A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up.
A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up.
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DOI：
10.1016/s0140-6736(14)60973-9
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发表时间：
2015-01-10
期刊：
影响因子：
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通讯作者：
Butler J
中科院分区：
文献类型：
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作者：
Kerrigan D;Kennedy CE;Morgan-Thomas R;Reza-Paul S;Mwangi P;Win KT;McFall A;Fonner VA;Butler J
基于社区赋权的艾滋病毒应对措施是一个过程，性工作者通过这个过程集体拥有各种方案，以实现最有效的艾滋病毒成果，并解决影响其整体健康和人权的社会和结构性障碍。增强社区权能已日益被视为解决性工作者艾滋病毒问题的一个关键办法，其重点是解决性工作者感染艾滋病毒风险增加的更广泛背景。然而，大规模实施基于社区赋权的方法受到限制。我们对社区赋权方法进行了全面审查，以解决性工作者中的艾滋病毒问题。在这项工作中，我们对中低收入国家性工作者社区赋权的有效性进行了系统性审查和荟萃分析。系统审查产生了包括30 325名参与者的研究;然而，只有3个国家的8个项目的评价符合资格标准。在荟萃分析中，社区赋权与艾滋病毒感染率的降低有关。（比值比[OR]：0.68; 95%置信区间[CI]：0.52 - 0.89），淋病（OR：0.61; 95% CI：0.46，0.82），衣原体（OR：0.74; 95%CI：0.57，0.98）和高滴度梅毒（OR：0.53; 95%CI：0.41，0.69）和与客户一致使用安全套的增加（OR：3.27; 95%CI：2.32，4.62）。鉴于研究设计相对薄弱，研究地理范围有限，研究结果并不能明确表明增强社区权能在各种环境中的预期效果，但确实表明了一贯的积极趋势。尽管有希望采取增强社区权能的办法，但我们的全面审查记录了在多个层面上执行和扩大的巨大结构性障碍。这些障碍包括倒退的国际话语和资金限制，将性工作定为犯罪的国家法律，以及交叉的社会耻辱，歧视和暴力。调查结果表明，需要加强性工作者社区赋权的证据基础并使其多样化，包括其在促进获得和采用艾滋病毒预防综合干预措施方面的作用。研究结果还表明，需要在全球和地方一级进行社会和政治变革，承认性工作是一种工作，以鼓励更多地支持增强社区权能应对艾滋病毒。
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.