Alcohol and sexual risk behavior among migrant female sex workers and male workers in districts with high in-migration from four high HIV prevalence states in India

Exploring risky health behaviors and vulnerability to sexually transmitted diseases among transnational undocumented labor migrants from Bangladesh: a qualitative study

BACKGROUND

In Bangladesh, remittances constitute a substantial portion of the country's foreign exchange earnings and serve as a primary source of income. However, a considerable number of Bangladeshi citizens reside overseas without proper documentation, exposing them to significant challenges such as limited access to healthcare and socioeconomic opportunities. Moreover, their irregular migration status often results in engaging in risky health behaviors that further exacerbate their vulnerability. Hence, this study aimed to investigate the risky health behavior and HIV/STI susceptibility of Bangladeshi irregular international migrants residing across the globe with undocumented status.

METHODS

Using a qualitative Interpretative Phenomenological Approach (IPA), 25 illegal migrants were interviewed who are currently living illegally or returned to their home country. The author used a thematic approach to code and analyze the data, combining an integrated data-driven inductive approach with a deductive approach. Concurrent processing and coding were facilitated by employing the Granheim model in data analysis.

RESULTS

The study identified four risky health behaviors among irregular Bangladeshi migrants: hazardous living conditions, risky jobs, suicidal ideation, and tobacco consumption. Additionally, the authors found some HIV/STI risk behavior among them including engaging in unprotected sex, consuming alcohol and drugs during sexual activity, and having limited access to medical facilities.

CONCLUSIONS

The findings of this study can be used by health professional, governments, policymakers, NGOs, and concerned agencies to develop welfare strategies and initiatives for vulnerable undocumented migrant workers.

Prevalence and Predictors of Risky Sexual Behavior Among Young Men in India: Evidence From National Family Health Survey

Objective

The study examines the prevalence and factors associated with high-risk sexual behavior among sexually active young Indian men.

Methods

This study used samples of 14,584 men aged 15 to 29 from the National Family Health Survey (NFHS-5), 2019-21.

Results

14% of men engaged in early sexual debut (<18 years), 68% had unprotected sex, and 4% had multiple sexual partners in the past 12 months. Age, marital status, educational attainment, occupation, wealth quintile, alcohol consumption, internet use, media exposure, and region were significant predictors of risky sexual behavior.

Conclusions

We suggest a tailored approach for effective policy design considering risk factors of risky sexual behavior.

Alcohol use and associated risk factors among female sex workers in low- and middle-income countries: A systematic review and meta-analysis

Due to its widespread use in the sex work industry, female sex workers (FSWs) in low- and middle-income countries (LMICs) are at high risk of harmful alcohol use and associated adverse health outcomes. Factors associated with harmful alcohol use include violence, mental health problems, drug use, sexual risk behaviors and HIV/STIs. To our knowledge, there has been no quantitative synthesis of FSW alcohol use data to date. This systematic review and meta-analysis aims to provide an estimate of the prevalence of harmful alcohol use among FSWs in LMICs and to examine associations with common health and social concerns. The review protocol was registered with PROSPERO, number CRD42021237438. We searched three electronic databases for peer-reviewed, quantitative studies from inception to 24th February 2021. Studies were selected for inclusion that reported any measure of prevalence or incidence of alcohol use among FSWs aged 18 or older from countries defined as LMIC in accordance with the World Bank income groups 2019. The following study designs were included: cross-sectional survey, case-control study, cohort study, case series analysis, or experimental study with baseline measures for alcohol use. Study quality was assessed with the Center for Evidence-Based Management (CEBMa) Critical Appraisal Tool. Pooled prevalence estimates were calculated for (i) any hazardous/harmful/dependent alcohol use, (ii) harmful/dependent alcohol use only, both overall and by region and (iii) daily alcohol use. Meta-analyses examined associations between harmful alcohol use and violence, condom use, HIV/STIs, mental health problems and other drug use. In total, 435 papers were identified. After screening, 99 papers reporting on 87 unique studies with 51,904 participants from 32 LMICs met the inclusion criteria. Study designs included cross-sectional (n = 89), cohort (n = 6) and experimental (n = 4). Overall, 5 scored as high quality, 79 studies scored as moderate and 15 scored as weak quality. Twenty-nine papers reporting on 22 unique studies used validated alcohol use tools including AUDIT, CAGE and WHO CIDI. The pooled prevalence of any hazardous/harmful/dependent alcohol use was 41% (95% CI: 31-51%), and of daily alcohol use was 26% (95% CI: 17-36%). There was variation in harmful alcohol use by global region (Sub-Saharan Africa: 38%; South Asia/Central Asia/ East Asia and Pacific: 47% and Latin America and the Caribbean:44%). Harmful alcohol use was significantly associated with inconsistent condom use (pooled unadjusted RR: 1.65; 95% CI: 1.01-2.67), STIs (pooled unadjusted OR: 1.29; 95% CI 1.15-1.46); and other drug use (pooled unadjusted OR of 2.44; 95% CI 1.24-4.80), but not with HIV, violence or mental health problems. We found a high prevalence of problem alcohol use and daily alcohol use among FSWs in LMICs. Harmful drinking was associated with important HIV risk factors such as inconsistent condom use, STIs and other drug use. Major limitations included heterogeneity in tools and cut-off scores to measure alcohol use and other common risk factors, and a paucity of longitudinal studies. There is an urgent need for tailored interventions for FSWs in LMICs that address alcohol use as well as the associated sex work risk environment.

Racism, xenophobia, and discrimination: mapping pathways to health outcomes

Despite being globally pervasive, racism, xenophobia, and discrimination are not universally recognised determinants of health. We challenge widespread beliefs related to the inevitability of increased mortality and morbidity associated with particular ethnicities and minoritised groups. In refuting that racial categories have a genetic basis and acknowledging that socioeconomic factors offer incomplete explanations in understanding these health disparities, we examine the pathways by which discrimination based on caste, ethnicity, Indigeneity, migratory status, race, religion, and skin colour affect health. Discrimination based on these categories, although having many unique historical and cultural contexts, operates in the same way, with overlapping pathways and health effects. We synthesise how such discrimination affects health systems, spatial determination, and communities, and how these processes manifest at the individual level, across the life course, and intergenerationally. We explore how individuals respond to and internalise these complex mechanisms psychologically, behaviourally, and physiologically. The evidence shows that racism, xenophobia, and discrimination affect a range of health outcomes across all ages around the world, and remain embedded within the universal challenges we face, from COVID-19 to the climate emergency.

Intimate Relationships and HIV Infection Risks Among Shan Female Sex Workers From Myanmar in Chiang Mai, Thailand: A Qualitative Study

This study aimed to investigate HIV risks among female sex workers (FSWs) who were from the Shan ethnic group, and how they relate to complex relationships with inconsistent condom use. The study was conducted using in-depth interviews with 17 Shan FSWs (aged 18-45 years old) in Chiang Mai. Intimate relationships between participants and regular clients/steady partners were found to facilitate inconsistent condom use. Participating Shan FSWs sustained intimacy with regular clients not only for economic ends but also for emotional support. Gender norms and male power dominated condom use decision making. Some participants lacked proper HIV preventive knowledge regarding condom breakage and HIV risks. Effective intervention and proper HIV preventive practices should address these intimate contexts. Capacity building among women would assist FSWs to make choices that protect them from HIV/STDs infections. Couples-based HIV interventions addressing emotional intimacy is an urgent need for HIV communication and service delivery in Thailand.

Association of intimate partner violence and other risk factors with HIV infection among married women in India: evidence from National Family Health Survey 2015-16

Background

Human immunodeficiency virus (HIV) infection remains an important public health concern in many countries. It is fuelled by gender inequality and disparity, which has resulted in a fundamental violation of women’s human rights. This study aims to find out the association of intimate partner violence (IPV) and other risk factors with the prevalence of HIV infection among married women in India.

Methods

This study is based on data from the India National Family Health Survey (2015–16). Bivariate analysis has been performed to estimate the prevalence of HIV. Logistic regression analysis is conducted to find out the association between IPV, factors such as having alcoholic husband and lifetime partner, and HIV infection among currently married women.

Results

Married women who had faced physical, sexual, and emotional violence from their husbands/partners were almost twice more likely to have tested HIV positive compared to married women who did not face violence [OR: 2.14, CI: 1.08–4.50]. The odds of testing for HIV positive was significantly higher among the married women experiencing IPV and having alcoholic husband [OR: 4.48, CI: 1.87–10.70] than those who did not experience IPV and had non-alcoholic husband. The use of condom did not show any significant association with HIV infection. Again, having more than one lifetime partner had a positive association with HIV infection compared to those with one partner [OR: 2.45, CI: 1.21–4.16].

