Gender based violence as a risk factor for HIV-associated risk behaviors among female sex workers in Armenia

Coping self-efficacy and social support as predictors of adolescent sex trafficking exit: Results of a secondary analysis

INTRODUCTION

Social work case management services are increasingly available to youth who want to exit commercial sexual exploitation (CSE). However, few empirical studies investigate the efficacy of such services, particularly whether these services promote an exit from CSE. Guided by ecological systems theory and the Intentions to Exit Prostitution (IEP) model, this study investigates the efficacy of social work case management services for youth CSE survivors.

METHODS

Youth survivors of CSE (n = 95) participated in a one-group, quasi-experimental double pre/posttest design study. Measures included the Multidimensional Scale of Perceived Social Support (MSPSS), Coping Self-Efficacy Scale (Cop-SE), and a modified version of the University of Rhode Island Change Assessment (URICA) surveys at zero- and six-months following study commencement. The research team also collected demographic and victimization data, the number and type of social work case management services received, and goal plan data. Analyses included repeated measures tests and linear and multinomial logistic regressions to determine if doses of social work case management are predictive of the positive short-term outcomes that are linked to increased readiness to exit CSE.

RESULTS

Youth CSE survivors experienced upward trends in perceived social support and coping self-efficacy scores between zero- and six-months following study commencement. Linear and logistic regressions demonstrated that variables like months of service time, trafficking classification, goal counts, race, and age can predict outcomes like survivor social support, coping self-efficacy, and intention to change behaviors that can lead to revictimization.

IMPLICATIONS

Results suggest social work case management services that improve coping self-efficacy and perceived social support can lead to cognitive changes that promote an exit from CSE. Practitioners should target services that adhere to dimensions of the IEP as these improvements are likely to support positive outcomes for youth survivors of CSE.

Reducing Partner Violence Against Women who Exchange Sex and use Drugs through a Combination Microfinance and HIV Risk Reduction Intervention: A Cluster Randomized Trial

Women who exchange sex and use drugs (WESUD) are at high risk for HIV infection and partner violence. The few tested interventions at the intersection of HIV and IPV show mixed results. This analysis examined the impact of a combination HIV risk reduction (HIVRR) and microfinance (MF) intervention on reported paying and intimate partner violence against WESUD in Kazakhstan. This cluster randomized controlled trial enrolled 354 women from 2015 to 2018 and randomized them to either a combination of HIVRR and MF intervention or HIVRR alone. Outcomes were assessed at four time points over 15 months. Logistic regression within a Bayesian approach assessed change in odds ratio (OR) of recent physical, psychological, or sexual violence perpetrated by current or past intimate partners; and paying partners/clients by study arm over time. Compared to the control arm, the combination intervention decreased the odds of participants experiencing physical violence from past intimate partners by 14% (OR = 0.861, p = 0.049). Women in the intervention group reported significantly lower rates of sexual violence from paying partners (HIVRR + MF - HIVRR: 25.9%; OR = 0.741, p = 0.019) at 12-month follow-up. No significant differences in rates from current intimate partners were found. A combination HIVRR and microfinance intervention may reduce gender-based violence from paying and intimate partners among WESUD above and beyond HIVRR interventions alone. Future research should examine how microfinance reduces partner violence and how to implement combination interventions in diverse settings.

Defiance and Strength: A Qualitative Study of Sex Trafficking Survivor-Advocate Coping Strategies

In the two decades since federal law prohibited the trafficking of humans for sexual or nonsexual services, researchers have generated knowledge related to the mental and physical health consequences of the experience, the individual and environmental factors that facilitate exploitation, and the best practices for prevention and intervention. Despite these advances in knowledge about human trafficking, relatively scant research has explored the resiliencies of survivors, as a deficit-based narrative persists when exploring and contemplating survivor experiences. While the movement increasingly recognizes the need to situate the survivor voice in service delivery, advocacy, and research, an inquiry that values survivor strengths remains nascent. Using the Intersectional-Standpoint Methodology (ISM) and phenomenology, this qualitative study explores the nuances of resiliency during exploitation and exit among seven sex trafficking survivor-advocates in a small midwestern state. Themes related to coping strategies, intrapersonal coping skills, and interpersonal coping skills were revealed and contextualized through the four variables proposed in ISM. Implications for service provision and policy are provided.

Association of gender-based violence with sexual and drug-related HIV risk among female sex workers who use drugs in Kazakhstan

BACKGROUND

Little is known about the prevalence of intimate partner violence (IPV) or client violence, and associated HIV risk among women who engage in sex work (WESW) and use drugs in Kazakhstan, despite a growing HIV epidemic.

METHODS

Women who reported engaging in sex work and using illicit drugs were recruited from Almaty and Temirtau, Kazakhstan between 2015 and 2017. A cross-sectional analysis was conducted to determine prevalence and correlates of physical and sexual violence perpetrated by intimate partners and clients. Associations between each type of violence with sexual and drug-related HIV risk behaviors were assessed with negative-binomial and logistic regression models, respectively.

RESULTS

Of the 400 women, 45% and 28% reported recent IPV and client violence, respectively. IPV and client violence was associated with a greater number of sex work clients [IPV: adjusted incidence rate ratio (aIRR)physical: 1.86, 1.28-2.71; aIRRsexual: 2.28, 1.56-3.35]; [client violence: aIRRphysical: 2.20, 1.44-3.42; aIRRsexual: 2.54, 1.72-3.83], and client violence was associated with greater frequency of condomless sex with clients [aIRRphysical: 2.33, 1.41-4.03; aIRRsexual: 2.16, 1.35-3.56]. Violence was not associated with injection drug use, despite exchanging sex for drugs being associated with higher odds of violence.

CONCLUSION

HIV prevention programs for WESW in Kazakhstan should consider multi-sectoral approaches that address economic hardship and relationship-based components, in addition to violence reduction.

Client-Perpetrated Violence Experience Among Female Sex Worker in Guangdong, South China: Results from a Cross-Sectional Study

Client-perpetrated violence (CPV) can lead to worse health consequences. However, little attention is paid to the CPV experience among Chinese female sex workers. Our study aimed to assess the association between CPV experience and health risk behaviors among FSWs in China. Data used in this study was from the baseline interviewer-administered questionnaire of a cluster randomized controlled trial conducted in June-October 2020. The collected information included sociodemographic characteristics, HIV/STI symptoms, number of clients, quality of the workplace, and past CPV experience. The association between violence experience and potential HIV/STI risk factors was explored using multivariable regression. Among 480 FSWs who participated in this study, 13.5% experienced CPV in the past. Compared to those who had never experienced CPV, FSWs who experienced CPV were more likely to report previous STI-related symptoms (aOR 4.29, 95% CI 1.73-10.64), more than 15 clients in the past month (aOR 2.56, 95% CI 1.18-5.52), a history of HIV testing (aOR 2.99, 95% CI 1.64-5.46), and work at low-tier workplaces (aOR 2.09, 95% CI 1.18-3.70). Overall, CPV prevalence is not low among Chinese FSWs, and there are some associations with HIV/STI risk factors; a future intervention targeting CPV in HIV/STI prevention programs is needed.

