, but do indicate consistently positive trends. Despite the promise of a community-empowerment approach, our comprehensive review documented formidable structural barriers to implementation and scale-up at multiple levels. These barriers include regressive international discourses and funding constraints, national laws criminalising sex work, and intersecting social stigmas, discrimination and violence. Findings indicate the need to strengthen and diversify the evidence base for community empowerment among sex workers, including its role in facilitating access to and uptake of combination HIV prevention interventions. Results also point to the need for social and political change regarding the recognition of sex work as work, globally and locally, to stimulate greater support for community empowerment responses to HIV.