Conclusions

The study revealed that factors such as experiencing all types of IPV, having an alcoholic husband, increased number of lifetime partners, being sexually inactive, belonging to vulnerable social groups, and urban place of residence are important risk factors of HIV infection among married women in India. The results also suggest that gender-based violence and an alcoholic husband may represent a significant factor of HIV infection among married women and interventions should on focus such vulnerable populations.

Factors determining sexual behaviour amongst siddi tribe migrating to Udupi district, India: A cross-sectional study

Background

Afro-Indians, locally known as Siddi, are the tribal community descended from the Bantu populace from eastern Africa found in Goa, Gujarat and Karnataka along the Indian west coast. This study determines knowledge, attitude and sexual behaviour amongst the Siddi population in the Udupi district.

Materials and Methods

A cross-sectional study was conducted from October 2018 to September 2019; men and women aged above 18 years who lived in the locality at the time of the survey were included in the study.

Results

A total of 108 Siddi individuals participated in this study. The mean age of the respondents was 31.8 ± 9.5 years. More than half (51.8%) of the respondents received information on sexual matters through friends. Awareness regarding the usage of condoms and other preventive measures was poor (34.7%). Around 65.7% of the respondents felt that sex education in school encourages sex amongst youngsters. The mean age at the first sexual intercourse amongst men and women was 20.3 years and 16.2 years, respectively. About 18.7% of the respondents had sex with a new partner in the migrated place within the last 1 month, of which 80% were married. Only 5% of the respondents used condoms while indulging in sex with a new partner at the migrated place. Factors such as age at marriage, age at the first sexual act and attitude towards sexual activity were significantly associated with a new sex partner at the arrival site.

Conclusion

There is a high prevalence of unsafe sexual practices amongst the migrated Siddi tribe at the place of destination. This poses the risk of sexually transmitted infections amongst the migrant tribes and local communities at the place of destination and the location of origin. The study finding shows that measures should be taken to create awareness, and change in attitude towards sexual matter should be channelised at an early age amongst the Siddi population.

Mapping Workplace Neighborhood Mobility Among Sex Workers in an Urban Canadian Setting: Results of a Community-Based Spatial Epidemiological Study From 2010-2016

Mobility among sex workers has been linked not only to improved economic and social opportunities, but also to concerns regarding displacement, criminalization, and violence. In 2014, new "end-demand" legislation criminalized new aspects of sex work in Canada (e.g., third-party advertising, purchasing) while leaving the sale of sex legal. Utilizing data from a longitudinal community-based cohort of women sex workers in Metro Vancouver (An Evaluation of Sex Workers Health Access [AESHA], 2010-2016), we used kernel density mapping to understand and identify geographic patterns of workplace neighborhood mobility (i.e., changing the primary neighborhood in which one worked in the last 6 months); multivariable logistic regression using generalized estimating equations was also used to model contextual (policing, violence, and safety) and individual correlates of workplace mobility among sex workers over the 6-year period, including potential changes in mobility patterns pre- and post-end-demand criminalization. A total of 543 sex workers were included in analyses, contributing 2,199 observations. A total of 402 (74.0%) experienced workplace neighborhood mobility during the study period. Neighborhood mobility was negatively correlated with age (adjusted odds ratio [AOR] = 0.98/year older, 95% confidence interval [CI] = [0.97, 0.99]) and positively correlated with homelessness (AOR = 1.43, 95% CI = [1.12, 1.82]), identifying as a gender/sexual minority (AOR = 1.31, 95% CI = [1.04, 1.70]), and servicing clients primarily outdoors (vs. informal indoor or in-call venues; AOR = 1.48, 95% CI = [1.21, 1.81]); police harassment (AOR = 1.19, 95% CI = [0.96, 1.48], p = .11) and changing one's neighborhood of work due to safety concerns (AOR = 1.37, 95% CI = [0.94, 2.00], p = .09) were both marginally correlated. Steps to promote safer working conditions for marginalized women in urban environments remain urgently needed, including shifts away from criminalized enforcement toward community-led initiatives and promoting access to safer indoor workspaces.

Migration and sexual partnerships among unmarried young men in Thailand: a longitudinal approach

OBJECTIVES

Migrants typically report more sexual behavior than non-migrants. In existing work, the potentially confounding effects of selection loom large. Our objective is to discern whether migrants actually do engage in more sexual activity than their non-migrating counterparts, once selection is accounted for.

METHODS

We used three waves of data from a longitudinal panel study in Thailand. Panel members were rural unmarried men, some of whom subsequently migrated to urban areas and were re-interviewed there. Migrants were compared to their non-migrant counterparts and to a separate sample of long-term urban dwellers.

RESULTS

There were no differences between eventual migrants and non-migrant counterparts in sexual partnerships before migration. Migration increased sexual partnerships with stable partners and strangers, compared with rural non-migrants.

CONCLUSIONS

Unmarried men who moved to urban areas had increased sexual partnerships with stable partners and strangers. Without proper means of protection, this pattern of behavior puts these men and their sexual partners at elevated risk of unwanted pregnancy and sexually transmitted infections (STIs). Public health programs should target unmarried male migrants for pregnancy control and STI prevention.

Prevalence of high-risk behaviors in reproductive age women in Alborz province in 2019 using unmatched count technique

Background

Our knowledge on the prevalence of high-risk behaviors among women of Alborz is not reliable due to the sensitivity of the issue. This study aimed to estimate the prevalence of seven risk behaviors among the reproductive age women in Alborz Province, Iran.

Method

In this cross-sectional study, 2000 women were randomly selected from a registered healthcare system in 2019. A researcher-made questionnaire was used to collect the required data. The prevalence of the risk behaviors including drug abuse, hookah, alcohol drinking, tobacco smoking, extramarital intercourse, and gambling was estimated using the unmatched count technique, and the prevalence rate was reported at a 95% confidence interval.

Results

The response rate for this study was 95%. The estimated prevalence for drug abuse, hookah, alcohol drinking, tobacco smoking, extramarital intercourse, and gambling were 3% (95%CI: 2.78 to 3.22), 10.5% (95%CI: 10.29 to 10.71), 7% (95%CI: 6.78 to 7.22), 10% (95%CI: 9.78 to 10.22), 8.7% (95%CI, 8.29 to 8.71), and 7.5% (95%CI, 4.71 to 7.28), respectively.

Conclusion

High risk behaviors are highly prevalent among Iranian women. Enforcing laws, prohibition, marketing restrictions, increasing taxation, expanding treatment, promoting condom distribution and providing community-based service are recommended to reduce the effects of high risk behaviors among women.

Hazardous Alcohol Consumption Moderates the Relationship Between Safer Sex Maintenance Strategies and Condomless Sex With Clients Among Female Sex Workers in Mexico

Understanding the relationship between cognitive and behavioral processes and long-term behavior change is critical to developing behavior change maintenance interventions. We examined the relationship between cognitive and behavioral safer sex maintenance strategies and condomless vaginal/anal sex with clients among female sex workers (FSWs) in Mexico. We hypothesized a moderating effect of hazardous alcohol use, such that the relationship between the use of safer sex maintenance strategies and condomless sex would be weaker among FSWs who meet criteria for hazardous alcohol consumption. Data were gathered from 602 FSWs enrolled in a sexual risk reduction intervention with a text messaging maintenance component. Seven cognitive and behavioral strategies purported to be critical in sustaining long-term behavior change were measured (e.g., maintenance self-efficacy). The relationship between FSWs’ use of safer sex maintenance strategies and condomless vaginal/anal sex with clients was moderated by hazardous alcohol consumption. The association was weaker among FSWs who met criteria for hazardous alcohol consumption. Among FSWs who met criteria for hazardous alcohol consumption, maintenance self-efficacy was associated with fewer condomless sex acts with clients ( b = −0.35, p < .001). Among FSWs who did not meet criteria for hazardous alcohol consumption, recovery self-efficacy ( b = −0.21, p < .05) and self-monitoring ( b = −0.34, p < .001) were associated with fewer acts of condomless sex. Results indicate the importance of examining the multidimensional nature of safer sex maintenance strategies and of exploring subgroup differences in their associations with behavioral outcomes. Interventions that address safer sex maintenance strategies in the context of alcohol treatment should be developed for this subgroup of FSWs.

Consistent Condom Use by Married and Cohabiting Female Sex Workers in India: Investigating Relational Norms with Commercial Versus Intimate Partners

This study examines determinants of consistent condom use (CCU) among married and cohabiting female sex workers (FSW) in India. Although CCU with clients is normative in the study area, most FSW do not consistently use condoms with intimate partners. Multiple logistic regression models indicated that condom use with intimate partners was associated with relationship status, cohabitation, HIV knowledge, STI symptoms, and being offered more money for sex without a condom by clients. Additionally, more days of sex work in the last week, serving as a peer educator, and participating in community mobilization activities were associated with higher odds of CCU across all partner types. Although improving economic security may increase CCU with clients, mobilization to reduce stigma and promote disclosure of sex work to non-cohabiting partners may be necessary to increase CCU overall.