Does individual advocacy work?: A research and evaluation protocol for a youth anti-sex trafficking program

Introduction

Thousands of youth are sexually trafficked each year worldwide. Increased public attention to the commercial sexual exploitation (CSE) of children has resulted in the rapid deployment of hybrid community public health and social service programs for these vulnerable youth. Research on the effectiveness of these advocacy programs is lacking, particularly whether they decrease psychosocial distress and increase readiness to leave CSE.

Methods and analysis

Cisgender girls under age 18 at the time of CSE, and who were identified as at-risk for sex trafficking revictimization, were included in an evaluation of an anti-trafficking advocacy program in the North Texas region of the United States. The program includes crisis response, case management, referral, and mentoring services in collaboration with multi-disciplinary team (MDT) responses to identified youth sex trafficking. Case management notes, needs assessments and individualized treatment plans were collected at intake and every 30 days until study conclusion. Standardized surveys, including the Multidimensional Scale of Perceived Social Support (MSPSS), the Coping Self-Efficacy Scale, and the University of Rhode Island Change Assessment (URICA) were collected at intake and every 180 days until the study concluded. Analyses included descriptive statistics, paired t-tests, chi-square, multivariate linear and logistic regressions, Poisson regressions, and latent profile analysis.

Ethics and dissemination

This study was approved by the Texas Christian University’s Institutional Review Board (IRB). Results of this study will be presented to the scientific community at conferences and in peer-reviewed journals and non-scholarly outlets such as public health and social service conferences.

The role of local business employees and community members in the HIV risk environment of female sex workers in an urban setting: associations between negative interactions and inconsistent condom use

Background

The role of business employees and community members in the HIV risk environment of female sex workers (FSW) is underexplored, despite sex work often located in commercial and residential urban areas. We explored the effect of negative interactions between business employees and community members on inconsistent condom use with clients of female sex workers.

Methods

This study uses baseline data from the EMERALD study, a community empowerment intervention with FSW. We recruited a sample of 361 FSW in Baltimore, Maryland using targeted sampling techniques in ten zones characterized by high rates of sex work, located throughout the city. Participants were recruited between September 2017 and January 2019 and completed a survey, HIV rapid testing, and self-administered gonorrhea and chlamydia testing. The outcome, inconsistent condom use, was defined as not reporting “always” using condoms with paying clients. Poisson regressions with robust variance were used to model the effect of business employee and/or community member interactions on inconsistent condom use.

Results

Over half (54%) the sample was between 18 and 40 years old, 44% Black or another race, and experienced a range of structural vulnerabilities such as housing instability and food insecurity. Forty-four percent of the sample reported inconsistent condom use with clients. FSW reported being reported to the police weekly or daily for selling drugs (14% by employees, 17% by community), for selling sex (19% by employees, 21% by community), and experiencing weekly or daily verbal or physical threats (18% by employees, 24% by community). In multivariable models, being reported to the police for selling sex weekly or daily by community members (vs. never, aRR = 1.42, 95% CI = 1.08, 1.86) and business owners (vs. never, aRR = 1.36, 95% CI = 1.05, 1.76) increased risk of inconsistent condom use, as did monthly verbal or physical threats by community members (vs. never, aRR = 1.43, 95% CI = 1.08, 1.91).

Conclusions

Results show that both actors play important roles in FSWs’ HIV risk environment. Businesses and community members are important targets for holistic HIV prevention interventions among FSW in communities where they coexist in close proximity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12293-4.

Trafficking, Client and Police Violence, Sexual Risk and Mental Health Among Women in the Sex Industry at the Thai-Myanmar Border

This study describes sex trafficking and associations with violence and health among female migrants in the sex industry in Mae Sot, Thailand. The mixed-methods study included a qualitative interview phase (n = 10), followed by a cross-sectional survey phase (n = 128). Entry via trafficking (force, fraud, or coercion [FFC], or as minors) was prevalent (76.6%), primarily FFC (73.4%). FFC was associated with inconsistent condom use, inability to refuse clients, poor health, and anxiety. Past-year violence was normative including client sexual violence (66.4%), client coercion for condom nonuse (> 95%), and police extortion (56%). Working conditions enabled violence irrespective of mode of entry. Profound unmet needs exist for safety and access to justice irrespective of trafficking history.

The Intersection of Alcohol Use, Gender Based Violence and HIV: Empirical Findings among Disadvantaged Service-Seeking Youth in Kampala, Uganda

The SAVA syndemic is frequently used to describe the co-occurrence of HIV, gender-based violence (GBV), and substance use. In this study we determine the extent to which the typologies of the SAVA syndemic can be described and utilized for intervention strategies among youth living in the slums of Kampala, Uganda. We analyzed the “Kampala Youth Survey 2014,” a cross-sectional survey conducted in the spring of 2014, consisting of a convenience sample (N = 1134) of urban youth (12–18 years of age). Descriptive statistics were computed for hypothesized risk factors and demographic variables among the 8 typologies of GBV, HIV, and alcohol use. Multinomial logistic regression was conducted to determine statistically significant correlates with each typology. The overall prevalence of GBV was 31.7%, whereas the overall prevalence of alcohol use in the past 12 months was 31.2%. HIV-Positive youth comprised 10.5% of the total sample. Females comprised the majority of the typology with no SAVA components compared to males (55% vs. 45%, respectively), as well as the SAVA syndemic typology (GBV + HIV + ALC +) (58% vs. 42%, respectively). Engaging in commercial sex work (36%), witnessing parental abuse (61%), and depression/suicidality (81%) were all highly prevalent among youth in the SAVA syndemic typology (GBV, HIV, and alcohol use). Sex work and observing parental abuse were associated with the SAVA syndemic typology in the multivariable model. In our study, alcohol rarely coexisted without GBV among the typologies. Therefore, prevention efforts including structural interventions may be particularly warranted in vulnerable populations to address alcohol use, which may directly or indirectly impact GBV and HIV.

Polyvictimization Among Russian Sex Workers: Intimate Partner, Police, and Pimp Violence Cluster With Client Violence

Female sex workers (FSW) are a key population in the HIV epidemic and face high levels of violence. While women globally are predominantly at risk of intimate partner violence (IPV), FSW are additionally vulnerable to violence from clients, police, and pimps associated with their occupation. FSW are therefore at risk of cumulative trauma from polyvictimization, or violence from multiple types of perpetrators. Polyvictimization is a driver of morbidity and mortality in numerous populations, but there has been little research on how multiple types of victimization are related to one another in FSW. A cross-sectional survey was conducted among 754 FSW from three cities in the Russian Federation. Surveys assessed lifetime experiences of client, police, intimate partner, and pimp violence. Multivariate log-binomial and Poisson regression were used to test associations between these types of violence. Forty-five percent experienced any type of violence, including 31.7% from clients, 16.0% from police, 15.7% from intimate partners, and 11.4% from pimps. One fifth (20.4%) experienced polyvictimization. Client violence was central to polyvictimization: Only 5.9% of polyvictimization occurs without client violence. When client violence was not present, police, pimp, or IPV co-occurred significantly less than would be expected under an assumption that these types of violence occur independently (p < .001). However, they co-occurred more than would be expected when client violence is present. After adjusting for other types of violence experienced and demographic factors, experiencing client violence was independently associated with police violence (adjusted relative risk [ARR] = 2.77, 95% confidence interval [CI] [1.67, 4.59]), IPV (ARR = 3.67, 95% CI [1.95, 6.89]), and pimp violence (ARR = 5.26, 95% CI [2.80, 9.86]). Client violence may drive exposure to other types of violence and enable polyvictimization in a way that other types of violence do not in this setting. Violence prevention interventions may achieve maximal effect in reducing multiple types of violence by focusing on client violence.

