A multilevel analysis of the impact of socio-structural and environmental influences on condom use among female sex workers

Peer education for HIV prevention among high-risk groups: a systematic review and meta-analysis

Background

Peer education has become a strategy for health promotion among high-risk groups for HIV infection worldwide. However, the extent to which peer education could have an impact on HIV prevention or the long-term effect of this impact is still unknown. This study thus quantifies the impact of peer education over time among high-risk HIV groups globally.

Method

Following the PRISMA guidelines, a systematic review and meta-analysis was used to assess the effects and duration of peer education. A thorough literature search of PubMed, Web of Science, Embase and Cochrane Library was performed, and studies about peer education on high-risk HIV groups were reviewed. Pooled effects were calculated and the sources of heterogeneity were explored using meta-regression and subgroup analysis.

Results

A total of 60 articles with 96,484 subjects were identified, and peer education was associated with 36% decreased rates of HIV infection among overall high risk groups (OR: 0.64; 95%CI: 0.47–0.87). Peer education can promote HIV testing (OR = 3.19; 95%CI:2.13,4.79) and condom use (OR = 2.66, 95% CI: 2.11–3.36) while reduce equipment sharing (OR = 0.50; 95%CI:0.33,0.75) and unprotected sex (OR = 0.82; 95%CI: 0.72–0.94). Time trend analysis revealed that peer education had a consistent effect on behavior change for over 24 months and the different follow-up times were a source of heterogeneity.

Conclusion

Our study shows that peer education is an effective tool with long-term impact for behavior change among high-risk HIV groups worldwide. Low and middle-income countries are encouraged to conduct large-scale peer education.

Trends and emerging directions in HIV risk and prevention research in the Philippines: A systematic review of the literature

BACKGROUND

The Philippines is experiencing one of the fastest growing epidemics globally. Evidence-based public health policies are needed. To describe the public health literature on HIV risk groups and prevention approaches in the Philippines, we reviewed published empirical studies with HIV-related outcomes.

METHODS

Based on an a priori systematic review protocol, we searched PubMed, PsycINFO and CINAHL databases for quantitative studies conducted in the Philippines that reported on HIV risk groups factors and interventions to prevent HIV. The search included studies published as of April 2018.

RESULTS

We identified 755 records, screened 699 unique titles and abstracts, and conducted full text review of 122 full reports of which 51 articles met inclusion criteria. The majority were cross-sectional studies describing HIV and STI prevalence and risk factors in samples recruited from the Philippines. Four HIV prevention programs conducted in the Philippines were identified, all of which reported improvements on HIV knowledge, attitudes, and behaviors. Overall, female sex workers (FSWs) constituted the primary study population, and few studies reported data from men who have sex with men (MSM), people who inject drugs (PWIDs), and youth. No studies reported on transgender populations. Most studies were focused on examining condom use-related outcomes and STI history, few had biomarkers for HIV, and none addressed biomedical HIV prevention strategies.

CONCLUSION

This review identifies an agenda for future HIV research that is needed to address the growing and shifting nature of the HIV epidemic in the Philippines.

Understanding the Relationship Between Female Sex Workers and Their Intimate Partners: Lessons and Initial Findings From Participatory Research in North Karnataka, South India

While traditional HIV prevention programs with female sex workers (FSWs) in Karnataka, India, have focused on reducing HIV transmission between FSWs and clients through increased condom use, these programs have not fully addressed the transmission risk between FSWs and their nonpaying intimate partners (IPs). Condom use is infrequent and violence is recurrent in these relationships: Furthermore, there is little evidence on the precise nature of FSW–IP relationships. Our study addresses this knowledge gap to inform HIV programs targeted at FSWs. A series of workshops, using participatory tools, was held to explore FSW-IP relationships; 31 FSWs and 37 IPs participated. Three aspects of FSW–IP relationships were examined: how FSWs and IPs understand and interpret their relationships, factors influencing condom use, and the role of violence and its consequences. FSWs wish to be perceived as their IPs’ wives, while IPs expect their FSW partners to accept their dominance in the relationship. Nonuse of condoms signals fidelity and elevates the status of the relationship almost to that of marriage, which helps FSWs enter the category of “good” (married) women. Tolerating and accepting violence in these relationships is normative, as in other marital relationships; IPs justify violence as necessary to establish and maintain their power within the relationship. Both FSWs and IPs value their relationships despite the high degree of risk posed by low condom use and high levels of violence. Implications for program design include addressing current norms around masculinity and gender roles, and improving communication within relationships.

