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There is some evidence that female sex workers FSWs receive greater earnings for providing unprotected sex. Using a unique, cross-sectional bio-behavioural dataset from FSWs located in the four Indian states where Avahan was implemented, we estimate the economic loss faced by FSWs who always use condoms.
We estimate the causal effect of condom use on the price charged during the last paid sexual intercourse using the random targeting of Avahan as an instrumental variable. Key Messages Using data from female sex workers FSWs located in four Indian states where the Avahan programme was implemented, we estimate the loss faced by FSWs who always use condoms. We use an instrumental variable to correct for endogeneity in the impact of condom use on act price.
Many FSWs in India report violence and intimidation by clients and the police, with experience of violence strongly associated with inconsistent condom use and lower levels of participation in HIV and sexually transmitted infection STI prevention activities Beattie et al. In the context of heightened economic and structural inequities, FSWs are highly financially dependent on sex work to support themselves and their families Bharat et al.
As a result, FSWs often need to make difficult decisions regarding their own health, alongside ensuring economic and social stability for themselves and their dependents. There is evidence in the economic literature that FSWs face a positive price premium for unprotected sex, defined as the condom differential Rao et al. Avahan was introduced in in four Southern Indian states in order to address proximal and distal determinants of HIV risk.
It delivered a comprehensive package of HIV prevention services including peer-education, STI treatment, condom promotion and distribution, and community mobilization to reduce social stigma Ramakrishnan et al. Many employed peer educators, current or former FSWs received training on HIV prevention and Avahan service delivery, before providing those services to an average of 25—50 persons at high risk of HIV. Peer educators shared prevention information, distributed condoms and lubricants, and provided referral for the management of STIs.
Avahan achieved an exceptional scale-up of HIV prevention services, reaching high-risk persons between anddistributing million condoms and conducting STI tests Ramakrishnan et al. In this study, we estimate the economic loss faced by FSWs who always use condoms.
This dataset is much larger than others in the economics literature, Cheapest prostitutes in india price data from over FSWs. In line with earlier studies, we use intervention exposure as an instrumental variable to correct for endogeneity bias, as a of factors could affect both condom and price negotiation. While there have been several studies that aimed to measure the condom differential price, there is no evidence of the size of the condom premium in the context of intensive HIV prevention.
Measuring the causal effect of condom use on prices charged for sex is challenging because many factors that may have a critical impact on both price are condom use are often not measured in surveys and will confound the effect. For example, those factors may include unobserved characteristics of a FSW and her client that might influence both the price bargaining and Cheapest prostitutes in india bargaining, such as negotiation skills, past experiences during negotiation e.
Even when observed, the reliability and validity of some factors can often be questioned. Therefore, simply regressing the price charged for sex on condom use will fall short in estimating a causal effect of condom use on price, and result in a biased estimate; this is the endogeneity problem. There have been many attempts in the literature to overcome the endogeneity problem in estimating the impact of condom use on price charged for sex.
Table 1 shows that published studies either used a fixed effect estimator that s for time-invariant unobserved characteristics of FSWs or an instrumental variable that induces an exogenous variation in condom use in order to overcome endogeneity. Evidence from studies that used an instrumental variable approach highlighted that the endogeneity bias resulted in an underestimation of the effect of condom use on price, suggesting that omitted variables may be positively correlated with condom use and the price charged e. InAvahan was implemented among FSWs and other key populations Activities included condom promotion, STI management and creating an environment where safe sex was socially accepted Chandrasekaran et al.
To assist in the evaluation of the programme, several cross-sectional bio-behavioural surveys [Integrated Behavioural and Biological Assessments IBBAs ] were carried out, and information on the construction and implementation of the programme and IBBA surveys has been widely published elsewhere Ramesh et al. The IBBAs aimed to inform a population-level analysis of Avahan in a causal-pathway-based modelling analysis Pickles et al. As described in detail elsewhere Saidel et al.