Access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: Coverage, barriers and facilitators

The provision of comprehensive prevention services is vital for reducing the high burden of HIV amongst Ukrainian female sex workers (FSWs). To identify barriers and facilitators that influence access to HIV prevention amongst this population between 2009 and 2017, we developed a literature-informed conceptual framework and conducted a document analysis to identify the components of the Ukrainian prevention package (PP). Using the Integrated Bio Behavioural Surveillance Surveys, we then conducted descriptive analyses to explore PP coverage from 2009 to 2017 and the influence of factors, identified by our conceptual framework. After increasing over four years, a drop in PP coverage was observed from 2013 onwards. Being a client of a non-governmental organisation, street and highway solicitation, non-condom use, and knowledge of HIV may influence access to HIV prevention in the Ukrainian context. Future interventions should consider barriers and facilitators to HIV prevention and the multiple structural levels on which they operate.

"Yes, I'm interested in taking PrEP!": PrEP interest among women respondents to the European community-based survey "Flash! PrEP in Europe"

The World Health Organization recommends pre-exposure prophylaxis (PrEP) for all populations at substantial risk of HIV infection, including women. However, data regarding PrEP interest among women is lacking, particularly in Europe. Factors associated with interest in using PrEP were assessed among women respondents to the Flash! PrEP in Europe (FPIE) survey. This community-based cross-sectional study, conducted in 12 European countries, aimed to assess PrEP knowledge and interest. "High objective risk" (HOR) was assessed using established risk criteria following EACS and CDC guidelines. Factors associated with interest in using PrEP were assessed in univariable and multivariable logistic regression models. Among 678 women, 12.5% (n = 85) were considered at HOR, 46.8% (n = 317) indicated prior PrEP knowledge and 18.0% (n = 122) reported interest in using PrEP. Among women at HOR, 40.0% (n = 34) were interested in PrEP. Factors significantly associated with PrEP interest in the final multivariable model were: younger age (18-29 years) (aOR 1.91[95CI: 1.07; 3.41]), bad self-perceived financial status (1.84[1.09; 3.11]), migrant status (south to north) (2.87[1.05; 7.89]), single or dating relationship status (1.93[1.23; 3.03]), sexual abuse history (1.86[1.17; 2.97]), "rather high"/ "high" self-perceived HIV risk (3.21[1.32; 7.81]), and HOR (2.49[1.42; 4.35]). These results show that women at HOR and those who perceived themselves to be at high risk are interested in using PrEP. There is a critical need for targeted information and improved access to PrEP to increase uptake of this HIV prevention tool to meet PrEP interest among women.

Prevalence and Correlates of Forced Sex as a Self-Reported Mode of HIV Acquisition Among a Cohort of Women Living With HIV in Canada

Gender-based violence (GBV) is a global epidemic associated with increased HIV exposure. We assessed the prevalence and correlates of HIV acquisition via forced sex among women living with HIV (WLWH) in Canada. Baseline questionnaire data were analyzed for WLWH (≥16 years) with data on self-reported mode of HIV acquisition, enrolled in a community-based cohort study in British Columbia, Ontario, and Québec. We assessed forced sex (childhood, adulthood) as a self-reported mode of HIV acquisition. Of 1,330 participants, the median age was 42 (interquartile range [IQR] = 35-50) years; 23.5% were Indigenous, 26.3% African/Caribbean/Black, 43% White, and 7.2% of Other ethnicities. Forced sex was the third dominant mode of HIV transmission at 16.5% (n = 219; vs. 51.6% consensual sex, 19.7% sharing needles, 5.3% blood transfusion, 3.8% perinatal, 1.3% contaminated needles, 0.4% other, 1.6% do not know/prefer not to answer). In multivariable analyses, significant correlates of HIV acquisition from forced versus consensual sex included legal status as a landed immigrant (adjusted odds ratio [aOR] = 1.99; 95% confidence interval [CI] = [1.12, 3.54]) or refugee (aOR = 3.62; 95% CI = [1.63, 8.04]) versus Canadian citizen; African/Caribbean/Black ethnicity versus Caucasian (aOR = 2.49; 95% CI = [1.43, 4.35]), posttraumatic stress disorder symptoms (aOR = 3.00; 95% CI = [1.68, 5.38]), histories of group home residence (aOR = 2.40; 95% CI = [1.10, 5.23]), foster care (aOR = 2.18; 95% CI = [1.10, 4.34]), and having one child relative to having three or more children (aOR = 0.52; 95% CI = [0.31, 0.89]). GBV must be considered a distinct HIV risk factor; forced sex is a significant underrecognized risk factor and mode of women's HIV acquistion. Public health reporting systems can separate consensual and forced sex in reporting modes of HIV acquisition. Practitioners can engage in screening practices to meet client needs.

Syndemic Psychosocial Health Conditions Associated with Recent Client-Perpetrated Violence Against Female Entertainment and Sex Workers in Cambodia

Female entertainment and sex workers (FESW) are vulnerable to violence, which impedes safer sex behaviors and increases risk of HIV. FESW are also disproportionately affected by co-occurring psychosocial health conditions, including substance use, depression, and economic insecurity, which increased risk of exposure to violence. We used a syndemic framework to examine the effects of co-occurring psychosocial conditions on the risk of client-perpetrated physical and sexual violence against FESW. Data were collected among 1198 Cambodian FESW on recent client-perpetrated physical and sexual violence, and psychosocial conditions (psychological distress, alcohol consumption, amphetamine-type stimulant (ATS) use, debts, housing, and food insecurity). Bivariate and multivariate logistic regressions were conducted. Prevalence of physical and sexual violence from clients was 4.8% and 6.9%, respectively. Client-perpetrated physical violence was associated with housing insecurity, ATS use, and psychological distress. All psychosocial conditions, except ATS, were associated with exposure to sexual violence. In multivariable models, odds of client-perpetrated physical violence were twice higher among women with ≥ 4 compared to ≤ 3 psychosocial conditions. Risk of sexual violence increased with the number of psychosocial conditions. Compared to those with ≤ 1 condition, FESW with two psychosocial conditions had twice the odds (AOR = 2.08; 95% CI 1.00-4.31) and women with 5-6 psychosocial conditions had eightfold higher odds (AOR = 8.10; 95% CI 3.4-19.31) of sexual violence from clients. Our findings support a syndemic model of co-occurring psychosocial conditions among FESW that are associated with increased risk of violence. Violence prevention interventions targeting FESW should adopt comprehensive approaches that address co-occurring psychosocial conditions.