Social Cohesion Among Sex Workers and Client Condom Refusal in a Canadian Setting: Implications for Structural and Community-Led Interventions

Community empowerment can be a powerful determinant of HIV risk among sex workers (SWs). This study modeled the impact of social cohesion on client condom refusal among SWs in Vancouver. Longitudinal data were drawn from a prospective cohort of SWs (2010-2013). Lippman and colleagues' Social Cohesion Scale measured SWs' connectedness (i.e., perception of mutual aid, trust, support). Multivariable logistic regression examined the independent effect of social cohesion on client condom refusal. Of 654 SWs, 22 % reported baseline client condom refusal and 34 % over 3 years. The baseline median social cohesion score was 24 (IQR 20-29, range 4-45). In the final confounding model, for every one-point increase in the social cohesion score, average odds of condom refusal decreased by 3 % (AOR 0.97; 95 % CI 0.95-0.99). Community empowerment can have a direct protective effect on HIV risk. These findings highlight the need for a legal framework that enables collectivization and SW-led efforts in the HIV response.

The role of dyad-level factors in shaping sexual and drug-related HIV/STI risks among sex workers with intimate partners

BACKGROUND

Despite high HIV burden among sex workers (SWs) globally, and relatively high prevalence of client condom use, research on potential HIV/STI risk pathways of intimate partnerships is limited. This study investigated partner/dyad-level factors associated with inconsistent condom use among SWs with intimate partners in Vancouver, Canada.

METHODS

Baseline data (2010-2013) were drawn from a community-based prospective cohort of women SWs. Multivariable generalized estimating equations logistic regression examined dyad-level factors associated with inconsistent condom use (<100% in last six months) with up to three male intimate partners per SW. Adjusted odds ratios and 95% confidence intervals were reported (AOR[95%CI]).

RESULTS

Overall, 369 SWs reported having at least one intimate partner, with 70.1% reporting inconsistent condom use. Median length of partnerships was 1.8 years, with longer duration linked to inconsistent condom use. In multivariable analysis, dyad factors significantly associated with increased odds of inconsistent condom use included: having a cohabiting (5.43[2.53-11.66]) or non-cohabiting intimate partner (2.15[1.11-4.19]) (versus casual partner), providing drugs (3.04[1.47-6.30]) or financial support to an intimate partner (2.46[1.05-5.74]), physical intimate partner violence (2.20[1.17-4.12]), and an intimate partner providing physical safety (2.08[1.11-3.91]); non-injection drug use was associated with a 68% reduced odds (0.32[0.17-0.60]).

CONCLUSIONS

Our study highlights the complex role of dyad-level factors in shaping sexual and drug-related HIV/STI risk pathways for SWs from intimate partners. Couple and gender-focused interventions efforts are needed to reduce HIV/STI risks to SWs through intimate partnerships. This research supports further calls for integrated violence and HIV prevention within broader sexual/reproductive health efforts for SWs.

Global epidemiology of HIV among female sex workers: influence of structural determinants

Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1-31) and 20% in Canada (95% UI 3-39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per μL could avert 34% (95% UI 25-42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8-36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33-46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.

HIV infection among female sex workers in concentrated and high prevalence epidemics: why a structural determinants framework is needed

PURPOSE OF REVIEW

This article reviews the current state of the epidemiological literature on female sex work and HIV from the past 18 months. We offer a conceptual framework for structural HIV determinants and sex work that unpacks intersecting structural, interpersonal, and individual biological and behavioural factors.

