In a small office on a busy road in north-western Bangalore, health workers from Swathi Mahila Sangha (SMS) congregate to participate in a monthly training session. SMS is a community organization for women in sex work (WISW) focused on providing community members with improved access to critical resources and services. In order to promote HIV treatment and prevention, SMS is implementing the MITHR programme, a community-led model for providing on-site HIV screening and counselling services to high-risk groups. The MITHR programme technology is minimally invasive and provides results within 20 minutes, which makes it a valuable tool to use in the field where 90% of HIV screenings in the programme take place.
A young woman arrives at the office escorting a friend she brought in for screening. The young woman’s name is Lakshmi* and she has been a member of SMS for a year and a half, during which time she became a strong advocate of HIV screening in her community. She describes how she used to have a strong fear of HIV screening because of the implications of testing positive. Lakshmi refused screening the first two times it was offered, and agreed the third time once she had become comfortable with SMS and was encouraged by her friend. She has now successfully convinced six of her friends to join SMS and undergo HIV screening. In the WISW community, community linkages such as these play an important role as many women are convinced to undergo screening because they have been persuaded by fellow community members. In this vein, SMS decided to undergo the process of task shifting HIV screening to members of the WISW community.
Task shifting is defined by the World Health Organization (WHO) as “a process of delegation whereby tasks are moved from highly specialized to less specialized health workers.” In recent years, task shifting has been viewed as a cost-effective solution to the common shortages of qualified medical personnel in many developing countries. The WHO and other thought leaders in public health have officially recommended the process as one that has the potential to catalyse results in the field of community health. A main benefit of this method, in addition to the cost-saving gains, is that community workers are often more in touch with the communities they serve than medical professionals at nearby health facilities, which makes them better positioned to deliver services. At SMS, the HIV screening has traditionally been conducted by professional counsellors. Now, however, the organization is working to task shift that role to members of the WISW community who will carry out the screenings instead.
HIV testing in the WISW community provides a key example of where task shifting has the potential to have major impact. At SMS, there is already one WISW who has been trained to conduct the HIV screenings, and she has been successful in her new role thus far. HIV is a disease associated with significant stigma, and for those who are members of marginalised communities, the implications of this stigma are even more potent. It is unsurprising that many WISWs avoid screening out of fear. Having a fellow community member conducting the screenings increases trust in the screening process, and if there is trust, the women are more likely to encourage their friends to take part as well.
Lakshmi, the community member who persuades her friends to undergo screening, is supportive of this transition. When Lakshmi meets other WISW, she convinces them to get tested by sharing her own experience and by building trust. She is able to tell her fellow community members that she faces the same challenges that they do, understands the same realities and risks of the profession, feels the same fears and hesitations that they have, and yet she has elected to undergo screening. That narrative sends a powerful and convincing message. A message that health workers outside the community do not have the ability to convey.
Lakshmi herself is not trained to conduct screenings, so when she persuades a woman to undergo screening, she must then convince her to come in to the SMS office or to invite the counsellors into her home. Both are challenging propositions. If Lakshmi were able to conduct the screenings without a dependency on the counsellors, she believes she would be more effective. She adds that when WISW conduct screenings, they will be able to have much more frank conversations about methods of HIV prevention and the importance of screening. She says it would facilitate an open dialogue and allow for discussion on issues that someone who is not from the community would not be able to understand, leading to behaviour change.
Even more importantly, these community women have the knowledge and experience to identify high-risk individuals within the WISW community, unlike the counsellors. Within the WISW community, the levels of HIV risk among members varies. A woman who engages in sex work on a daily basis will have a higher risk of contracting HIV than a woman who practices sex work every few months when financial needs are higher. The level of risk varies depending on the frequency of sex work engagements, the types of services offered in sex work, and the presence of other high-risk behaviours such as intravenous drug use. Health workers from outside the community are often not equipped to identify the women who classify as being the most high-risk. The WISW community member that SMS has hired to conduct screenings has already been highly successful at identifying these high-risk women.
While task shifting for HIV screening in the WISW community has a great deal of potential, it is yet to be determined if the change achieves the desired and anticipated results. In an enclave of the SMS office, a 26-year-old sex worker named Divya* prepares to undergo HIV screening for the first time. Despite knowledge of her high-risk status, she never found time to get tested and did not feel urgency to do so. Her work hours as an accountant prevented her from accessing government testing services offering during limited timings. Situations such as Divya’s are not uncommon. Many women do not prioritize HIV screening, many WISW do not realize that they have a higher risk of contracting HIV, and for many the fear and the stigma is too great to overcome. At SMS, task shifting has already shown promising results and may make great strides towards overcoming these barriers, but the work of HIV screening is challenging, emotionally stressful and unrelenting. Provided with support and resources, WISW screeners may thrive and forever change the way community health in this marginalized community operates, but only time will give us a definitive answer.
*All names have been changed.