Barriers to Condom Use Among Female Sex Workers in Tehran, Iran: A Qualitative Study

Background

There are many barriers for condom use, which was one of the most important methods to prevent the transmission of HIV among female sex workers. Therefore, the aim of the present study was to identify the barriers to condom use among female sex workers in Tehran, Iran.

Methods

This study was conducted with a qualitative approach and conventional content analysis among female sex workers in Tehran. Twenty-two female sex workers were selected through snowball sampling and purposive sampling. The data gathering method was a semi-structured interview and the data were analyzed using Graneheim and Lundman method. Guba and Lincoln criteria were used for evaluating research transferability.

Results

The results of data analysis were categorized in three categories and seven sub-categories included 1) individual factors (not knowing HIV/AIDS properly, anti-loyalty and love, and personality traits), 2) structural factors (partner’s desire, problems with condom availability), and 3) cultural factors (cultural taboos, following the models).

Conclusion

The results showed that lack of condom use is the consequence of different individual, structural, and cultural factors. So, it can be useful to take some initiatives at the individual level by raising awareness and understanding of female sex workers about HIV at the structural level by lowering the price of condoms and providing them extensively and at the societal level, by changing the beliefs and taboos about condoms.

Inconsistent Condom Use Among Female Sex Workers: Partner-specific Influences of Substance Use, Violence, and Condom Coercion

Female sex workers (FSWs) are disproportionately affected by HIV. Inconsistent condom use (ICU) represents the most proximal risk for acquisition and transmission. We evaluate associations of partner-specific factors including physical and sexual violence, coercion, and substance use with ICU with clients and regular non-paying partners, respectively, among FSWs. Baseline survey data from a prospective cohort of 250 street-based FSW in Baltimore, Maryland, USA included partner-level drug and alcohol use, violence, condom coercion and ICU, in addition to individual and structural exposures. Logistic regression analyses were stratified by partner type, followed by path analysis where indicated. Within client and regular non-paying partnerships, FSWs reported prevalent recent violence (34.8%, 16%, respectively), condom coercion (42.4%, 9.9%, respectively) and ICU (39.2%, 44.4%, respectively). Recent physical or sexual violence enabled coercive condom negotiation (AOR_client 8.22, 95% CI 4.30, 15.73; AOR_{nonpayingpartner} 3.01 95% CI 1.05, 8.63). ICU with clients was associated with client condom coercion (AOR 1.76, 95% CI 1.03, 3.02), and client intoxication during sex (AOR 2.25, 95% CI 1.13, 4.45). In path analysis of client-FSW partnerships, condom coercion fully mediated the influences of both sex worker intoxication and recent violence on ICU. ICU with non-paying partners was associated with FSW intoxication during sex (AOR 8.66, 95% CI 3.73, 20.10), and past-year police violence (AOR 2.92, 1.30, 6.57). Partner-level substance use and gendered power differentials influenced FSWs' ICU patterns differently by partner type. ICU with clients was rooted solely in partner factors, and coercive condom negotiation mediated the roles of violence and partner-level substance use on ICU. By contrast, ICU with non-paying partners was rooted in partner-level substance use and police violence as a structural determinant. Addressing HIV risk behavior for FSWs requires condom promotion efforts tailored to partner type that addresses power differentials.

Psychosocial correlates of self-reported HIV among youth in the slums of Kampala

Background

Human immunodeficiency virus (HIV) rates are high in Uganda (6.7%), and rates are especially high among at-risk groups such as youth living in the slums of Kampala, Uganda. The objective of this study was to assess the psychosocial correlates, particularly alcohol use, associated with HIV among youth living in the slums of Kampala, Uganda.

Methods

Analyses are based on cross-sectional survey data collected in Spring of 2014. Participants comprised a convenience sample (N = 1134) of urban service-seeking youth living on the streets or in the slums, 12–18 years of age who were participating in a Uganda Youth Development Link drop-in center (56.1% female and 43.9% male). Chi-Square Tests were used to determine differences in the proportions of alcohol use patterns between self-reported HIV-positive and HIV-negative youth. Bivariate and multivariable logistic regression were conducted to determine the associated risk factors with self-reported HIV. Institutional Review Board approvals were obtained from the Georgia State University and the Uganda National Council for Science and Technology.

Results

Among the total sample of youth (N = 1103), 10.5% (n = 116) reported being HIV-positive. There were statistically significant differences between HIV-positive and HIV-negative youth on ever living on the streets (χ² =10.14, df = 1, p = 0.002), past 12-month alcohol use (χ² =16.38, df = 1, p < .0001), ever having sexual intercourse (χ² =14.52, df = 1, p = 0.0001), ever engaging in sex work (χ² =13.19, df = 1, p = 0.0003), inconsistent condom use in the past 3 months (χ² =5.03, df = 1, p = 0.03), and ever being raped (χ² =15.29, df = 1, p < 0.0001). A higher percentage of HIV-positive youth were classified as problem drinkers, defined by the CAGE scores (21.6% vs. 13.9%, respectively). In the multivariable analysis, previously being raped (OR: 1.70; 95% CI: 1.02, 2.83) and alcohol use without problem drinking (OR: 2.14; 95% CI: 1.24, 3.69) was associated with HIV.

Conclusion

Youth living in the slums of Kampala, Uganda have a high prevalence of HIV. These youth are in dire need of interventions which address both alcohol use behaviors and sexual risk behaviors to reduce further complications of their existing health conditions, including HIV.

Social and structural factors increase inconsistent condom use by sex workers' one-time and regular clients in Northern Uganda

While sex workers (SWs) bear the brunt of the epidemic in Uganda, there remains a dearth of empirical research on the structural drivers of HIV prevention among SWs. This study examined the drivers of inconsistent condom use by one-time and regular clients of young women SWs in Gulu, Northern Uganda. Data were drawn from the Gulu Sexual Health Study, a cross-sectional study of young SWs, aged 14 years and older (2011-2012). SWs were recruited using peer/SW-led outreach, in partnership with The AIDS Support Organization and other CBOs. Multivariable logistic regression was used to examine the correlates of inconsistent condom use by one-time and regular clients. In total, 84.5% of the 381 SWs servicing regular clients and 76.8% of the 393 SWs servicing one-time clients reported inconsistent client condom use. In multivariable analysis, physical/sexual violence by clients (AOR = 5.39; 95%CI 3.05-9.49), low sexual control by workers (measured by the validated Pulweritz scale) (AOR = 2.86; 95%CI 1.47-5.58), alcohol/drug use while working (AOR = 1.98; 95%CI 1.17-3.35) and migration to Gulu for sex work (AOR = 1.73; 95%CI 0.95-3.14) were positively correlated with inconsistent condom use by one-time clients. Correlates of inconsistent condom use by regular clients included: low sexual control by workers (AOR = 4.63; 95%CI 2.32-9.23); physical/sexual violence by clients (AOR = 3.48; 95%CI 1.85-6.53); police harassment (AOR = 2.57; 95%CI 1.17-5.65); and being a single mother (AOR = 2.07; 95%CI 1.09-3.93). Structural and interpersonal factors strongly influence inconsistent condom use by clients, with violence by clients and police, low sexual control by workers, migration and single-parenthood all linked to non-condom use. There is a need for peer-led structural interventions that improve access to occupational health and safety standards (e.g., violence prevention and alcohol/drug harm reduction policies/programming). Shifts away from the current punitive approaches towards SWs are integral to the success of such interventions, as they continue to undermine HIV prevention efforts.