RECENT FINDINGS

Our review suggests that despite the heavy HIV burden among female sex workers (FSWs) globally, data on the structural determinants shaping HIV transmission dynamics have only begun to emerge. Emerging research suggests that factors operating at macrostructural (e.g., migration, stigma, criminalized laws), community organization (e.g., empowerment) and work environment levels (e.g., violence, policing, access to condoms HIV testing, HAART) act dynamically with interpersonal (e.g., dyad factors, sexual networks) and individual biological and behavioural factors to confer risks or protections for HIV transmission in female sex work.

SUMMARY

Future research should be guided by a Structural HIV Determinants Framework to better elucidate the complex and iterative effects of structural determinants with interpersonal and individual biological and behavioural factors on HIV transmission pathways among FSWs, and meet critical gaps in optimal access to HIV prevention, treatment, and care for FSWs globally.

Lessons learned from a review of interventions for adolescent and young key populations in Asia Pacific and opportunities for programming

BACKGROUND

Over a third of new HIV infections globally are among 15-24 year-olds and over 20% among adolescents aged 10-19 years in Asia Pacific. The review was initiated to identify interventions in the region with demonstrated or potential impact for adolescent and young key populations (YKP) looking at the role of individual and structural factors in accessibility and delivery. The review is a component of a more comprehensive review undertaken by UNICEF and partners in the region.

METHODS

This was a desk review of over 1000 articles, and 37 were selected. Journal articles in PubMed, Cochrane Library, Cochrane DARE, EMBASE, PsycINFO, CINAHL, and Web of Science databases were searched for HIV intervention-related information for adolescent and YKP.

RESULTS AND DISCUSSION

Findings showed that except for low levels of risk perception, most individual decisions regarding safe behavior and testing uptake were mediated by structural factors. Critical enablers such as design and delivery of services, peer education, and condom policies were associated with the uptake of high-impact interventions. Synergistic development interventions such as sexuality education, rights-based enforcement of antitrafficking laws, and addressing violence and abuse could increase safer behaviors.

CONCLUSIONS

Although structural factors play a key role in access and uptake of HIV prevention services for adolescent and YKP, further qualitative research is needed to understand and mitigate the drivers of vulnerability and constructed perceptions of risk.

Underage youth trading sex in the Philippines: trafficking and HIV risk

This study examines the socio-structural sexual health risks of female youth (aged 14-17) working in bar/spa venues and brothels in the Philippines, compared to their older counterparts. Aside from this study, few female sex work studies have interviewed youth under 18. On four southern Philippines islands, 770 female sex workers (FSWs), aged 14-48, were recruited from bar/spa venues and brothels to participate in a socio-structural HIV prevention study. Controlling for the effects of a larger HIV prevention intervention study involving 1484 female bar/spa workers, the minors, compared to older FSWs, had less education (AOR: 0.81, CI: 0.70-0.94), less children (AOR: 0.19, CI: 0.10-0.37), and were more likely to work in illegal brothels (AOR: 4.60, CI: 1.66-12.75) and to be high on drugs during sex (AOR: 2.26, CI: 1.39-3.67). It was less likely that anyone talked to them about HIV prevention (AOR: 0.32, CI: 0.15-0.72), but more likely they were recruited by venue owners (AOR: 5.67, 1.56-20.56) and were told by their managers to have sex without a condom (AOR: 6.80, CI: 2.06-22.39). Results suggest a need for organizational and policy level interventions to protect adolescent females from working in unsafe environments in the Philippines and to prevent youth from being recruited into high-risk situations.

Social support and recovery among Mexican female sex workers who inject drugs

This qualitative study describes social support that female sex workers who inject drugs (FSW-IDUs) receive and recovery efforts in the context of relationships with family and intimate partners. We conducted thematic analysis of in-depth interviews with 47 FSW-IDUs enrolled in an intervention study to reduce injection/sexual risk behaviors in Tijuana, Mexico. FSW-IDUs received instrumental and emotional social support, which positively and negatively influenced recovery efforts. Participants reported how some intimate partners provided conflicting positive and negative support during recovery attempts. Problematic support (i.e., well-intended support with unintended consequences) occurred in strained family relationships, limiting the positive effects of support. Mexican drug treatment programs should consider addressing social support in recovery curricula through evidence-based interventions that engage intimate partners, children and family to better reflect socio-cultural and contextual determinants of substance abuse.