Data were available for two other states Manipur and Nagaland ; however, due to a substantively different epidemic context, specifically the prevalence of injecting drug use, we elect not to include this state in this analysis. X i contains a of relevant covariates. First, we consider the type of alternative employment available to FSWs as this may affect the quantity and type of sex she needs to sell to earn a living Reed et al. Second, the environment where FSWs entertain clients, e.
Fourth, we consider FSW community cohesion proxied by a variable denoting whether or not a woman feels a strong sense of unity with other FSWs. Violence towards FSWs can be enabled by unsupportive institutions, often als isolation or disempowerment of the FSW community, and substantively impacts negotiation between FSWs and clients Siegfried et al. Characteristics of women in sex work that objectively appeal to all clients, including various physical or personality features, are difficult to measure. The economic literature has typically simplified these features by attempting to capture the physical attractiveness of FSWs or clients Arunachalam and Shah, ; Islam and Smyth, Outside of sex work, there is some evidence from labour economics that attractiveness is associated with better bargaining outcomes, more generous treatment and greater cooperation in negotiation Mulford et al.
Ultimately, these physical or personality traits influence the price charged by FSWs. The IBBA surveys do not contain direct measures of attractiveness, so we created a set of proxy variables that encompass multiple features of bargaining power and acknowledge economic work on the influence of physical features: FSW education a binary variable if the FSW is literate ; the of children she has, the ratio of her age divided by her tenure in sex work in years and whether she is currently married.
Data were from FSWs from districts in four states and Table 2 summarizes key descriptive statistics. On average, FSWs worked 4. The median of regular and occasional clients in the last 10 days were 7 IQR: 5—8 and 3 IQR: 2—5respectively. Table 3a presents ordinary least squares OLS model estimates. Table 3b i displays our main model, an instrumental variable IV estimation of equation 2 using the last condom instrument in the 2SLS regression. Table 3b ii gives the first-stage output, equation 1. The difference between OLS and IV estimates suggests that, as anticipated, not controlling for omitted variable bias in the OLS specification le to the underestimation of the effect of condom use on price.
Furthermore, we note that the magnitude and direction of other variables do not change substantially between the two specifications. Robust standard errors. For presentation due to partialling out, coefficients for place of entertainment in a are not shown but were included in the model. First-stage of model d shown in Supplementary Table S1. While not the main focus of the article, the highlight that other factors affect prices charged for sex work.
Table 3 d displays the of using just this instrument, and Table 3 e the over-identified specification with both instruments; both show consistent for the coefficient of interest, and the effect of covariates on price. We apply the Sargan test Sargan, to the over-identified model and are unable to reject the null hypothesis that both instruments are valid.
While it is not possible to test Cheapest prostitutes in india the instrument does not violate the exclusion restriction, we question whether FSWs who received their last condom from Avahan were not systematically different than those who did not receive their last condom from Avahan. To assess the likelihood of a particular peer outreach worker contacting a FSW, we extensively examined the strategy outreach staff used to reach women.
Peer outreach workers had a responsibility to reach and engage with every FSW operating in an allocated geographic area, whilst we note that this was not dependent on the place of work since Avahan targeted all types of FSWs including street-based, bar-based or brothel-based FSWs. If a proportion of the population was non-randomly chosen to receive information or supplies of free condomsthe exclusion restriction would not be satisfied and our biased.
Because all of the sample was reached at some point by Avahan, we assume that knowledge of the risks of unprotected sex is uniform across our sample and will not directly influence price according to FSW characteristics. Table 4 explores if there are systematic differences between FSWs who did and did not receive their last condom from Avahan, i. We test for differences between factors included in the models above, except those which Avahan explicitly --aimed to change since data come from after programme implementation using non-condom contraception and feeling unity with other FSWs.
In addition, we test for differences in five other indicators which may al greater or lesser FSW risk-taking behaviours. These generally support the argument that condoms were distributed with little regard for FSW characteristics, though we find that FSWs receiving their last condom from a peer educator were more likely to be literate and less likely to be married.
Differences between FSWs receiving and not receiving last condom from Avahan. We used Avahan outreach as Cheapest prostitutes in india instrumental variable to investigate the effect of using condom on the price charged in India.