Male labor migration, patriarchy, and the awareness-behavior gap: HIV risks and prevention among migrants' wives in Armenia

Unlike in most of the world, HIV incidence in the former Soviet Union continues to rise. While international labor migration has been identified as a potentially important contributor to this trend, most attention has been focused on risks of male migrants themselves. This study uses recent household survey data to examine HIV-related perceptions and actions of migrants' left-behind wives in Armenia. Multivariate logistic regression analyses show that migrants' wives are significantly more likely to suspect their husbands of extramarital sex than are non-migrants' wives. The analyses detect greater worries about HIV infection and a higher likelihood of spousal communication on HIV matters among migrants' wives, compared to non-migrants' wives, but these differences are largely explained by the suspicion of husband's extramarital sex. Finally, no difference between the two categories of women in the probability of consistent condom use with husbands is found. These findings are interpreted within the context of patriarchal culture and unequal gender relations in Armenian society as they are further reinforced by male migration. Implications of these findings for policies to increase women's awareness of HIV risks associated with migration and their ability to reduce those risks are discussed.

Reducing violence and increasing condom use in the intimate partnerships of female sex workers: study protocol for Samvedana Plus, a cluster randomised controlled trial in Karnataka state, south India

BACKGROUND

Female sex workers (FSWs) are at increased risk of HIV and STIs compared to women in the general population, and frequently experience violence in their working and domestic lives from a variety of perpetrators, which can enhance this risk. While progress has been made in addressing violence by police and clients, little work has been done to understand and prevent violence by intimate partners (IPs) among FSW populations.

METHODS

Samvedana Plus is a multi-level intervention programme that works with FSWs, their IPs, the sex worker community, and the general population, and aims to reduce violence and increase consistent condom use within these 'intimate' relationships. The programme involves shifting norms around the acceptability of beating as a form of discipline, challenging gender roles that give men authority over women, and working with men and women to encourage new relationship models based on gender equity and respect. The programme will aim to cover 800 FSWs and their IPs living in 47 villages in Bagalkot district, northern Karnataka. The study is designed to assess two primary outcomes: the proportion of FSWs who report: (i) physical or sexual partner violence; and (ii) consistent condom use in their intimate relationship, within the past 6 months. The evaluation will employ a cluster-randomised controlled trial design, with 50 % of the village clusters (n = 24) randomly selected to receive the intervention for the first 24 months and the remaining 50 % (n = 23) receiving the intervention thereafter. Statisticians will be blinded to treatment arm allocation. The evaluation will use an adjusted, cluster-level intention to treat analysis, comparing outcomes in intervention and control villages at midline (12 months) and endline (24 months). The evaluation design will involve quantitative and qualitative assessments with (i) all FSWs who report an IP (ii) IPs; and process/ implementation monitoring. Baseline data collection was completed in April 2015, and endline data collection is anticipated in May 2017.

CONCLUSIONS

This is an innovative intervention programme that aims to address violence by IPs as part of HIV prevention programming with FSWs. Reducing violence is expected to reduce vulnerability to HIV acquisition, and help women to work and live without fear of violence.

TRIAL REGISTRATION

Clinical Trials NCT02807259 Jun 24 2016 (retrospectively registered).

Association between violence exposure and condom non-use among transgender sex workers in the Dominican Republic: the mediating role of trust

Transgender women are a high-risk population, and transgender female sex workers are one of the most vulnerable populations globally. Transgender female sex workers have high rates of sexually transmitted infections, HIV, and exposure to violence compared to cisgender sex workers; these negative exposures are associated with an increase in HIV risk behaviors. Thus, the aim of this study is to examine the relationship between exposure to violence and condom non-use in transgender female sex workers residing in the Dominican Republic. We hypothesize that mediation exists wherein the effects of violence on condom non-use are mediated by distrust. Facilitated interview data ( N = 78) were used. Primary outcome was condom non-use with coercive partner. Four logistic regression models and a mediation analysis were employed. Respondents' mean age was 23.0 years (SD = 4.8) with an average level education attainment of 10.1 years (SD = 2.6); 35% reported experiencing violence; 17% believed that a person who asks a partner to use a condom does not trust that partner. Exploratory mediation analyses yielded a significant indirect effect of experience with violence on condom non-use through distrust (b = 0.64, SE = 0.33, p = .05). Results suggest that distrust mediates the association between experienced violence and condom use with coercive partners. It was concluded that developing interventions on increasing resilience and perceived self-worth, plus provision of screening for violence and referral services may reduce maladaptive attributions and cognitions about condom use. Furthermore, by implementing policies that protect vulnerable populations, and subsequently enforcing them, the Dominican Republic has the opportunity to improve overall population health and protect their most disadvantaged citizens.

Prevalence of HIV and Associated Risks of Sex Work among Youth in the Slums of Kampala

Purpose. The purpose of this study is to examine the prevalence of and risk factors for engaging in sex work among youth living in Kampala, Uganda. Methods. Analyses are based on a cross-sectional study (N = 1,134) of youth aged 12-18 years, living in the slums of Kampala, conducted in Spring of 2014. The analytic sample consisted of only sexually active youth (n = 590). Youth who reported engaging in sex work were compared to youth who did not report sex work. Multivariable analyses were conducted to examine factors associated with sex work. Results. Among the youth who had ever had sexual intercourse (n = 590), 13.7% (n = 81) reported engaging in sex work. Self-reported HIV prevalence was 13.9% among the total sample (n = 81) and 22.5% (n = 18) among youth engaged in sex work. Engaging in sex work was associated with being female (AOR 10.4; 95% CI: 3.9, 27.4), being an orphan (AOR 3.8; 95% CI: 1.7, 8.4), ever drinking alcohol (AOR 8.3; 95% CI 3.7, 19.0), and experiencing any rape (AOR 5.3; 95% CI: 2.9, 9.5). Discussion. The reported prevalence of sex work is high among youth in the slums of Kampala and is associated with high HIV prevalence, ever drinking alcohol, previously being raped, and being an orphan.

Psychological health and HIV transmission among female sex workers: a systematic review and meta-analysis

Current HIV prevention interventions for female sex workers (FSWs) have tended to target the cognitive factors in changing their behaviors, yet little attention has been paid to the psychological factors that influence the behavior of women in sex work. This review aimed to explore the associations between the psychological health of FSWs and HIV risk. A total of eight studies published in English before July 2013 were identified and reviewed. FSWs had reported psychological issues, including depression, suicidal thoughts as well as lower quality of life, and the pooled prevalence of probable depression was as high as 62.4%. The majority of studies showed that higher scores in psychological health problems were associated with increased HIV risk behavior, in particular inconsistent condom use, or sexually transmitted infections. Among the five studies which measured symptoms of depression, four documented that higher depression scores were significantly associated with inconsistent condom use among FSWs with their clients and/or partners. Meta-analysis using a fixed-effects model was performed to examine the association between depression and inconsistent condom use and found that higher scores in depression were significantly associated with inconsistent condom use (odds ratio = 2.57, p < .001). This review contends that future HIV preventive interventions should take psychological health of FSWs into consideration.

