title: 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.
authors.affiliation: Department of Marketing and Entrepreneurship, Institute for Health Care Marketing, C. T. Bauer College of Business, University of Houston, Houston, Texas, United States of America.|Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America.|Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas, United States of America.
authors.forename: Parthasarathy
authors.initials: P
authors.lastname: Krishnamurthy
authors.affiliation: Department of Marketing and Entrepreneurship, C. T. Bauer College of Business, University of Houston, Houston, Texas, United States of America.
authors.forename: Sam K
authors.initials: SK
authors.lastname: Hui
authors.affiliation: Swasti Health Resource Center, Bangalore, Karnataka, India.
authors.forename: Narayanan
authors.initials: N
authors.lastname: Shivkumar
authors.affiliation: Swades Foundation, Mumbai, Maharashtra, India.
authors.forename: Chandrasekhar
authors.initials: C
authors.lastname: Gowda
authors.affiliation: Swathi Mahila Sangha, Bangalore, Karnataka, India.
authors.forename: R
authors.initials: R
authors.lastname: Pushpalatha
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000517:prevention & control; D006801:Humans; D016013:Likelihood Functions; D010379:Peer Group; D011477:Sex Work; D012749:Sexually Transmitted Diseases / Q000517:prevention & control