Context matters: the moderating role of bar context in the association between substance use during sex and condom use among male clients of female sex workers in Tijuana, Mexico

Joint effects of alcohol and stimulant use disorders on self-reported sexually transmitted infections in a prospective study of Cambodian female entertainment and sex workers

Female entertainment and sex workers (FESW) have high rates of alcohol and amphetamine-type stimulant (ATS) use, increasing risk for HIV/sexually transmitted infections (STI), and other negative outcomes. A prospective cohort of 1,198 FESW in a HIV/ATS use prevention intervention in Cambodia was assessed for alcohol and stimulant use disorders (AUD and SUD) using the Alcohol and Substance Use Involvement (ASSIST) scale. STI history was measured by self-report at baseline and at quarterly follow-up visits. Participants were asked if they had been diagnosed with an STI by a medical provider in the past 3 months. Marginal structural models were used to estimate joint effects of AUD and SUD on recent STI. At baseline, one-in-four screened AUD positive and 7% screened positive for SUD. At 18-months, 26% reported ≥1 recent STI. Accounting for time-varying and other known confounders, the adjusted odds ratio (AOR) for recent STI associated with AUD alone and SUD alone were 2.8 (95% CI:1.5-5.1) and 3.5 (95% CI:1.1-11.3), respectively. The AOR for joint effects of AUD and SUD was 5.7 (95% CI:2.2-15.2). AUD and SUD are independently and jointly associated with greater odds of STI among Cambodian FESW. Further research is critical for understanding how AUD and SUD potentiate biological and behavioural pathways that influence STI acquisition and to inform HIV risk-reduction interventions in FESW.

Prevalence of Substance Use Among Patients of Community Health Centers in East Los Angeles and Tijuana

BACKGROUND

Given the increased use of psychoactive substances on the United States-Mexico border, a binational study (Tijuana, Mexico-Los Angeles, USA) was conducted to identify the prevalence of substance use in primary care settings.

OBJECTIVES

To compare the prevalence and characteristics of patients at risk for substance use disorders in Tijuana and East Los Angeles (LA) community clinics with special attention paid to drug use.

METHODS

This was an observational, cross-sectional, analytical study, comparing substance use screening results from patients in Tijuana and LA. The settings were 2 community clinics in LA and 6 in Tijuana. Participants were 2,507 adult patients in LA and 2,890 in Tijuana eligible for WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) screening during March-October 2013. Patients anonymously self-administered the WHO ASSIST on a tablet PC in the clinic waiting rooms.

RESULTS

Of eligible patients, 96.4% completed the ASSIST in Tijuana and 88.7% in LA (mean 1.34 minutes and 4.20 minutes, respectively). The prevalence of patients with moderate-to-high substance use was higher in LA than Tijuana for each substance: drugs 19.4% vs. 5.7%, alcohol 15.2% vs. 6.5%, tobacco 20.4% vs. 16.2%. LA patients born in Mexico had 2x the odds and LA patients born in the United States had 6x the odds of being a moderate-to-high drug user compared to Tijuana patients born in Mexico.

CONCLUSIONS

Moderate-to-high drug use is higher in LA than in Tijuana but rates are sufficiently high in both to suggest that screening for drug use (along with alcohol and tobacco use) should be integrated into routine primary care of community clinics in both cities.

A mixed methods study of the social support networks of female sex workers and their primary noncommercial male partners in Tijuana, Mexico

Female sex workers (FSWs) are at risk for multiple health harms, including HIV. This article describes a mixed methods study of the social support networks of 19 FSWs and their primary male sex partners in Tijuana, Mexico. We collected quantitative and qualitative social network data, including quantitative network measures, qualitative narratives, and network visualizations. Methodologically, we illustrate how a convergent mixed methods approach to studying personal social support networks of female sex workers can yield a more holistic understanding of network composition and role. From a health-related perspective, we show how migration/deportation and stigma shape social networks and might be leveraged to support HIV prevention interventions. We believe others can benefit from a mixed methods approach to studying social networks.

High prevalence of unhealthy alcohol use and comparison of self-reported alcohol consumption to phosphatidylethanol among women engaged in sex work and their male clients in Cambodia

BACKGROUND

In Cambodia, most of the female sex workers (FSW) work in venues where unhealthy alcohol use is ubiquitous and potentially contributing to the HIV epidemic. However, no accurate data exists. We compare self-reported unhealthy alcohol consumption to a biomarker of alcohol intake in Cambodian FSW and male clients, and determine factors associated with unhealthy alcohol use.

METHODS

A cross-sectional study was conducted among FSW (n=100) and male clients (n=100) in entertainment and sex work venues in Cambodia. Self-reported unhealthy alcohol use (AUDIT-C) was compared to phosphatidylethanol (PEth) positive (≥50ng/ml), a biomarker of alcohol intake. Sociodemographics data was collected. Correlates of self-reported unhealthy alcohol use and PEth positive were determined.

RESULTS

The prevalence of PEth positive in FSW was 60.0%. Self-reported unhealthy alcohol consumption was reported by 85.0% of the women. Almost all women (95.0%) testing PEth positive also reported unhealthy alcohol use. Prevalence of unhealthy alcohol consumption (self-report and PEth positive) was higher in FSW working in entertainment establishments compared to other sex work venues (p<0.01). Among male clients, 47.0% reported unhealthy alcohol consumption and 42.0% had a PEth positive. However, only 57.1% of male clients with PEth positive reported unhealthy alcohol use.

CONCLUSIONS

Unhealthy alcohol consumption is prevalent in Cambodian sex work settings. Self-reported unhealthy alcohol use is well reported by FSW, but less by male clients. These findings highlight the urgency of using accurate measures of unhealthy alcohol consumption and integrating this health issue into HIV prevention interventions.

