Assessing the Impact of Peer Educator Outreach on the Likelihood and Acceleration of Clinic Utilization among Sex Workers

Abstract

Objective: Peer-led outreach is a critical element of HIV and STI-reduction interventions aimed at sex workers. We study the association between peer-led outreach to sex workers and the time to utilize health facilities for timely STI syndromic-detection and treatment. Using data on the timing of peer-outreach interventions and clinic visits, we utilize an Extended Cox model to assess whether peer educator outreach intensity is associated with accelerated clinic utilization among sex workers.

Methods: Our data comes from 2705 female sex workers registered into Pragati, a women-in-sex-work outreach program, and followed from 2008 through 2012. We analyze this data using an Extended Cox model with the density of peer educator visits in a 30-day rolling window as the key predictor, while controlling for the sex workers' age, client volume, location of sex work, and education level. The principal outcome of interest is the timing of the first voluntary clinic utilization.

Results: More frequent peer visit is associated with earlier first clinic visit (HR: 1.83, 95% CI, 1.75-1.91, p < .001). In addition, 18% of all syndrome-based STI detected come from clinic visits in which the sex worker reports no symptoms, underscoring the importance of inducing clinic visits in the detection of STI. Additional models to test the robustness of these findings indicate consistent beneficial effect of peer educator outreach.

Conclusions: Peer outreach density is associated with increased likelihood of-and shortened duration to-clinic utilization among female sex workers, suggesting potential staff resourcing implications. Given the observational nature of our study, however, these findings should be interpreted as an association rather than as a causal relationship.

Fig 1. Estimated Survival Curve under different Densities of Peer Educator Outreach.

The y-axis represents the event-free survival probability, i.e., likelihood of not experiencing the focal event of first clinic visit. The x-axis represents number of days from first contact. The different lines represent the counterfactuals pertaining to zero, 1X, 2X and 4X the observed outreach density. As the outreach density increases, the event-free survival probability goes down for the same number of days. Alternately, the median time to clinic visit, represented as the cross mark “×” on the horizontal reference line, becomes shorter (moves left) as the outreach density increases from 0 to 1X, to 2X to 4X.