Work-related mobility and experiences of gender-based violence among female sex workers in Iringa, Tanzania: a cross-sectional analysis of baseline data from Project Shikamana

OBJECTIVES

To examine how work-related mobility among female sex workers (FSWs) is associated with gender-based violence (GBV) in Iringa, Tanzania.

DESIGN

Cross-sectional analyses were conducted on baseline data gathered between October 2015 and April 2016 from FSWs participating in Project Shikamana, a community empowerment-based combination HIV prevention intervention.

SETTING

Participants were recruited for the baseline study using venue-based time-location sampling in two communities in Iringa, Tanzania.

PARTICIPANTS

FSWs were eligible for participation if they were 18 years or older and had exchanged sex for money within the past month. Four-hundred ninety-six FSWs participated in the baseline survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Any recent experience of GBV was examined by recent work-related mobility among FSWs. Any recent experience of GBV was also disaggregated by severity for analyses. All bivariate and multivariate binary and multinomial logistic regressions adjusted for intraclass correlations among women recruited from the same venues.

RESULTS

Forty per cent of participants experienced recent physical or sexual violence, and 30% recently experienced severe physical or sexual violence. Thirty-three per cent of participants recently exchanged sex for money outside of their district or region, and 12% were both intraregionally and inter-regionally mobile for sex work. Intraregionally and inter-regionally mobile FSWs had 1.9 times greater odds of reporting recent GBV (adjusted OR: 1.89; 95% CI: 1.06 to 3.38; p=0.031) compared with non-mobile FSWs and a 2.5 times higher relative risk for recent experience of severe GBV relative to no recent GBV (relative risk ratio: 2.51; 95% CI: 1.33 to 4.74; p=0.005).

CONCLUSIONS

Mobility for sex work may increase FSWs' exposure to GBV, particularly more severe GBV. The vulnerability of mobile FSWs to violence, particularly severe forms, demands inclusive services that are accessible to mobile FSWs.

Cervical cancer screening among transactional female sex workers in the Dominican Republic

Cervical cancer is the third leading cause of cancer-related death and the second most diagnosed cancer among women in developing countries. We determined the prevalence of abnormal Papanicolaou (Pap), high-risk HPV (hrHPV), and colposcopy among transactional female sex workers (FSWs) in La Romana, Dominican Republic. The results of 144 FSWs of ages 18-54 years who completed a demographic interview and Pap testing with hrHPV detection between June 2015 and April 2016 were analyzed. Women with abnormal results were referred for colposcopy. Risk factors for abnormal Pap were assessed through bivariate and multivariate analyses. Overall, 36.1% (52/144) of Paps were abnormal and 43.4% (62/143) had hrHPV. Of all women with hrHPV and/or abnormal Pap (68/144; 47.2%), 61 (89.7%) were referred and 16 (26.2) underwent colposcopy. HPV16 and/or 18/45 was detected in 33.3% (15/45) of low-grade Paps. Binge drinking, weekly (AOR 5.1, 95% CI: 1.8-14.5) or daily (AOR 4.9, 95% CI: 1.5-16.6), and age at first sexual relation (AOR 1.2, 95% CI: 1.0-1.5) were significantly associated ( p < 0.05) with abnormal Pap. Although almost half of participants had abnormal Pap or hrHPV, few underwent colposcopy. Improving access to cervical cancer screening and follow-up for FSWs is imperative.

Correlates of HIV prevalence among female sex workers in four north and east Indian states: findings of a national bio-behavioural survey

The socio-demographic, sex work characteristics and the factors affecting HIV prevalence among female sex workers (FSWs) are not well known in low prevalence states showing rising trends within the HIV epidemic. This paper studies these attributes among FSWs in three north (Punjab, Rajasthan and Uttar Pradesh) and one east Indian states (Jharkhand). Integrated Biological and Behavioural Surveillance (IBBS) data, collected from 4491 FSWs in the study states, were analysed, with HIV status as the dependent variable and several socio-demographic, sex work, knowledge and agency characteristics as independent variables. Multivariate analysis found a number of factors such as age above 25 years (adjusted odds ratio [AOR] 5.0, 95% confidence interval [CI] 1.4-18.1), client solicitation in rented rooms (AOR 2.8, 95% CI 1.2-6.4) and the use of mobile phones for client solicitation (AOR 5.1, 95% CI 1.6-16.0) to be significantly associated with HIV risk. The study found low levels of HIV programme services uptake and HIV/AIDS knowledge among FSWs in the study states. There is an urgent need to focus on these risk factors for improving the effectiveness of the ongoing HIV prevention efforts and attaining the 'Sustainable Development Goals' goal of 'Ending the AIDS epidemic' by 2030.

Vulnerabilities and risks of HIV infection among migrants in the Thane district, India

OBJECTIVES

To explore the vulnerabilities and risks of HIV infection among female migrants compared with male migrants in the Thane district of Maharashtra, India.

STUDY DESIGN

This is a cross-sectional epidemiological study.

METHODS

Data from 35,841 migrants (men 96.2% and women 3.8%) were collected using the web-based 'Migrant Service Delivery System.' The data were then analysed in SPSS, version 23.0. Statistical analysis, including Chi-squared test and multivariate logistic regression, was used to identify factors influencing HIV infection for both male and female migrants.

RESULTS

It was observed that 2.96% of female migrants had HIV infection compared with 0.77% of male migrants. We found that 12.1% of women consumed alcohol compared with 41.9% of men, and access to bars was 1.5% among women and 3.5% in men. We observed an even larger difference between men and women in their previous history of using brothels for sex; only 5.9% of female migrants reported previously having used brothels for sex, compared with 62.9% of male migrants. Approximately 12.3% of married women and 93.6% of married men had sex with someone other than their spouse. We found that 67.0% of married women and 73.9% of married men reported using a condom during their last sexual act compared with 60.9% of unmarried women and 68.1% of unmarried men.

CONCLUSIONS

In Thane, female migrants faced higher vulnerabilities and risks of HIV infection than male migrants. Consequently, innovative strategies are required to address these particular needs of female migrants.

Alcohol Use and Experiences of Partner Violence Among Female Sex Workers in Coastal Andhra Pradesh, India

This cross-sectional study describes the prevalence and context of violence by sexual partners against female sex workers (FSWs, N = 589) in Andhra Pradesh and its association with alcohol use by FSWs and abusive partners. In all, 84% of FSWs reported alcohol use; 65% reported lifetime physical abuse by a sexual partner. Most abused women suffered abuse from multiple partners, often triggered by inebriation or FSW's defiance. In multivariate logistic regressions, frequency of FSW's alcohol use was associated with abuse by clients and primary partner, whereas partner's alcohol use was only significant for abuse by primary partner, not clients.

Identifying the Intersection of Alcohol, Adherence and Sex in HIV Positive Men on ART Treatment in India Using an Adapted Timeline Followback Procedure

People living with HIV (PLHIV) on anti-retroviral treatment (ART) who drink are less adherent and more likely to engage in unprotected sex but the connections among these events are correlational. Using an adapted Timeline Follow-Back (A-TLFB) procedure, this paper examines the day by day interface of alcohol, medication adherence and sex to provide a fine grained understanding of how multiple behavioral risks coincide in time and space, explores concordance/discordance of measures with survey data and identifies potential recall bias. Data are drawn from a survey of behavior, knowledge and attitudes, and a 30 day TLFB assessment of multiple risk behaviors adapted for the Indian PLHIV context, administered to 940 alcohol-consuming, HIV positive men on ART at the baseline evaluation stage of a multilevel, multi-centric intervention study. On days participants drank they were significantly more likely to be medication non-adherent and to have unprotected sex. In the first day after their alcohol consuming day, the pattern of nonadherence persisted. Binge and regular drinking days were associated with nonadherence but only binge drinking co-occurred with unprotected sex. Asking about specific "drinking days" improved recall for drinking days and number of drinks consumed. Recall declined for both drinking days and nonadherence from the first week to subsequent weeks but varied randomly for sex risk. There was high concordance and low discordance between A-TLFB drinking and nonadherence but these results were reversed for unprotected sex. Moving beyond simple drinking-adherence correlational analysis, the A-TLFB offers improved recall probes and provides researchers and interventionists with the opportunity to identify types of risky days and tailor behavioral modification to reduce alcohol consumption, nonadherence and risky sex on those days.