Evidence suggests that the Avahan programme has been successful in reducing the HIV epidemic and is estimated to have prevented up to infections over the decade since its introduction in Chandrashkar et al. Explanations for the persistence of the condom differential in India can be found through exploring both the supply and demand sides to understand the intersecting vulnerabilities faced by FSWs. Firstly, the price premium for unprotected sex may have Cheapest prostitutes in india high 4 years into the Avahan intervention if the programme constrained the supply of unprotected sex by reducing the of FSWs who agree to client demands for unprotected sex.
If client demand remained constant, or fell at a lower rate than the supply of unprotected sex, remaining FSWs who agreed to sex without a condom would be able to command higher prices. Secondly, FSWs may agree to better-compensated condomless sex because of unpredictable income fluctuations.
Programmes which aim to reduce the economic vulnerability of women, such as encouraging lending through formal microfinance or banking systems which are often denied to FSWs due to stigmatizing structural institutional practices may limit FSW need to agree to sex without a condom Evans and Lambert,or reduce dependence on informal lending Sherman et al.
Thirdly, our suggest that FSWs who feel unity with colleagues in sex work may be able to negotiate higher prices, supporting the focus of many FSW programmes on supporting community empowerment, e. A major barrier to the development of safer sex work spaces is the current legal framework surrounding sex work, where working in indoor, organized settings is criminalized, including in southern India. Finally, recent advances in the efficacy of bio-medical interventions, which reduce the risk of contracting HIV in the absence of condoms, are starting to change the landscape of HIV prevention AVAC, In addition, HIV treatment continues to be scaled-up, decreasing the Cheapest prostitutes in india people living with HIV who are likely to be infectious Cheapest prostitutes in india AIDS Control Organisation, although implementing this in the sex work context is likely to be challenging.
Introducing treatment or prevention methods may be seen as exogenous shocks to the market for commercial sex, yet many trials and implementation programmes do not collect data on market or pricing dynamics. Our indicate that HIV prevention programmes do not occur in a vacuum and may have indirect but important influences on the preferences and incentives of FSWs and clients.
We acknowledge that our study has some limitations. As in any application of instrumental variable methods, we are unable to test whether our instrument operates in violation of the exclusion restriction. However, through exploring intuition and testing where possible, we showed that our last condom instrument convincingly satisfies the relevance and exogeneity conditions.
One difficulty in interpreting the estimates of IV methods is that not everybody responds in the same way to exposure to the instrument Angrist and Krueger, For example, there may be a subset of FSWs who would always or never provide protected intercourse, whether or not they are contacted by Avahan or receive free condoms. We acknowledge that the IV method may not eliminate all sources of bias. In this study, we are only able to estimate the premium for unprotected intercourse for FSWs whose choice of using condom has been influenced by receiving their last condom from Avahan.
Although data were captured on condom use for regular and occasional clients, pricing data were not available for each group and we were therefore unable to decompose our premium estimate by client type. Because protection and pricing dynamics may be substantially different with different clients, it would be useful for further work to explore this. Finally, because information on condom used is sensitive and self-reported by FSWs, our are susceptible to acceptability biases.
Finally, because of a range of factors, including gender-based social inequities and social stigmatization of sex work, few studies of clients have been conducted. Gaining a better understanding of why clients demand unprotected sex, and how this demand can be mitigated through HIV prevention programming, is critically important to reducing HIV risk to FSWs and the overall HIV epidemic in southern India. We applied instrumental variable method to a large dataset of FSWs in India to estimate the size of the price premium for unprotected sex, 4 years following the initiation of the Avahan HIV prevention intervention.
This study finds that a premium for unprotected sex is almost identical to that found in work in India before Avahan. Given the uncertainty regarding how HIV treatment and prevention programs may affect the commercial sex market, we recommend that such programs explicitly consider the critical role that social, structural and economic vulnerability can play in FSW agency, and specifically decision making for protected intercourse.
We note, however, that analysis of these states indicated similar to those included in this study, available upon request. No funder had a role in the de, analysis or writing of this article. Ethical approval. Adriaenssens SHendrickx J.Cheapest prostitutes in india
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