Program Implications

The results of this study should prove useful for developing new and improving existing HIV prevention and treatment programs for female sex workers in St.

Petersburg. The information about where female sex workers are most likely to get tested for HIV and where they are first diagnosed with HIV is crucial to determining where to target interventions for enrolling these women into care and treatment programs. Knowledge about HIV is high, indicating that prevention efforts to-date have been successful in educating female sex worker about their risk behaviors for HIV infection. However, as shown in this study, female sex workers admit that there are instances when they are not able to exercise everything they know about HIV prevention. Therefore, further program components are warranted that focus on increasing female sex workers’ agency in making decisions about condom use and drug use. Given that this decision-

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making process often does not depend only on the female sex worker and due to the power dynamics (gender, economic status) and high rates of violence against sex workers, interventions are needed with male clients and/or the community at-large. Community-level interventions have shown a significant reduction in risk behaviors (Kerrigan et al., 2006), limited decrease in violence (Wechsberg et al., 2006), and improved utilization of heath care services (Gangopadhyay et al., 2005) among female sex workers. An intervention designed to empower sex workers to become able to make changes in their lives, such as the successful Sonagachi in India (Jana et al., 2004; Gangopadhyay et al., 2005), could improve the conditions female sex workers face in Russia. Like some of the current programs in St. Petersburg, the Sonagachi project

promoted condom use, distributed condoms, and made referrals to clinics (Gangopadhyay et al., 2005). In addition, the Sonagachi intervention also focused on organizing women through empowerment to better their social, political, and economical conditions

(Gangopadhyay et al., 2005). Interventions targeted at clients of sex workers are needed; however, successful examples of such programs are absent in the scientific literature. There is evidence to suggest that in some settings social networks among male clients influence condom use and may be an avenue for effective interventions (Barrington et al., 2009).

Also, female sex workers, especially HIV-positive women, may benefit from more information on treatment options and the importance of receiving continuous care. Many of the participants had misconceptions about ARVs and/or expressed uncertainty about whether treatment even existed. Also, many of the HIV-positive participants felt that as long as they were not experiencing any symptoms it was not necessary to seek any

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care. PMTCT programs appear to be an effective means to get women involved in going to the AIDS Center. Therefore, these programs should contain components designed to increase adherence to HIV treatment for women in the longer term. It is important to note that programs with an educational component would only be a start to addressing the reasons female sex workers are not utilizing available services.

Peer-to-peer programs may be effective in addressing many aspects of HIV prevention among female sex workers. However, as demonstrated by the results of this study, not all female sex workers feel a connection to their peers and the nature of many of the relationships between colleagues is very complex. Programs that work with the family or another source of support of female sex workers may be more successful. However, any program that focuses on family support should recognize that stigma against the sex work and drug using behaviors is very high and not all women report having family members that support them, or in some cases the sex workers have been estranged from their families. In cases where women do not have a family or friend for support, a case management style program may be a solution. The model developed for HIV-positive mothers (for example, MAMA+, which has developed a case-management program for helping HIV-positive mothers receive services for themselves and their children) could be adapted to reach female sex workers who feel marginalized from the health care system and other social services. These types of programs are designed to help socially marginalized populations better navigate the complex, bureaucratic health care system by offering accompaniment on health care visits, referrals based on formal or even informal connections, and psychological support.

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Interventions that are designed to reach female sex workers would be best achieved through an outreach service component. Based on the information gathered as part of this study, the programs in St. Petersburg that utilize outreach teams are most successful at establishing contact with sex workers. Efforts should be expanded to include more outreach to other venues for sex work, including apartment-based brothels. Given that currently not all HIV prevention and treatment services (namely ARV

distribution) could be incorporated into outreach services, interventions are needed to connect these two groups into collaborative efforts in order to reduce barriers for sex workers to obtaining the necessary services. Female sex workers in this study reported fear of accessing services because of perceived stigma and discrimination. Interventions to reduce stigma in health care settings are imperative to encouraging sex workers, especially drug using and HIV-positive sex workers, to utilize available services. While interventions targeted directly towards health care providers may have some effect, the organization of the health care system and the historically marginalizing policies within the health care system (namely the registration of cases and system of documentation) must be addressed. As noted by other researchers, the success of HIV programs is highly dependent on changes in the overall health care system (Tkatchenko-Schmidt et al., 2010).

Interventions that have made great progress in improving the organization of care in Russia are limited. In addition to the frequent lack of accord between government and nongovernment services for HIV prevention noted in this study, there are other examples where the organization of the health care system has been a barrier to achieving the integration of vulnerable populations into the health care system. The directly observed

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treatment (DOT) strategy for addressing the tuberculosis epidemic in Russia encountered critical implementation barriers rooted within the health care system because of

financing, organizational structures, and overall inefficiency (Atun et al., 2005) One successful model that should be considered in developing an approach to HIV service provision improvement is an integrated approach to mental health reform in Russia (Jenkins et al., 2007). Mental health service clients have long been marginalized in Russian society and mental health has continuously been a low priority in the health care system. The situational analysis at all levels of the mental health care system provided the researchers with necessary information about the barriers to system change (Jenkins et al., 2007). One of the reasons for the success of this project was continual communication with the stakeholders at all levels and the establishment of intersectoral collaboration at both the strategic (to gain political support) and operational levels (Jenkins et al., 2007). This initiative also included NGOs, and their collaboration with government institutions was important to the success of the program. The researchers acknowledged that there were legal, structural, and financial barriers inherent in the Russian health care system and that the process was lengthy and challenging. However, changes are possible through engagement of stakeholders at multiple levels and use of pilot programs to demonstrate success to other regions and also inform policy (Jenkins et al., 2007).