Alcohol use, expectancies and HIV-related sexual risk: a cross-sectional survey of male migrant workers in South India

Male migrant workers (MMWs) in India are vulnerable to developing alcohol-related problems and engaging in unprotected sex, putting them at risk of HIV. Research has shown that alcohol-related expectancies mediate vulnerability to alcoholism. We examined which expectancies were associated with sexual risk and drinking. We surveyed 1085 heterosexual MMWs in two South Indian municipalities, assessing expectancies, sex under the influence, and unprotected sex with female sex workers (FSW) and casual female partners in the prior 30 days. Men more strongly endorsed positive than negative expectancies (t = 53.59, p < .01). In multivariate logistic regression, the expectancy of having more fun helped drive the combination of alcohol and unprotected sex with FSW partners (OR = 1.22, p < .05), whereas the expectancy of better sex helped drive a similar combination with casual partners (OR = 1.24, p < .01). Men concerned about alcohol-induced deficits were less likely to drink with FSW partners (OR = 0.81, p < .01), but more likely to have unprotected sex with them (OR = 1.78, p < .01). To reduce risk, MMWs would benefit from combination prevention approaches that use behavioral strategies to address drinking norms and awareness of risk, while using biomedical strategies to reduce viral transmission when risk does occur.

The Role of Alcohol on Antiretroviral Therapy Adherence Among Persons Living With HIV in Urban India

OBJECTIVE

The purpose of this study was to estimate the prevalence of alcohol use among men living with HIV on antiretroviral therapy (ART) and examine the association of alcohol use and psychosocial variables on ART adherence. The study was a cross-sectional survey supplemented by medical records and qualitative narratives as a part of the initial formative stage of a multilevel, multicentric intervention and evaluation project.

METHOD

A screening instrument was administered to men living with HIV (n = 3,088) at four ART Centers using the Alcohol Use Disorders Identification Test-consumption questions (AUDIT-C) to determine alcohol use for study eligibility. Alcohol screening data were triangulated with medical records of men living with HIV (n = 15,747) from 13 ART Centers to estimate alcohol consumption among men on ART in greater Mumbai. A survey instrument to identify associations between ART adherence and alcohol, psychosocial, and contextual factors was administered to eligible men living with HIV (n = 361), and in-depth interviews (n = 55) were conducted to elucidate the ways in which these factors are manifest in men's lives.

RESULTS

Nearly one fifth of men living with HIV on ART in the Mumbai area have consumed alcohol in the last 30 days. Non-adherence was associated with a higher AUDIT score, consumption of more types of alcohol, and poorer self-ratings on quality of life, depression, and external stigma. The qualitative data demonstrate that non-adherence results from avoiding the mixing of alcohol with medication, forgetfulness when drinking, and skipping medication for fear of disclosure of HIV status when drinking with friends.

CONCLUSIONS

As the demand for ART expands, Indian government programs will need to more effectively address alcohol to reduce risk and maintain effective adherence.

Targeting vulnerable populations: a synthetic review on alcohol use and risky sexual behaviour among migrant populations

Background

Research has demonstrated a link between alcohol use and risky sexual behaviour among different types of migrant populations. Therefore, research investigating risk factors associated with alcohol consumption among them is a public health priority. This review aimed to explore the intersection between migration, alcohol consumption and risky sexual behaviour.

Methods

This article is a synthetic review of empirical studies on the association of alcohol and high-risk sexual behaviour among different types of the migrant populations, focusing on measurable outcomes generated from quantitative data. A descriptive analysis generated from global and situational studies was used to interpret the reviewed research and to discuss critically the factors that drive migrants to engage in alcohol consumption and high-risk behaviour.

Results

This review found out that there is a significant and positive association between global and situational alcohol use and several outcomes of risky sexual behaviour among different types of migrant populations. This association was however mainly observed at high quantities and frequencies of alcohol use, mainly among male migrants, and was often tied to a specific situation or context, for instance the type of sexual partner, the level of mobility and to environmental factors such as living arrangements and entertainment venues.

Conclusions

The study supports previous research that alcohol use is associated with risky sexual behaviour among different types of migrant populations. Therefore, future interventions should target mobile, male migrant heavy drinkers. Additional research is needed using more event-level and longitudinal methodologies that overcome prior methodological limitations.

Relationship between mobility, violence and major depression among female sex workers: a cross-sectional study in southern India

BACKGROUND

The relationship between mobility, violence and mental health has largely been unexplored in developing countries. This study screens for signs of major depression, and assesses its association with mobility and violence among female sex workers (FSWs) in southern India.

METHODS

Data (N=2400) for this study were used from a cross-sectional Behavioral Tracking Survey (BTS-2014) conducted among FSWs from a southern state of India as part of the Avahan programme. Major depression of FSWs was assessed using the Patient Health Questionnaire-2 depression scale. Descriptive statistics, frequency, bivariate, interaction effect and multivariate logistic regression techniques were used for the analysis.

RESULTS

More than one-fourth of FSWs (29%) screened positive for major depression. The likelihood of screening positive for major depression was 6 times higher among FSWs who were both mobile for sex work outside their district of residence and had experienced any violence (combined association) during the past 1 year (62% vs 19%, adjusted OR 6.1, 95% CI 4.4 to 8.6) compared with those who reported neither. The individual association results show that FSWs who reported being mobile outside the district, and FSWs who were beaten or raped in the past 1 year, were 3 times more likely to screen positive for major depression.

CONCLUSIONS

The findings indicate that violence and mobility are independently associated with major depression among FSWs. The combined association of mobility and violence poses a greater risk to the mental health of FSWs than their independent association. These results point to the need for creating an enabling environment for FSWs to enhance existing efforts to reduce the spread of HIV and mental health problems. The study highlights that HIV prevention efforts among FSWs in India require evidence-based research and integrated programme approaches to address mental health issues.

Structural determinants of inconsistent condom use with clients among migrant sex workers: findings of longitudinal research in an urban canadian setting

BACKGROUND

Migrant women in sex work experience unique risks and protective factors related to their sexual health. Given the dearth of knowledge in high-income countries, we explored factors associated with inconsistent condom use by clients among migrant female sex workers over time in Vancouver, BC.

METHODS

Questionnaire and HIV/sexually transmitted infection testing data from a longitudinal cohort, An Evaluation of Sex Workers Health Access, were collected from 2010 to 2013. Logistic regression using generalized estimating equations was used to model correlates of inconsistent condom use by clients among international migrant sex workers over a 3-year study period.

RESULTS

Of 685 participants, analyses were restricted to 182 (27%) international migrants who primarily originated from China. In multivariate generalized estimating equations analyses, difficulty accessing condoms (adjusted odds ratio [AOR], 3.76; 95% confidence interval [CI], 1.13-12.47) independently correlated with increased odds of inconsistent condom use by clients. Servicing clients in indoor sex work establishments (e.g., massage parlors) (AOR, 0.34; 95% CI, 0.15-0.77), and high school attainment (AOR, 0.22; 95% CI, 0.09-0.50) had independent protective effects on the odds of inconsistent condom use by clients.

CONCLUSIONS

Findings of this longitudinal study highlight the persistent challenges faced by migrant sex workers in terms of accessing and using condoms. Migrant sex workers who experienced difficulty in accessing condoms were more than 3 times as likely to report inconsistent condom use by clients. Laws, policies, and programs promoting access to safer, decriminalized indoor work environments remain urgently needed to promote health, safety, and human rights for migrant workers in the sex industry.

Enhancing the Ethical Conduct of HIV Research with Migrant Sex Workers: Human Rights, Policy, and Social Contextual Influences

BACKGROUND

Migrant sex workers are often highly marginalized and disproportionately experience health and social inequities, including high prevalence of HIV, sexually transmitted infections, and human rights violations. In recent years, research involving migrant sex workers has increased, yet many knowledge gaps remain regarding how best to protect research participant rights and welfare. Our objective was to identify key challenges and opportunities related to the responsible conduct of HIV research with migrant sex workers.

METHODS

Focus groups and interviews conducted with 33 female sex workers ≥18 years old at the Guatemala-Mexico border from June 2013-February 2014 were analyzed. Participants were recruited through community outreach by a local HIV prevention organization to sex work establishments such as bars, hotels, street corners, and truck stops.

RESULTS

Key themes influencing research engagement for migrant sex workers included researcher mistrust and fear related to research participation, rooted in the social isolation frequently faced by recent migrants; intersecting concerns related to immigration status, fear of criminalization, and compliance with sex work regulations; and perceived benefits and risks of HIV/STI testing for migrants (e.g., immigration implications, stigma) represent potential barriers and opportunities for the responsible conduct of research involving migrant sex workers.