HIV Risks, Testing, and Treatment in the Former Soviet Union: Challenges and Future Directions in Research and Methodology

Background

The dissolution of the USSR resulted in independence for constituent republics but left them battling an unstable economic environment and healthcare. Increases in injection drug use, prostitution, and migration were all widespread responses to this transition and have contributed to the emergence of an HIV epidemic in the countries of former Soviet Union. Researchers have begun to identify the risks of HIV infection as well as the barriers to HIV testing and treatment in the former Soviet Union. Significant methodological challenges have arisen and need to be addressed. The objective of this review is to determine common threads in HIV research in the former Soviet Union and provide useful recommendations for future research studies.

Methods

In this systematic review of the literature, Pubmed was searched for English-language studies using the key search terms "HIV", "AIDS", "human immunodeficiency virus", "acquired immune deficiency syndrome", "Central Asia", "Kazakhstan", "Kyrgyzstan", "Uzbekistan", "Tajikistan", "Turkmenistan", "Russia", "Ukraine", "Armenia", "Azerbaijan", and "Georgia". Studies were evaluated against eligibility criteria for inclusion.

Results

Thirty-nine studies were identified across the two main topic areas of HIV risk and barriers to testing and treatment, themes subsequently referred to as "risk" and "barriers". Study design was predominantly cross-sectional. The most frequently used sampling methods were peer-to-peer and non-probabilistic sampling. The most frequently reported risks were condom misuse, risky intercourse, and unsafe practices among injection drug users. Common barriers to testing included that testing was inconvenient, and that results would not remain confidential. Frequent barriers to treatment were based on a distrust in the treatment system.

Conclusion

The findings of this review reveal methodological limitations that span the existing studies. Small sample size, cross-sectional design, and non-probabilistic sampling methods were frequently reported limitations. Future work is needed to examine barriers to testing and treatment as well as longitudinal studies on HIV risk over time in most-at-risk populations.

Understanding the experiences and needs of female commercial sex workers in Kathmandu, Nepal

Through this exploratory study, we sought to better understand Nepali female commercial sex workers' (FCSWs') experiences in order to inform HIV prevention and health promotion interventions for this vulnerable and hard-to-reach population. Data were collected through phenomenological interviews with eight FCSWs. Through analysis we reveal promising intervention points to enhance FCSW health, empowerment, and overall well-being. Researchers suggest a combination of structural and individual programs is essential to improving the circumstances of Nepali FCSWs and preventing the spread of HIV. Given Nepal's limited resources and complex environment, it is imperative future prevention programs are focused and guided by FCSWs' lived experiences.

HIV and gender-based violence: welcome policies and programmes, but is the research keeping up?

The global HIV policy arena has seen a surge of interest in gender-related dimensions of vulnerability to HIV and violence. UNAIDS and other prominent actors have named gender-based violence a key priority, and there seems to be genuine understanding and commitment to addressing gender inequalities as they impact key populations in the AIDS response. In the quest for evidence-informed interventions, there is usually a strong connection between the research conducted and the policies and programmes that follow. Regarding gender, HIV and violence, is this the case? This discussion paper asks whether the relevant peer-reviewed literature is suitably representative of all affected populations--including heterosexual men, transgender men and women, women who have sex with women, and men who have sex with men--as well as whether the literature sufficiently considers gender norms and dynamics in how research is framed. Conclusions about violence in the context of heterosexual relationships, and with specific attention to heterosexual women, should not be presented as insights about gender-based violence more generally, with little attention to gender dynamics. Research framed by a more comprehensive understanding of what is meant by gender-based violence as it relates to all of the diverse populations affected by HIV would potentially guide policies and programmes more effectively.

Declines in violence and police arrest among female sex workers in Karnataka state, south India, following a comprehensive HIV prevention programme

Introduction

Female sex workers (FSWs) frequently experience violence, harassment and arrest by the police or their clients, but there is little evidence as to the impact that such factors may have on HIV risk or whether community interventions could mitigate this impact.

Methods

As part of the evaluation of the Avahan programme in Karnataka, serial integrated behavioural and biological assessment (IBBA) surveys (four districts) (2005 to 2011) and anonymous polling booth surveys (PBS) (16 districts) (2007 to 2011) were conducted with random samples of FSWs. Logistic regression analysis was used to assess 1) changes in reported violence and arrests over time and 2) associations between violence by non-partners and police arrest and HIV/STI risk and prevalence. Mediation analysis was used to identify mediating factors.

Results

5,792 FSWs participated in the IBBAs and 15,813 participated in the PBS. Over time, there were significant reductions in the percentages of FSWs reporting being raped in the past year (PBS) (30.0% in 2007, 10.0% in 2011, p<0.001), being arrested in the past year [adjusted odds ratio (AOR) 0.57 (0.35, 0.93), p=0.025] and being beaten in the past six months by a non-partner (clients, police, pimps, strangers, rowdies) [AOR 0.69 (0.49, 0.95), p=0.024)] (IBBA). The proportion drinking alcohol (during the past week) also fell significantly (32.5% in 2005, 24.9% in 2008, 16.8% in 2011; p<0.001). Violence by non-partners (being raped in the past year and/or beaten in the past six months) and being arrested in the past year were both strongly associated with HIV infection [AOR 1.59 (1.18, 2.15), p=0.002; AOR 1.91 (1.17, 3.12), p=0.01, respectively]. They were also associated with drinking alcohol (during the past week) [AOR 1.98 (1.54, 2.53), p<0.001; AOR 2.79 (1.93, 4.04), p<0.001, respectively], reduced condom self-efficacy with clients [AOR 0.36 (0.27, 0.47), p<0.001; AOR 0.62 (0.39, 0.98), p=0.039, respectively], symptomatic STI (during the past year) [AOR 2.62 (2.07, 3.30), p<0.001; AOR 2.17 (1.51, 3.13), p<0.001, respectively], gonorrhoea infection [AOR 2.79 (1.51, 5.15), p=0.001; AOR 2.69 (0.96, 7.56), p=0.060, respectively] and syphilis infection [AOR 1.86 (1.04, 3.31), p=0.036; AOR 3.35 (1.78, 6.28), p<0.001, respectively], but not with exposure to peer education, community mobilization or HIV testing uptake. Mediation analysis suggests that alcohol use and STIs may partially mediate the association between violence or arrests and HIV prevalence.

Discussion

Violence by non-partners and arrest are both strongly associated with HIV infection among FSWs. Large-scale, comprehensive HIV prevention programming can reduce violence, arrests and HIV/STI infection among FSWs.

Declines in violence and police arrest among female sex workers in Karnataka state, south India, following a comprehensive HIV prevention programme

INTRODUCTION

Female sex workers (FSWs) frequently experience violence, harassment and arrest by the police or their clients, but there is little evidence as to the impact that such factors may have on HIV risk or whether community interventions could mitigate this impact.