Correlates of unprotected sex with male clients among female sex workers in 13 Mexican cities

This study examined correlates of unprotected vaginal and anal sex (UVA) with male clients among female sex workers (FSWs). Baseline data were gathered from 1089 FSWs recruited from 13 cities across Mexico enrolled in an evidence-based sexual risk reduction intervention. We used generalised estimating equations (GEE) to predict total UVA while controlling for the nested structure of the data. Total UVA with clients in the past month was examined in relation to selected sociodemographic, substance-use, and micro- and macro-environmental factors. A greater number of UVA acts was associated with three micro-level environmental factors (i.e. never getting condoms for free, unaffordability of condoms, greater number of clients per month), and three macro-level environmental factors (i.e. lower health and higher education indices, greater population size of city). These findings suggest the development of social and structural approaches to HIV prevention for FSWs in Mexico, including modification of venue-based policies that pressure FSWs to maximise client volume, changes to the work environment that promote availability and affordability of condoms, and improved population health. Moreover, our findings call for the development of context-specific HIV interventions that take into account variations in the sexual risk behaviours and HIV risk environments of FSWs throughout Mexico.

A Framework for Sexual Decision-Making Among Female Sex Workers in Jamaica

The Jamaican government has provided targeted HIV and sexually transmitted infection prevention, treatment, and other services for female sex workers (FSW) since 1989. HIV prevalence among FSW declined from 20 to 12% between 1989 and 1994, then to 9% in 2005, 5% in 2008, and 4.1% in 2011. This article distills the literature and two decades of experience working with FSW in Jamaica. Drawing on the constant comparative method, we put forward an innovative conceptual framework for explaining sexual decision-making and risk behaviors within both transactional and relational sexual situations. This framework helps fill the gaps in existing models that focus on individual behaviors. The model identifies interactions between environmental and structural elements of sex work, and three individual-level factors: risk perception, perceived relationship intimacy, and perceived control, as the four primary mediating factors influencing sexual decision-making among FSW. We propose that other factors such as violence, socioeconomic vulnerability, and policy/legal frameworks influence sexual decision-making through these primary mediating factors. This conceptual model may offer a useful framework for planning and evaluating prevention interventions among sex workers. However, it remains to be tested in order to establish its value.

Toward Development of Enhanced Preventive Interventions for HIV Sexual Risk among Alcohol-Using Populations: Confronting the 'Mere Pause from Thinking'

The papers in this issue detail state-of-the science knowledge regarding the role of alcohol use in HIV/AIDS risk, as well as offer suggestions for ways forward for behavioral HIV prevention for at-risk alcohol-using populations. In light of recent evidence suggesting that the anticipated uptake of the newer biomedical HIV prevention approaches, prominently including pre-exposure prophylaxis, has been stalled owing to a host of barriers, it has become ever more clear that behavioral prevention avenues must continue to receive due consideration as a viable HIV/AIDS prevention approach. The papers collected here make a valuable contribution to "combination prevention" efforts to curb HIV spread.

Reducing HIV Risks in the Places Where People Drink: Prevention Interventions in Alcohol Venues

Apart from individual alcohol drinking behavior, the context or places where people drink play a significant role in HIV transmission risk. In this paper, we review the research that has been conducted on alcohol venues to identify the social and structural factors (e.g., social norms, sexual behavior) that are associated with HIV risk in these places, to review HIV prevention interventions based in alcohol venues, and to discuss appropriate methodologies for alcohol venue research. Alcohol venues are defined here as places that sell or serve alcohol for onsite consumption, including bars, bottle stores, nightclubs, wine shops, and informal shebeens. Despite the many established HIV risk factors at play in alcohol venues, limited prevention strategies have been implemented in such places. A total of 11 HIV prevention interventions or programs were identified. HIV prevention interventions in alcohol venues may be conducted at the individual, social, or structural level. However, multilevel interventions that target more than one level appear to lead to the most sustainable behavior change. Strategies to incorporate alcohol venues in biomedical prevention strategies including antiretroviral therapy for alcohol users are also discussed.

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.

Hazardous drinking and HIV-risk-related behavior among male clients of female sex workers in Tijuana, Mexico

BACKGROUND AND OBJECTIVES

Male clients of female sex workers (FSWs) are at high risk for HIV. Whereas the HIV risks of alcohol use are well understood, less is known about hazardous alcohol use among male clients of FSWs, particularly in Mexico. We sought to identify risk factors for hazardous alcohol use and test associations between hazardous alcohol use and HIV risk behavior among male clients in Tijuana.

METHOD

Male clients of FSWs in Tijuana (n = 400) completed a quantitative interview in 2008. The AUDIT was used to characterize hazardous alcohol use. Multivariate logistic regression was used to determine independent associations of demographic and HIV risk variables with hazardous alcohol use (vs. non-hazardous).

RESULTS

Forty percent of our sample met criteria for hazardous alcohol use. Variables independently associated with hazardous drinking were reporting any sexually transmitted infection (STI), having sex with a FSW while under the influence of alcohol, being younger than 36 years of age, living in Tijuana, and ever having been jailed. Hazardous drinkers were less likely ever to have been deported or to have shared injection drugs.

DISCUSSION AND CONCLUSIONS

Hazardous alcohol use is associated with HIV risk, including engaging in sex with FSWs while intoxicated and having an STI among male clients of FSWs in Tijuana.

SCIENTIFIC SIGNIFICANCE

We systematically described patterns and correlates of hazardous alcohol use among male clients of FSWs in Tijuana, Mexico. The results suggest that HIV/STI risk reduction interventions must target hazardous alcohol users, and be tailored to address alcohol use.