CONCLUSIONS

Results highlight the intersection between the human rights vulnerabilities of migrant sex workers and barriers to research participation, including social isolation of migrants and policy/legal barriers related to immigration and sex work. Findings illustrate the need for researchers to develop population-tailored procedures to address fears related to immigration and criminalization, and to reinforce positive and non-stigmatizing relationships with migrant sex workers. Community-led efforts to reduce stigma and foster community organization and supports for migrant sex workers are recommended, as are broader policy shifts that move away from punitive legal approaches towards approaches that safeguard and prioritize the human rights of migrant sex workers.

Pornography, Sexual Enhancement Products, and Sexual Risk of Female Sex Workers and their Clients in Southern India

Despite their large numbers, and important role in the HIV epidemic in India, male clients of female sex workers (FSWs) are a difficult to reach population and little is known about their sexual behaviors. Using data from an integrated behavioral and biological assessment of 684 clients in Bangalore in 2012, we examined factors associated with their reports of having sex with three or more different female sex workers in the last month, and anal sex with sex workers. We included sociodemographic and sexual behavior factors and, for the first time in client studies in India, included data on the use of pornography and sexual enhancement products (SEPs) such as pills, oils, and sprays, in our multivariable analyses of client risk. Seventy-eight percent of clients had seen pornographic material and 8% reported ever having used SEPs. The profiles of men practicing the two risk behaviors examined were quite different. Travel in the past year, drunkenness in the past month, young age at first commercial sex, non-use of condoms at last sex, and finding sex workers in public places (but not use of pornography and SEPs) were independently associated with multiple partnering. Sex with a man or transsexual, being a white collar worker, seeking out FSWs at home, pornography and SEP use, and condom use at last FSW sex, were all independently associated with anal sex with an FSW. More research is needed to better understand the links between pornography and SEPs, and HIV risk behaviors, and HIV prevention programs need to be cognizant of the importance of ensuring that condom use is adequately promoted and supported in the context of anal sex in female sex worker-client interactions.

Degree and correlates of sexual mixing in female sex workers in Karnataka, India

Background The degree of sexual mixing plays an important role in understanding disparities in sexually transmissible infections and HIV across social groups. This study examines the degree of sexual age mixing, and explores its individual and partnership level correlates among female sex workers (FSWs) in Karnataka, India.

METHODS

Data were drawn from special behavioural surveys conducted in 2006-07 among 577 FSWs in two districts of Karnataka: Belgaum and Bangalore. Sexual mixing in age was assessed as the difference in age between FSWs and their sexual partners, and the degree of assortativeness in sexual mixing was assessed using Newman's assortativity coefficient.

RESULTS

A total of 577 FSWs were interviewed; 418 of whom reported two or more partnerships, resulting in 942 partnerships. In about half (52%) of these partnerships, the age difference between the FSW and her sexual partner was 5 years or more. The degree of assortativity in age mixing was 0.098, indicating minimally assortative mixing. The disassortativeness in age mixing was positively associated with young age and no formal education, and negatively with duration in sex work. Partnerships which were of a commercial nature were more likely to be disassortative than noncommercial partnerships.

CONCLUSION

The minimally assortative age mixing indicates sexually transmissible infections can transfer from members of one age group to another. Efforts are required to limit the transmission of infection from one group to other by promoting safer sexual behaviour.

Tobacco Consumption Among HIV-Positive Respondents: Findings From the Third Round of the National Family Health Survey

INTRODUCTION

HIV-positive people are often more susceptible to illnesses associated with smoking, for example, cardiovascular disease, than those in the general population. The purpose of this article is to examine the association between tobacco use and HIV-status in India.

METHODS

This article analyzed data from the National Family Health Survey III, which provides a representative sample of the Indian population. Patterns in tobacco consumption among HIV-positive and negative respondents were assessed through logistic and ordinal regression models. Associations between smoking, asthma, and tuberculosis were examined through bivariate logistic regressions.

RESULTS

A greater percentage of male HIV-positive participants (68%) reported current tobacco use in comparison to male HIV-negative respondents (58%) and female HIV-positive (12%) and negative (11%) participants. Multivariable logistic regression analyses revealed that there was a positive correlation between male respondents' HIV-status and their propensity to use tobacco (odds ratio [OR] = 1.48, confidence interval [CI] = 1.05-2.1, P < .05) when controlled for extraneous variables. Results from ordinal regression analyses illustrated that male HIV-positive respondents had a twofold increased OR of smoking 20 or more cigarettes (OR = 2.1, CI = 1.4-3.2, P < .005). Finally, there was a positive association between being HIV-infected (adjusted odds ratio [AOR] = 4.6, CI = 2.02-10.6, P < .005), smoking 15-19 cigarettes (AOR = 2.11, CI = 1.1-4.1, P < .05) and male participants' TB-status.

CONCLUSIONS

Results in this article suggest HIV-positive men in India were not only significantly more likely to consume tobacco, but they also smoked a higher number of cigarettes compared to their HIV-negative counterparts. This is a cause for concern as our analyses revealed a possible association between the number of cigarettes smoked and TB-status.

IMPLICATIONS

This article contributes to knowledge on the intertwining epidemics of HIV and smoking through using cross-sectional data from the National Family Survey III to demonstrate that HIV-positive men in India display patterns of tobacco consumption which differs to that of HIV-negative men. These findings could have strong implications for long-term treatment of HIV-positive patients as smoking has been proven to increase the likelihood of contracting HIV-related illnesses.

Prevalence and Correlates of Hazardous Drinking among Female Sex Workers in 13 Mexican Cities

AIMS

To describe the prevalence and correlates of hazardous drinking among female sex workers (FSWs) at 13 sites throughout Mexico.

METHODS

FSWs (N = 1089) who were enrolled in a brief sexual risk reduction intervention (Mujer Segura) were queried about their sexual risk and substance use practices and their work contexts. Participants were classified as hazardous or non-hazardous drinkers based on the Alcohol Use Disorders test (AUDIT-C). Logistic regression models were used to examine individual, contextual, and community-level factors as correlates of hazardous drinking.

RESULTS

Ninety-two percent of participants reported alcohol consumption in the past month. Among drinkers (N = 1001), 83% met AUDIT-C criteria for hazardous drinking. Factors that were independently associated with hazardous drinking included: drug use in the past month (adjusted odds ratio (AOR) = 3.31; 95% CI 1.29-8.45), being a cigarette smoker (AOR = 1.71; 95% CI 1.13-2.58), being a barmaid or dance hostess (AOR = 3.40; 95% CI 1.95-5.91), alcohol use before or during sex with clients (AOR = 7.78; 95% CI 4.84-12.52), and working in a city with a higher marginalization index (AOR = 1.07; 95% CI 1.04-1.11).

CONCLUSIONS

Findings support the high prioritization by public health authorities of alcohol prevention and treatment programs for FSWs.

FACTORS ASSOCIATED WITH THE LIKELIHOOD OF FURTHER MOVEMENT AMONG MOBILE FEMALE SEX WORKERS IN INDIA: A MULTINOMIAL LOGIT APPROACH

Female sex workers (FSWs) are vulnerable to HIV infection. Their socioeconomic and behavioural vulnerabilities are crucial push factors for movement for sex work. This paper assesses the factors associated with the likelihood of movement of sex workers from their current place of work. Data were derived from a cross-sectional survey conducted among 5498 mobile FSWs in 22 districts of high in-migration across four states in southern India. A multinomial logit model was constructed to predict the likelihood of FSWs moving from their current place of work. Ten per cent of the sampled mobile FSWs were planning to move from their current place of sex work. Educational attainment, marital status, income at current place of work, debt, sexual coercion, experience of violence and having tested for HIV and collected the results were found to be significant predictors of the likelihood of movement from the current place of work. Consistent condom use with different clients was significantly low among those planning to move. Likewise, the likelihood of movement was significantly higher among those who had any STI symptom in the last six months and those who had a high self-perceived risk of HIV. The findings highlight the need to address factors associated with movement among mobile FSWs as part of HIV prevention and access to care interventions.

Alcohol use among Latino migrant workers in South Florida

BACKGROUND

A significant segment of the Latino migrant worker population in the United States is at high risk for alcohol abuse and related risk behaviors. Information about the prevalence of alcohol use and abuse and its association with sociodemographic and psychological variables is needed for designing effective intervention prevention strategies.

METHODS

Cross-sectional data were drawn from a baseline assessment that was part of a randomized controlled trial of 278 Latino migrant workers (LMWs) conducted between 2008 and 2010.

RESULTS

About one-third (32%) of participants engaged in heavy drinking in the past 30 days prior to baseline interview. More females than males reported no alcohol use in the past 30 days (53.5% vs. 20.5%). On the other hand, more males reported drinking every day or nearly (25.2% vs. 7.1%). Five factors-gender, country of origin, relationship status, living arrangements, and acculturation-were significantly associated with frequency of alcohol consumption. Multivariate analyses indicated that gender, country of origin, education attainment, relationship status, living arrangement, living with children, length of stay in the US, religious beliefs, acculturation, and depression were associated with frequent heavy drinking, alcohol abuse/dependence, and unprotected sex under the influence of alcohol.

