1. Johns Hopkins Bloomberg School of Public Health
Social cohesion, social participation, and HIV related risk among female sex workers in Swaziland
Virginia Fonner
Johns Hopkins Bloomberg School of Public Health
July 3, 2013

2. Background Sex workers are disproportionately affected by HIV
Research and interventions among sex workers are lacking in Swaziland
Social capital can potentially reduce HIV vulnerabilities by:
Facilitating internal group-related mutual aid and support
Providing access to social and material resources
Social capital is related to community empowerment, an intervention strategy recommended by WHO and endorsed by sex workers
The concept of social capital is notoriously difficult to define and operationalize

3. Conceptual Framework Social Cohesion Social Participation
SOCIAL CAPITAL
Social Cohesion
(mutual aid, trust, and solidarity among sex workers)
Social Participation
(engagement in community activities outside of sex work)
Impact on structural and environmental context
Access to social and material resources
Community support
Social acceptance
Collective action
Communication/negotiation skills
HIV knowledge/awareness
Self-efficacy
Reduced vulnerability to HIV
Behavior change

4. Study Objective
Assess relationships between social cohesion, social participation, and HIV-related risk among female sex workers in Swaziland
HIV-related risk assessed through:
Behavioral outcomes (ex: condom use)
Biological outcomes (ex: HIV serostatus)
Social discrimination and exposure to violence
Collective action

5. Methods
Cross-sectional survey among women in Swaziland who reported selling sex in the past year
325 women recruited using respondent-driven sampling
Social cohesion: 9-item scale (α= 0.76)
Social participation: 4-item index accounting for levels of participation in various social groups
Both social capital constructs were dichotomized for analysis
Logistic regression used to asses relationships of social capital constructs and HIV-related risk

6. Results Social Cohesion Results Social Participation Results Outcome
Median score: 16 (range: 0-27)
Results
(comparing high vs. low levels of cohesion)
Social Participation
Median score: 1 (range: 0-7)
Results
(comparing high vs. low levels of participation)
Outcome
aOR*
95% Confidence Interval
Consistent condom use in past week
2.10
Reported refusal of police protection
0.56
Participating in meetings to promote sex worker rights
2.02
Outcome
aOR*
95% Confidence Interval
Received HIV test in previous year
2.27
Condom use with non-paying partners
1.72
Reported verbal or physical harassment
0.58
* Adjusted for age, income, education, marital status, region, and RDS weights based on estimated population proportions of outcome variables.. Odds ratios compare participants with high vs. low social cohesion/participation.

7. Conclusions
High levels of social cohesion and social participation are associated with protective behaviors related to HIV.
More research is needed to understand the social context of female sex workers in Swaziland, such as the extent to which sex workers are willing and able to collectivize and how sex workers are portrayed and treated by the larger community.
Building social capital could potentially improve access to resources, enhance social support, and change HIV-related behaviors among this population.

8. All study participants
Acknowledgements:
Co-Authors: Deanna Kerrigan, Zandile Mnisi, Sosthenes Ketende, Caitlin Kennedy, Stefan Baral
Partners: Swaziland National AIDS Program, USAID, PSI Swaziland, Rock of Hope, JHU/R2P
All study participants
The USAID | Project SEARCH, Task Order No.2, is funded by the U.S. Agency for International Development under Contract No. GHH-I , beginning September 30, 2008, and supported by the President’s Emergency Plan for AIDS Relief. The Research to Prevention (R2P) Project is led by the Johns Hopkins Center for Global Health and managed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (CCP).