Impact evaluation of a sexually transmitted disease preventive intervention among female sex workers in Hohhot, China

OBJECTIVES

The aim of this study was to evaluate the impact of HIV and sexually transmitted disease (STD) prevention interventions among female sex workers (FSWs) in the city of Hohhot in northern China.

METHODS

Three serial cross-sectional surveys were conducted in 2006, 2007, and 2008 among FSWs. A questionnaire was administered to the FSWs, and HIV and syphilis tests were performed for all participants. Intervention activities including condom promotion and provision, increased condom availability and accessibility, and voluntary HIV counseling and testing (VCT) were carried out among FSWs.

RESULTS

There were 624 participants in the 2006 survey, 444 in the 2007 survey, and 451 in the 2008 survey. The United Nations General Assembly Special Session (UNGASS) indicators for FSWs increased from 13.9% in 2006 to 37.7% in 2008 (p<0.001). The average rate of consistent condom use with commercial clients in the month preceding the interview increased significantly from 39.8% in 2006 to 59.6% in 2008 (p<0.001). Not a single HIV-positive case was found among the FSWs over these 3 years, and the prevalence of syphilis decreased remarkably from 9.5% in 2006 to 1.3% in 2008. Logistic regression analysis showed that sauna or hair salon work venues, receiving services from intervention programs, and accepting HIV tests were factors associated with consistent condom use.

CONCLUSIONS

The findings suggest that consistent condom use and awareness of HIV/AIDS prevention-related knowledge among FSWs have been improved by the intervention. Further prioritized and combined prevention programs aimed at FSWs are needed in order to prevent the HIV/AIDS epidemic spreading in the general population in China.

Social, psychological, and environmental-structural factors determine consistent condom use among rural-to-urban migrant female sex workers in Shanghai China

BACKGROUND

To determine potential social, psychological, and environmental-structural factors that may result in motivating female sex workers (FSWs), who are rural-to-urban migrants, and their paying partners in Shanghai, China to promote consistent condom use (CCU).

METHODS

A cross-sectional study was conducted in five districts of Shanghai, including three suburbs and two downtown locales. We adopted a cluster randomized sampling method to obtain 20 geographic sites, which consisted of 1 or more communities/villages proximal to a location where FSWs were accessible. Five hundred four FSWs from 132 Xitou Fang (shampoo wash rooms), massage parlors, and hair salons who explicitly provided sexual services were enrolled in the study. Each participant completed a questionnaire survey and interview aimed to collect information on the perceptions and behaviors of individuals associated with a risk for human immunodeficiency virus/acquired immunodeficiency syndrome(HIV/AIDS),self-efficacy at negotiating safe sex,and the physical, social, and policy environment of the establishments where they worked.

RESULTS

The percentage of FSWs who reported consistent condom use with their paying partners was 63.3%. Controlling for socio-demographic characteristics in multivariate analyses, environmental-structural support (OR, 3.96; CI, 2.52-6.22) for condom use was the most significant positive predictor of CCU among FSWs and their regular paying partners. A high perception of susceptibility and risk of HIV/AIDS (OR, 1.96; CI, 1.25-3.01), a high perception of benefits on condom use to protect themselves (OR, 2.06; CI, 1.32-3.22), and high safe sex self-efficacy (OR, 2.52; CI, 1.64-3.85) also play important roles on CCU based on multivariate analyses.

CONCLUSIONS

Environmental-structural factor support for condom use, in addition to social, psychological, and individual cognitive factors are significant predictors of CCU among FSWs, which should be assessed and addressed in research and interventions related to HIV/AIDS prevention among FSWs in China.