CONCLUSIONS

There is significant variation in alcohol use among Latino migrant workers. Although a substantial proportion of this population abstains from alcohol, an equally substantial proportion report levels of alcohol use that pose significant risk. More research is needed to better understand drinking patterns in this community in order to design prevention strategies specifically tailored for this population.

Complexities of short-term mobility for sex work and migration among sex workers: violence and sexual risks, barriers to care, and enhanced social and economic opportunities

Despite research on the health and safety of mobile and migrant populations in the formal and informal sectors globally, limited information is available regarding the working conditions, health, and safety of sex workers who engage in short-term mobility and migration. The objective of this study was to longitudinally examine work environment, health, and safety experiences linked to short-term mobility/migration (i.e., worked or lived in another city, province, or country) among sex workers in Vancouver, Canada, over a 2.5-year study period (2010-2012). We examined longitudinal correlates of short-term mobility/migration (i.e., worked or lived in another city, province, or country over the 3-year follow-up period) among 646 street and off-street sex workers in a longitudinal community-based study (AESHA). Of 646 sex workers, 10.84 % (n = 70) worked or lived in another city, province, or country during the study. In a multivariate generalized estimating equations (GEE) model, short-term mobility/migration was independently correlated with older age (adjusted odds ratio (AOR) 0.95, 95 % confidence interval (CI) 0.92-0.98), soliciting clients in indoor (in-call) establishments (AOR 2.25, 95 % CI 1.27-3.96), intimate partner condom refusal (AOR 3.00, 1.02-8.84), and barriers to health care (AOR 1.77, 95 % CI 1.08-2.89). In a second multivariate GEE model, short-term mobility for sex work (i.e., worked in another city, province, or country) was correlated with client physical/sexual violence (AOR 1.92, 95 % CI 1.02-3.61). In this study, mobile/migrant sex workers were more likely to be younger, work in indoor sex work establishments, and earn higher income, suggesting that short-term mobility for sex work and migration increase social and economic opportunities. However, mobility and migration also correlated with reduced control over sexual negotiation with intimate partners and reduced health care access, and mobility for sex work was associated with enhanced workplace sexual/physical violence, suggesting that mobility/migration may confer risks through less control over work environment and isolation from health services. Structural and community-led interventions, including policy support to allow for more formal organizing of sex work collectives and access to workplace safety standards, remain critical to supporting health, safety, and access to care for mobile and migrant sex workers.

Sexual behavior and knowledge of human immunodeficiency virus/aids and sexually transmitted infections among women inmates of Briman Prison, Jeddah, Saudi Arabia

Background

To reduce the incidence of HIV and sexually transmitted infections (STIs), it is necessary to target high-risk populations such as prison inmates. This study aims to explore the range of knowledge on HIV and STIs, sexual behaviors, and adoption of preventive measures among women inmates.

Methods

This was a survey conducted between July 1, 2012 and July 29, 2012 among women inmates at Briman Prison, Jeddah, Saudi Arabia. The author gave an educational lecture on STIs in a conference room at the prison. Educational material was distributed to the attendees after the lecture, and the survey was conducted one week later. All the participants were asked to complete an anonymous 40-item self-administered questionnaire in the presence of a professional health assistant and a translator, for non-Arabic speakers. Data collected included the personal data of the respondent, her alleged criminal background, penal status, accumulative time in prison, history of smoking, alcohol or drug addiction, knowledge about the seven most common STIs, symptoms, modes of transmission, prevention, sexual activity, addiction, and means of protection. Descriptive analysis was performed using Microsoft Excel.

Results

We interviewed 204 women aged 16-60 years (mean, 33.3 years). Most of the respondents (n = 170; 83 · 0%) were not aware of STIs; 117 respondents (57 · 4%) did not undergo screening for STIs before marriage or intercourse, while only 59 (28 · 9%) did. Over half of the respondents (n = 107; 52.5%) thought they knew how to protect themselves from STIs. Nevertheless, 87 (42.6%) were uncertain about the role of condoms in protection from STIs and (n = 41; 20.1%) thought condoms provide 100% protection against STIs, while 72 respondents (35.3%) thought condoms did not confer 100% protection against STIs. Only 10 respondents (4.9%) used condoms to protect themselves from STIs. Saudi women (P = 0.033) and those with a higher level of education (P < 0.01) were significantly more likely to have better knowledge.

Conclusion

Women inmates at Briman Prison have poor knowledge of STIs as well as risky sexual behaviors. Campaigns aimed at increasing awareness of STIs should also target prison inmates, who in general constitute high-risk populations.

The effect of mobility on sexual risk behaviour and HIV infection: a cross-sectional study of men who have sex with men in southern India

Objectives

Mobility is an important factor contributing to the spread of HIV among key population at risk for HIV; however, research linking this relationship among men who have sex men (MSM) is scarce in India. This study examines the association between mobility and sexual risk behaviour and HIV infection among MSM in southern India.

Methods

Data are drawn from a cross-sectional biobehavioural survey of 1608 self-identified MSM from four districts of Andhra Pradesh in India, recruited through a probability-based sampling in 2009–2010. Logistic regression models were used to estimate odds ratios and 95% CIs for sexual risk behaviours (unprotected sex with any male partner) and HIV infection based on the mobility status (travelled and had sex in the past year) after adjusting for sociodemographics and risk behaviours.

Results

Of the 1608 MSM, one-fourth (26%) were mobile. Of these, three-fourths had travelled across districts but within the state (56%), and one-fifth (20%) across states. As compared to non-mobile MSM, a higher proportion of MSM who were mobile across districts (adjusted (OR=1.42, 95% CI 1.04 to 1.95) or states (adjusted OR=3.20, 95% CI 1.65 to 6.17) reported having unprotected sex with any male sexual partner. Further, mobility across districts (adjusted OR=1.43, 95% CI 1.01 to 2.03) or states (adjusted OR=2.45, 95% CI 1.46 to 4.10) was significantly associated with HIV infection.

Conclusions

Mobile MSM have a higher likelihood of contracting HIV. Interventions extending the ways to reach out to MSM with greater mobility may augment ongoing efforts to reduce the spread of HIV/AIDS in India.

[Study of determinants of unprotected sex in sailors of the Senegalese merchant navy]

Sailors are a mobile population travelling a lot and therefore being often exposed to casual sex. The aim of this study is to analyze the determinants of unprotected sex among sailors in Senegal. A descriptive and analytical study was conducted among sailors of the merchant navy. Data on knowledge, attitudes and practices were collected during a personal interview. A multivariate analysis was performed using a multiple logistic regression. A total of 400 sailors were interviewed, 57.9% had casual sex of whom 23.7% were not protected. Sexual intercourse without protection was more common among the uneducated (OR = 2.29 [1.23 to 5.99]) and married (OR = 2.29 [1.23-5.99]). Sailors who thought that using condom reduces pleasure during sexual intercourse (OR = 2.5 [1.2-5.1]) and those who consumed alcohol (OR = 5.4 [2.07-14.2]) were less protected during casual sex. Sexual contact is one of the main modes of transmission of HIV / AIDS. Sailors often have unprotected sex. Interventions using specific ways must be performed taking into account the mobility of these men who are often uneducated.

Alcohol and condom use among HIV-positive and HIV-negative female sex workers in Nagaland, India

This study examines the relationship between alcohol use, HIV status, and condom use among female sex workers in Nagaland, India. We analyzed data from a cross-sectional survey undertaken in 2009, using descriptive and multivariate statistics. Out of 417 female sex workers, one-fifth used alcohol daily and one-tenth were HIV-positive. HIV-positive female sex workers were more likely than HIV-negative female sex workers to consume alcohol daily (30.2% vs. 18.0%). HIV-positive daily alcohol users reported lower condom use at last sex with regular clients compared to HIV-positive non-daily alcohol users (46.2% vs. 79.3%), a relationship not evident among HIV-negative female sex workers. There is a need to promote awareness of synergies between alcohol use and HIV, and to screen for problematic alcohol use among female sex workers in order to reduce the spread of HIV.

Exposure to HIV prevention programmes associated with improved condom use and uptake of HIV testing by female sex workers in Nagaland, Northeast India

Background

There a concentrated HIV epidemic among female sex workers (FSWs) in the state of Nagaland, located in the north-east of India. Local non-government organisations (NGOs) are supported by the National State AIDS Control Society (NSACS) and the Avahan-funded Project ORCHID (Avahan is the India AIDS initiative of Bill & Melinda Gates Foundation in India) to deliver a range of interventions to FSWs including safe sex promotion, condom distribution, and testing and treatment of sexually transmitted infections (STIs). The commercial hub of Nagaland, Dimapur, is an important transportation node, and hosts a concentration of FSWs. This paper reports on comparative analysis of Integrated Behavioural and Biological Assessment (IBBA) data collected from FSWs in Dimapur in 2006 and 2009 to assess changes in condom use, HIV testing, and exposure to interventions.

