Magazine article Forced Migration Review

Mobility and Power in HIV Transmission

Magazine article Forced Migration Review

Mobility and Power in HIV Transmission

Article excerpt

Social scientists are working with epidemiologists to produce evidence that questions traditional epidemiological HIV 'core group' models.

Epidemiological analysis and mathematical modelling have demonstrated the significance of commercial sex and high-risk behaviours as factors in the widespread transmission of HIV. This has frequently singled out commercial sex-workers as a focal point of the spread of the epidemic. Research in the social sciences has spotlighted the multifaceted complexities of participants in sex work settings, describing their mobility, particular vulnerabilities and heterogeneities. This variation includes the diversity of the sex industry in high- and low-conflict and post-conflict settings where, for example, women may move to locations where military troops are based to sell sex, or where women in refugee settings may sell or trade sex to survive.

Classic 'core group theory' proposes that core groups (those who, when infected, are most likely to spread HIV multiple times) spread infection among a wider 'bridge' population of male clients who may in turn pass the virus to their partners. The identified core group is generally the primary population targeted for HIV prevention and, as such, most likely to be stigmatised. Results from our modelling exercise on HIV core groups suggest the potential significance of police and other men in positions of power for HIV transmission and question the long-held assumption that sex workers form a core group of HIV transmitters.

Shortcomings of classic core group theory

When considering HIV prevention, epidemiological theories can help identify priorities within HIV responses. Core group theory has offered considerable guidance in priority-setting, but, in its simplicity, it may miss important elements.

Within classic core group theory, there is an assumption that sex workers are a homogeneous group with equal potential to transmit infection. However, social science research, in particular, highlights the many variables indicating the heterogeneity of this group, including sex worker mobility, age, stage of progression of the disease, access to services and protection, experiences of violence and work environment e.g. those in regulated brothels compared to individuals in informal settings or transactional and survival sex).

Traditional core group theories predict that the total number of people that an HIV-positive person will infect in a susceptible population is determined, in part, by the rate of partner change. However, there is limited attention given to men who are often central to sex work settings, including non-commercial or nonpaying users and those who control or profit from the local sex industry. These are frequently men in positions of power, including pimps, police or soldiers. Importantly, current theories also fail to consider how mobility - the movement of groups in and out of a setting and the length of time in different locations-might influence the risk of transmission and transmission patterns.

We have introduced a new equation to reflect both the number of sexual partners and the average duration that an individual is infectious in a particular setting. This reconfiguration is especially important in commercial sex situations, which often have high levels of both sexual activity and mobility. …

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