METHODS

As part of the evaluation of the Avahan programme in Karnataka, serial integrated behavioural and biological assessment (IBBA) surveys (four districts) (2005 to 2011) and anonymous polling booth surveys (PBS) (16 districts) (2007 to 2011) were conducted with random samples of FSWs. Logistic regression analysis was used to assess 1) changes in reported violence and arrests over time and 2) associations between violence by non-partners and police arrest and HIV/STI risk and prevalence. Mediation analysis was used to identify mediating factors.

RESULTS

5,792 FSWs participated in the IBBAs and 15,813 participated in the PBS. Over time, there were significant reductions in the percentages of FSWs reporting being raped in the past year (PBS) (30.0% in 2007, 10.0% in 2011, p<0.001), being arrested in the past year [adjusted odds ratio (AOR) 0.57 (0.35, 0.93), p=0.025] and being beaten in the past six months by a non-partner (clients, police, pimps, strangers, rowdies) [AOR 0.69 (0.49, 0.95), p=0.024)] (IBBA). The proportion drinking alcohol (during the past week) also fell significantly (32.5% in 2005, 24.9% in 2008, 16.8% in 2011; p<0.001). Violence by non-partners (being raped in the past year and/or beaten in the past six months) and being arrested in the past year were both strongly associated with HIV infection [AOR 1.59 (1.18, 2.15), p=0.002; AOR 1.91 (1.17, 3.12), p=0.01, respectively]. They were also associated with drinking alcohol (during the past week) [AOR 1.98 (1.54, 2.53), p<0.001; AOR 2.79 (1.93, 4.04), p<0.001, respectively], reduced condom self-efficacy with clients [AOR 0.36 (0.27, 0.47), p<0.001; AOR 0.62 (0.39, 0.98), p=0.039, respectively], symptomatic STI (during the past year) [AOR 2.62 (2.07, 3.30), p<0.001; AOR 2.17 (1.51, 3.13), p<0.001, respectively], gonorrhoea infection [AOR 2.79 (1.51, 5.15), p=0.001; AOR 2.69 (0.96, 7.56), p=0.060, respectively] and syphilis infection [AOR 1.86 (1.04, 3.31), p=0.036; AOR 3.35 (1.78, 6.28), p<0.001, respectively], but not with exposure to peer education, community mobilization or HIV testing uptake. Mediation analysis suggests that alcohol use and STIs may partially mediate the association between violence or arrests and HIV prevalence.

DISCUSSION

Violence by non-partners and arrest are both strongly associated with HIV infection among FSWs. Large-scale, comprehensive HIV prevention programming can reduce violence, arrests and HIV/STI infection among FSWs.

Intimate-Partner and Client-Initiated Violence among Female Street-Based Sex Workers in China: Does a Support Network Help?

Background

Globally, female street-based sex workers are vulnerable to gender-based violence. Previous research has shown having a peer social network can reduce sex workers’ risks of victimization. However, mechanisms of how social network impacts violence among female street-based sex workers are still far from clear.

Methods

Our study was based on data abstracted from a paper-and-pencil survey administered among 218 female street-based sex workers in Shanghai, China. We focused on self-reported client-initiated violence and intimate-partner violence in emotional, physical, and sexual forms. Social networks were characterized by the size and sources of financial and psychosocial support (e.g. family, friends, and peers). Multi-variable logistic regression was used to estimate adjusted odds ratios (AOR) of each type of violence exposure by social network structure after the adjustment of age, education, and years in Shanghai.

Results

The street-based female sex workers in our study were primarily rural-to-urban migrants (95.7%) with an average age of 41 years old. 24.3% and 62.8% of the sex workers reported intimate-partner violence and client-initiated violence respectively. Lack of financial support, as defined by having only one individual or none in her peer support system to help financially, was significantly associated with self-reported intimate-partner violence (AOR: 2.5; 95% CI: 1.1–5.9). Respondents who reported client-initiated violence, by contrast, were more likely to report lacked psychosocial support from family (AOR: 2.2, 95% CI: 1.0–4.6) and peers (AOR: 5.1, 95% CI: 2.2–11).

Conclusion

This study is one of the first to systematically analyze the associations between social network and gender-based violence among street-based female sex worker. We reported a high prevalence of both types of gender-based violence and their complex associations with family, friends, and peer support network. Policies with goals to reduce violence against women may apply these findings to leverage social network in the interventions against gender-based violence.

Sexual violence, condom negotiation, and condom use in the context of sex work: results from two West African countries

BACKGROUND

Female sex workers (FSWs) are vulnerable to violence within and beyond the workplace. Violence is associated with increased burden of HIV, possibly explained through physiologic or behavioral causal pathways. These analyses sought to determine the relationship between lifetime sexual violence with unprotected, condomless vaginal intercourse (UVI) among FSWs in West Africa.

METHODS

FSWs (aged ≥18 years) were recruited into a cross-sectional study through respondent-driven sampling in two West African countries, Togo and Burkina Faso. A total of 1380 participants were enrolled from January to July 2013, and completed a sociobehavioral questionnaire and HIV testing. Measures included sex work history, lifetime experiences of violence victimization, sexual practices, and UVI (past month). Crude and adjusted robust log binomial regression was conducted to estimate prevalence ratios (PrR) as a measure of association between UVI with clients and the primary exposure, forced sex.

RESULTS

Self-reported lifetime physical abuse (47.3%), forced sex (33.0%), and any violence (57.9%) were common. Almost one-quarter (23.9%) reported recent UVI with clients. History of forced sex was independently associated with recent UVI with clients [vs. none, adjusted PrR: 1.49; 95% confidence interval (CI): 1.18 to 1.88], with evidence of partial mediation by difficult condom negotiation with regular (aPrR: 1.83; 95% CI: 1.43 to 2.34) and new clients (aPrR: 1.60; 95% CI: 1.13 to 2.29).

DISCUSSION

These data demonstrate the significant relationship between sexual violence experienced by FSWs and unprotected sex with clients. Comprehensive interventions reducing vulnerabilities to violence combined with improved condom negotiation are needed to address the complex influences of condom use during sex work as a means of ultimately lowering HIV acquisition and transmission.

Human rights violations against sex workers: burden and effect on HIV

We reviewed evidence from more than 800 studies and reports on the burden and HIV implications of human rights violations against sex workers. Published research documents widespread abuses of human rights perpetrated by both state and non-state actors. Such violations directly and indirectly increase HIV susceptibility, and undermine effective HIV-prevention and intervention efforts. Violations include homicide; physical and sexual violence, from law enforcement, clients, and intimate partners; unlawful arrest and detention; discrimination in accessing health services; and forced HIV testing. Abuses occur across all policy regimes, although most profoundly where sex work is criminalised through punitive law. Protection of sex workers is essential to respect, protect, and meet their human rights, and to improve their health and wellbeing. Research findings affirm the value of rights-based HIV responses for sex workers, and underscore the obligation of states to uphold the rights of this marginalised population.