Methods

Two IBBA cross-sectional surveys were undertaken among FSWs in Dimapur in 2006 (Round 1) and 2009 (Round 2) using an interviewer-administered questionnaire and the collection of blood and urine samples. Respondent-driven sampling (RDS), a sampling technique for use among hidden populations, was used to recruit the samples.

Results

When round 1 is compared with round 2, there was a marked and statistically significant improvement in the use of condoms at last sex with both occasional (35.2% to 72.4%) and regular (25.8% to 57.7%) clients, and an increase in the proportion having ever had an HIV test (8.9% to 29.1%). There was no evidence of an improvement in the proportional coverage of the HIV prevention services delivered to FSWs in Dimapur between round 1 and round 2. In round 2, FSWs exposed to the programme were more than twice (OR=2.27) as likely to consistently use condoms with occasional clients, four times (OR: 4.11) more likely to use condoms consistently with regular clients and nine times (OR: 9.08) more likely to have ever had an HIV test.

Conclusions

We found evidence of an increase in condom use and HIV testing, and a strong and consistent association between programme exposure and condom use and HIV testing indicating that NGO HIV prevention programmes have been making a substantial contribution to HIV prevention among FSWs in Dimapur. However, there was no evidence of improved coverage of HIV prevention services, and there is a clear need to expand the reach of services in order for them to have an impact on a larger pool of FSWs.

Factors associated with risky sexual practices among female sex workers in Karnataka, India

Introduction

The objectives of this study are to develop a summary measure of risky sexual practice and examine the factors associated with this among female sex workers (FSWs) in Karnataka, India.

Materials and Methods

Data were drawn from special behavioral surveys (SBS) conducted in 2007 among 577 FSWs in two districts of Karnataka, India: Belgaum and Bangalore. FSWs were recruited using the two-stage probability sampling design. FSWs' sexual practice was considered risky if they reported inconsistent condom use with any sexual partner and reported experience of one of the following vulnerabilities to HIV risk: anal sex, alcohol consumption prior to sex and concurrent sexual relationships.

Results

About 51% of FSWs had engaged in risky sexual practice. The odds of engaging in risky sex were higher among FSWs who were older (35+ years) than younger (18–25 years) (58% vs. 45%, Adjusted Odds Ratio (AOR): 2.0, 95% confidence interval (CI): 1.2–3.4), who were currently married than never married (61% vs. 51%, AOR: 4.8, 95% CI: 2.5–9.3), who were in sex work for 10+ years than those who were in sex work for less than five years (66% vs. 39%, AOR: 2.6, 95% CI: 1.6–4.2), and who had sex with 3+ clients/day than those who had sex with fewer clients (67% vs. 38%, AOR: 3.7, 95% CI:2.5–5.5).

Conclusion

FSWs who are older, currently married, practicing sex work for longer duration and with higher clientele were more likely to engage in risky sexual practices. HIV prevention programs should develop strategies to reach these most-at risk group of FSWs to optimize the effectiveness of such programs.

Falling through the cracks: a qualitative study of HIV risks among women who use drugs and alcohol in Northeast India

Background

HIV risks for women who inject drugs and those who engage in sex work are well documented. Women who are dependent on non-injecting drugs and alcohol are also likely to have increased vulnerability to HIV infection, but until they actually inject drugs or engage in sex work, are unlikely to come to the attention of HIV prevention programs.

Methods

We undertook a qualitative study involving nine focus group discussions (FGDs) and 27 key informant interviews to investigate the context of female drug and alcohol use in two high HIV prevalence states of India (Manipur and Nagaland) and to describe their HIV risks. The FGD and interview transcripts were thematically analyzed

Results

The women were relatively young (mean age 31 years in Manipur and 28 years in Nagaland), but 64% in Manipur and 35% in Nagaland were widowed or divorced. Both heroin and alcohol were commonly used by the women from Manipur, while alcohol was primarily used by the women from Nagaland, especially in the context of ‘booze joints’ (illicit bars). Reasons for drug and alcohol use included: to avoid symptoms of withdrawal, to suppress emotional pain, to overcome the shame of sex work, pleasure, and widowhood. HIV vulnerability was clearly described, not only in relation to injecting drug use and sex work, but also alcohol consumption.

Conclusions

The contribution of alcohol use to the HIV vulnerability of women is not currently considered when HIV prevention programs are being designed and implemented leaving a group of high-risk women uncovered by much needed services such as treatment for a range of health problems including alcohol dependence.

High risk health behaviors and healthcare access among female adult entertainment club employees

BACKGROUND

Prior studies of adult entertainment club employees have been qualitative and lacked information regarding a range of important health factors.

METHODS

Sixty-nine female club employees completed a computer-assisted survey on healthcare access and health behaviors. An age-matched comparison sample was obtained from the Behavioral Risk Factor Surveillance System. Researchers calculated descriptive characteristics and developed multivariable logistic regression models to provide the adjusted odds of health factors.

RESULTS

In the combined study sample, the mean age was 28.5 years; 75% were white, 20% Hispanic/Latino; 58% were single; 46% had at least one child. Compared to the Behavioral Risk Factor Surveillance System sample, significantly fewer club employees had health insurance or a primary care provider, and more reported not seeing a physician due to cost. Club employees had significantly higher adjusted odds of smoking (aOR 4.38, 95% CI 1.13-16.88), high-risk drinking (aOR 5.68, 95% CI 1.73-18.67), HIV risk factors (aOR 4.91, 95% CI 1.26-28.2), and lower odds of HIV testing (aOR 0.10, 95% CI 0.04-0.27) than the comparison group.

CONCLUSIONS

Compared to a national sample of women, more club employees reported high-risk drinking and HIV risk behaviors, and fewer reported HIV testing and access to healthcare. Adult club employees may benefit from interventions to reduce harmful behaviors and increase healthcare access.

Meeting the needs of women who use drugs and alcohol in North-east India - a challenge for HIV prevention services

Background

The North-east Indian states of Manipur and Nagaland consistently report relatively high HIV prevalence. The targeted HIV prevention interventions in these two states are mostly delivered by non-government organizations (NGOs), and prevention of HIV transmission by injecting drug use is their main focus. Most injecting drug users (IDUs) are male, and the services are primarily tailored to meet their needs, which are not necessarily the same as those for women. This qualitative study describes the health service needs of women who use drugs and alcohol in Manipur and Nagaland, with the goal of identifying strategies and activities that can be implemented by NGOs wanting to improve their reach among vulnerable women.

Methods

In 2009-10, semi-structured in-depth interviews were conducted with 27 key informants and nine focus group discussions (FGDs) with women who use drugs and alcohol, and two FGDs with male IDUs. The thematic areas covered included: the context of female drug and alcohol use; drug and alcohol use patterns; HIV risk behaviours; barriers and facilitators of service use; perceived health needs; and expressed health service needs. The data were recorded, transcribed, translated and thematically analysed.

Results

The most problematic substance for women from Nagaland was alcohol, and for women from Manipur it was heroin. The most commonly identified health problems were primarily related to the women’s drug and alcohol use, reproductive health and mental health. Other problems of major concern included social exclusion, violence, children’s welfare, and financial difficulties. The expressed service needs of these women were women-only integrated health services, women-only detoxification and rehabilitation services, mental health services, desensitization of mainstream health workers, free access to medicines, assistance to meet basic needs, and a safe place for engaging in sex work.

Conclusion

The expressed health and other service needs of women who use drugs and alcohol in Manipur and Nagaland do not match the services currently provided by HIV prevention NGOs, and this may, in part, account for the relatively poor uptake of these services by women. Strategies and activities that can be implemented by NGOs to strengthen their reach to vulnerable women are identified. However, many of these women’s needs are beyond the scope of services typically offered by HIV prevention NGOs, and require a coordinated multi-sectoral response.

Relationship between mobility, violence and HIV/STI among female sex workers in Andhra Pradesh, India

BACKGROUND

Violence and mobility have been identified as critical factors contributing to the spread of HIV worldwide. This study aimed to assess the independent and combined associations of mobility and violence with sexual risk behaviors and HIV, STI prevalence among female sex workers (FSWs) in India.

METHODS

Data were drawn from a cross-sectional, bio-behavioral survey conducted among 2042 FSWs across five districts of southern India in 2005-06. Regression models were used to estimate odds ratios and 95% confidence intervals (CIs) for sexual risk behaviors and HIV infection based on experience of violence and mobility after adjusting for socio-demographic and sex work related characteristics.

RESULTS

One-fifth of FSWs (19%) reported experiencing violence; 68% reported travelling outside their current place of residence at least once in the past year and practicing sex work during their visit. Mobile FSWs were more likely to report violence compared to their counterparts (23% vs. 10%, p < 0.001). Approximately 1 in 5 tested positive for HIV. In adjusted models, FSWs reporting both mobility and violence as compared to their counterparts were more likely to be infected with HIV (Adjusted odds ratio (adjusted OR): 2.07, 95% CI: 1.42-3.03) and to report unprotected sex with occasional (adjusted OR: 2.86, 95% CI: 1.76-4.65) and regular clients (adjusted OR: 2.07, 95% CI: 1.40-3.06).

CONCLUSIONS

The findings indicate that mobility and violence were independently associated with HIV infection. Notably, the combined effect of mobility and violence posed greater HIV risk than their independent effect. These results point to the need for the provision of an enabling environment and safe spaces for FSWs who are mobile, to augment existing efforts to reduce the spread of HIV/AIDS.

Changing epidemiology of HIV in Mumbai: an application of the Asian epidemic model

Background:

Mumbai is one of the most populous and high HIV prevalence cities in India. It has witnessed substantial changes in HIV-risk behaviors and a decline in HIV prevalence among high-risk groups during the past decade.

Aim:

To examine the changing pattern in the number of new HIV infections by transmission routes in Mumbai during 2000-2017.

Methods:

We used the Asian Epidemic Model by dividing the adult population (aged 15 and above) into seven subgroups: brothel-based and non-brothel based female sex workers (FSWs), heterosexual clients of FSWs, men who have sex with men/transgendered people (MSM), injecting drug users (IDUs), general women and general men. The MSM subgroup included homosexual and bisexual men.

Results:

New HIV infections among adults reduced by 86% during 2000-2010. The highest decline was among FSWs and their heterosexual clients (95%-98%), followed by MSM (82%), general women (77%), IDUs (51%) and general men (42%). Most new HIV infections during 2011-2017 are expected to occur among general women (1666) and general men (977) followed by MSM (715). Bisexual men were estimated to contribute about 14% of the new HIV infections among general women in 2010 and this proportion was estimated to increase to 19% in 2017.

Discussion:

HIV prevention programs for MSM and the general population need to be strengthened. Ensuring early detection of HIV, and higher levels of consistent condom use by HIV-infected men and women are essential to prevent new HIV infections in future.

Alcohol consumption patterns and sexual risk behavior among female sex workers in two South Indian communities

BACKGROUND

HIV transmission in India is primarily heterosexual and there is a concentrated HIV epidemic among female sex workers (FSWs). Earlier reports demonstrate that many FSWs consume alcohol regularly before sexual encounters. This qualitative study is part of a larger quantitative study designed to assess alcohol consumption patterns among female sex workers and their association with sexual risk taking. Here we investigate the environmental influence, reasons for and consequences of consuming alcohol in the FSW population.

METHODS

Trained staff from two Non-Governmental Organizations in Andhra Pradesh and Kerala conducted semi-structured interviews with 63 FSWs in Chirala, Andhra Pradesh (n = 35) and Calicut, Kerala (n = 28) following extensive formative research, including social mapping and key informant interviews, to assess drinking patterns and sexual risk behaviors.

RESULTS

FSWs reported consuming alcohol in multiple contexts: sexual, social, mental health and self-medication. Alcohol consumption during sexual encounters with clients was usually forced, but some women drank voluntarily. Social drinking took place in public locations such as bars and in private locations including deserted buildings, roads and inside autorickshaws (motorcycle taxis). Consequences of alcohol consumption included failure to use condoms and to collect payments from clients, violence, legal problems, gastrointestinal side effects, economic loss and interference with family responsibilities.

CONCLUSION

FSWs consume alcohol in multilevel contexts. Alcohol consumption during transactional sex is often forced and can lead to failure to use condoms. Social drinkers consume alcohol with other trusted FSWs for entertainment and to help cope with psychosocial stressors. There are multiple reasons for and consequences of alcohol consumption in this population and future interventions should target each specific aspect of alcohol use.

Indicators of mobility, socio-economic vulnerabilities and HIV risk behaviours among mobile female sex workers in India

This paper examines the relationship between indicators of mobility, socio-economic vulnerabilities, and HIV risk behaviours among 5,498 mobile female sex workers (FSWs) living in the four high HIV prevalence states in India. Female sex workers with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they experienced physical violence, and consumed alcohol prior to sex. Further, FSWs with greater degree of mobility reported significantly more often than the FSWs with lesser degree of mobility that they had inconsistent condom use in sex with clients, even after controlling for several demographic characteristics and socio-economic vulnerabilities including experiences of violence. Additionally, short duration visits and visit to the Jatra (religious fairs) places found to have significant association with their inconsistent condom use in sex with clients as well as continuation of sex despite having STI symptoms. These findings suggest the need for screening FSWs for higher degree of mobility and to mobilize them to form community networks so as to deal with violence, reduce alcohol use and promote consistent condom use along the routes of mobility. HIV prevention interventions aimed at FSWs require an increased attention to address the socio-economic vulnerabilities including alcohol use, with particular emphasis on those FSWs who are on the move in India and elsewhere.

The Extent and Nature of Fluidity in Typologies of Female Sex Work in Southern India: Implications for HIV Prevention Programs

These authors examine the nature and extent of fluidity in defining the typology of female sex work based on the place of solicitation or place of sex or both places together, and whether sex workers belonging to a particular typology are at increased risk of HIV in southern India. Data are drawn from a cross-sectional survey conducted during 2007-2008 among mobile female sex workers (N = 5301) in four Indian states. Findings from this study address an important policy issue: Should programmatic prevention interventions be spread to cover all places of sex work or be focused on a few places that cover a large majority of sex workers? Results indicate that most female sex workers, including those who are usually hard to reach such as those who are mobile or who use homes for soliciting clients or sex, can be reached programmatically multiple times by concentrating on a smaller number of categories, such as street-, lodge-, and brothel-based sex workers.

Male migration and risky sexual behavior in rural India: is the place of origin critical for HIV prevention programs?

Background

Recent studies of male migrants in India indicate that those who are infected with HIV are spreading the epidemic from high risk populations in high prevalence areas to populations in low prevalence areas. In this context, migrant men are believed to initiate and have risky sexual behaviors in places of destination and not in places of origin. The paucity of information on men's risky sexual behaviors in places of origin limits the decision to initiate HIV prevention interventions among populations in high out-migration areas in India.

Methods

A cross-sectional behavioral survey was conducted among non-migrants, returned migrants (with a history of migration), and active (current) migrants in rural areas across two districts with high levels of male out-migration: Prakasam district in Andhra Pradesh and Azamgarh district in Uttar Pradesh. Surveys assessed participant demographics, migration status, migration history, and sexual behavior along the migration routes, place of initiation of sex. District-stratified regression models were used to understand the associations between migration and risky sexual behaviors (number of partners, condom use at last sex) and descriptive analyses of migrants' place of sexual initiation and continuation along migration routes.

Results

The average age at migration of our study sample was 19 years. Adjusted regression analyses revealed that active migrants were more likely to engage in sex with sex workers in the past 12 months (Prakasam: 15 percent vs. 8 percent; adjusted odds ratio (aOR)=2.1, 95% CI 1.2-3.4; Azamgarh: 19 percent vs.7 percent; aOR=4.0, 95% CI 2.4-6.6) as well as have multiple (3+) sex partners (Prakasam: 18 percent vs. 9 percent; aOR=2.0, 95% CI 1.3-3.2; Azamgarh: 28 percent vs. 21 percent; aOR=1.9, 95% CI 1.2-3.0) than non-migrants. Contrary to popular belief, a high proportion of active and returned migrants (almost 75 percent of those who had sex) initiated sex at the place of origin before migrating, which is equivalent to the proportion of non-migrants who engaged in sex with sex workers as well as with casual unpaid partners. Moreover, non-migrants were more likely than migrants to engage in unprotected sex.

Conclusion

Findings of this study document that returned migrants and active migrants have higher sexual risk behaviors than the non-migrants. Most migrants initiate non-marital sex in the place of origin and many continue these behaviors in places of destination. Migrants’ destination area behaviors are linked to sex with sex workers and they continue to practice such behaviors in the place of origin as well. Unprotected sex in places of destination with high HIV prevalence settings poses a risk of transmission from high risk population groups to migrants, and in turn to their married and other sexual partners in places of origin. These findings suggest the need for controlling the spread of HIV among both men and women resulting from unsafe sex in places of origin that have high vulnerability due to the frequent migratory nature of populations.