Correlates of Inconsistent Refusal of Unprotected Sex among Armenian Female Sex Workers

This cross-sectional study assessed the prevalence and correlates of inconsistent refusal of unprotected sex among female sex workers (FSWs) in Armenia. One hundred and eighteen street-based FSWs between the ages of 20 and 52 completed a questionnaire assessing FSWs' demographic, psychosocial, and behavioral characteristics. A total of 52.5% (n = 62) of FSWs reported inconsistent refusal of unprotected sex with clients in the past 3 months. Logistic regression analysis controlling for participants' age and education revealed that perceiving more barriers toward condom use (AOR = 1.1; P < 0.01), reporting more types of abuse (AOR = 2.1; P < 0.01), and setting lower fees for service (AOR = 0.9; P = 0.02) significantly predicted inconsistent refusal of unprotected sex. HIV-risk-reduction behavioral interventions tailored to FSWs working in Yerevan Armenia should address the factors identified in this study toward the goal of enhancing refusal of unprotected sex and ultimately preventing acquisition of sexually transmitted infections (STIs) including HIV.

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.

Enhancing benefits or increasing harms: community responses for HIV among men who have sex with men, transgender women, female sex workers, and people who inject drugs

Studies completed over the past 15 years have consistently demonstrated the importance of community-level determinants in potentiating or mitigating risks for the acquisition and transmission of HIV. Structural determinants are especially important in mediating HIV risk among key populations, including men who have sex with men, people who inject drugs, sex workers of all genders, and transgender women. The objective of this systematic review was to synthesize the evidence characterizing the community-level determinants that potentiate or mitigate HIV-related outcomes for key populations. The results of the review suggest that although health communication programs represent community-level strategies that have demonstrated the effectiveness in increasing the uptake of HIV testing and decreasing the experienced stigma among people living with HIV, there are limited studies focused on key populations in low- and middle-income settings. Moreover, interpretation from the 22 studies that met inclusion and exclusion criteria reinforce the importance of the continued measurement of community-level determinants of HIV risks and of the innovation in tools to effectively address these risks as components of the next generation of the HIV response. Consequently, the next generation of effective HIV prevention science research must improve our understanding of the multiple levels of HIV risk factors, while programming for key populations must address each of these risk levels. Failure to do so will cost lives, harm communities, and undermine the gains of the HIV response.

Access to antiretroviral therapy and survival in eastern Europe and central Asia: a case study in Armenia

Introduction

Antiretroviral therapy (ART) substantially improves the health of people living with HIV and contributes to preventing new infections. While HIV incidence is decreasing in most regions, the epidemic in eastern Europe continues to rise, as new infections currently outnumber the rate of ART initiation. In this study, we assess ART use in Armenia and its impact on the number of AIDS diagnoses and mortality.

Methods

National surveillance data were obtained from the National Centre for AIDS Prevention, Armenia. Cox-proportional hazard models were used to determine the effect of demographic and clinical risk factors, including access to ART, on AIDS and mortality.

Results

Among people diagnosed with HIV since 2005, approximately 40% per year were diagnosed with CD4<200 cells per mL. Overall, 232 people (57.1%) with AIDS or a low CD4 count had not received ART by the end of 2010. Mortality was 34.1% among people living with HIV who did not initiate ART, and 0.3% among people who received ART. Among people diagnosed with HIV from 1996 to 2010, age at diagnosis, no use of ART, likely mode of transmission, likely place of transmission, low baseline CD4 count and no STI diagnosis at last contact are significantly associated with death.

Discussion

In Armenia, HIV is frequently diagnosed at a late stage of disease, indicating low testing rates. Of people diagnosed with HIV and in need of ART, a large proportion (approximately 60%) either do not provide consent for treatment, or are who migrants who cannot be located.

Conclusions

Globally, the scale-up of ART has resulted in substantial reductions in mortality among individuals initiating therapy. However, in an era of momentum for treatment as prevention, treatment levels are not at adequate levels for preventing morbidities and mortality in some settings. Particular focus should be placed on key at-risk subgroups.

Work-related violence and inconsistent condom use with non-paying partners among female sex workers in Adama City, Ethiopia

BACKGROUND

Although reported condom use between female sex workers and their clients is high in Ethiopia, condom use with regular, non-paying partners remains low, posing a substantial risk of HIV infection to sex workers, their partners and the general population. Previous studies have identified the synergistic effects of substance abuse, violence and HIV risk, but few have examined these inter-relationships among female sex workers and their regular, non-paying partners. This study explored the associations between work-related violence, alcohol abuse and inconsistent condom use among establishment-based female sex workers and their regular, non-paying partners in Adama City, Ethiopia.

METHODS

A cross-sectional survey was conducted with 350 establishment-based female sex workers, aged 15-35, at 63 bars, hotels and nightclubs. Multivariate logistic regression analysis was conducted to test the association between work-related violence and condom use with regular, non-paying partners, controlling for age, overall income, education and sex workers' total number of sexual partners in the past week. Alcohol abuse was explored as an effect modifier.

RESULTS

Respondents reported a high prevalence of work-related violence (59%) and alcohol abuse (51%). Work-related violence was statistically significantly associated with unprotected sex with regular, non-paying partners among those who abused alcohol (OR: 6.34, 95% CI: 2.43-16.56) and among those who did not (OR: 2.98, 95% CI: 1.36-6.54). Alcohol abuse was not associated with inconsistent condom use within these partnerships, though it may strengthen the effect of work-related violence on unprotected sex.

CONCLUSIONS

Findings suggest violence against establishment-based female sex workers is associated with HIV risk within regular, non-paying partnerships. Qualitative work is needed to better understand the links between a violent work environment and condom use with regular, non-paying partners and how interventions can be implemented in this context to prevent violence against sex workers and reduce HIV transmission.

Heterosexual anal intercourse: a neglected risk factor for HIV?

Heterosexual anal intercourse confers a much greater risk of HIV transmission than vaginal intercourse, yet its contribution to heterosexual HIV epidemics has been under-researched. In this article we review the current state of knowledge of heterosexual anal intercourse practice worldwide and identify the information required to assess its role in HIV transmission within heterosexual populations, including input measures required to inform mathematical models. We then discuss the evidence relating anal intercourse and HIV with sexual violence.

Violence as a barrier for HIV prevention among female sex workers in Argentina

BACKGROUND

Violence against female sex workers (FSWs) has been increasingly reported as an important determinant of HIV infection risk. This study explores the frequency of different violent experiences (sexual abuse, rejection, beating and imprisonment) among FSWs in Argentina and its association with condom use and HIV and T. pallidum prevalence.

METHODS

A convenience sample of 1255 FSWs was included in a cross-sectional study conducted between October 2006 and November 2009.

RESULTS

Sexual abuse was reported by 24.1% (219/907) of women. A total of 34.7% (42/1234) reported rejection experiences, 21.9% (267/1215) reported having been beaten and 45.4% (561/1236) stated having been arrested because of their sex work activity. There was a higher frequency of inconsistent condom use with clients among FSWs who had experienced sexual abuse, rejection, and police detention. A higher frequency of HIV and T. pallidum infection was detected among FSWs who reported having been arrested by the police.

CONCLUSION

The study shows for the first time the frequency of different violent situations among FSWs in Argentina. The association between violence against sex workers, condom use and STI prevalence demonstrated here calls for measures to reduce stigma and violence against FSWs. Such violent experiences may increase vulnerability to STI through coerced unprotected sex.