Patterns of Gender-Based Violence and Associations with Mental Health and HIV Risk Behavior Among Female Sex Workers in Mombasa, Kenya: A Latent Class Analysis

Post-Gender-Based Violence Services Utilization Among Female Entertainment Workers in Cambodia: A Cross-Sectional Study

Little is known about service utilization among female entertainment workers (FEWs) after experiencing gender-based violence (GBV). This study explored factors associated with post-GBV service utilization among FEWs in Cambodia. We included 299 FEWs, who experienced any forms of GBV in the past 12 months. This study highlights low access (14.05%) to post-GBV services among FEWs. Factors associated with post-GBV services utilization were marital status, living conditions, mental health, and types of entertainment venues. To improve post-GBV services utilization, ensuring quality, and availability of services are required. Further research is needed to develop pathways toward a supportive environment for FEWs to access these services.

ART coverage and viral suppression among female sex workers living with HIV in eThekwini, South Africa: Baseline findings from the Siyaphambili study

In South Africa >60% of female sex workers (FSW) are living with HIV, the majority of whom are not virally suppressed. Identifying multi-level determinants of viral suppression is central to developing implementation strategies to promote retention in HIV care and viral suppression among FSW with unmet treatment needs. Adult cisgender FSW living with HIV for ≥6 months, conducting sex work as their primary source of income, and residing in Durban (South Africa) were enrolled into the Siyaphambili Study, a sequential multiple assignment randomized trial. Baseline viral load and CD4 were assessed, and an interviewer-administered survey was conducted, capturing socio-demographic, reproductive and sexual history and behaviors, vulnerabilities, substance use, mental health, and stigma. We assessed baseline determinants of viral suppression (<50 copies/mL) using bivariate and multivariable robust poisson regression, considering associations across the individual, network, environmental and macrostructural levels. From June 2018 -March 2020, 1,644 women were screened, with 1,391 eligible FSW living with HIV enrolled. The analyses were conducted among the 1,373 participants with baseline data. Overall, 65% (889/1,373) of participants were reported to be on antiretroviral therapy and 38% (520/1,373) were virally suppressed. In the multivariable model, FSW who experienced a lack of housing in the prior six months were less likely to be virally suppressed (aPR: 0.72, 95%CI 0.56-0.91), while older FSW (aPR: 1.46 95%CI: 1.16-1.83 for 30-39 years old vs. 18-29 years old; aPR: 2.15 95%CI: 1.64-2.80 for 40+ years vs. 18-29 years old) and FSW reporting hormonal or long-acting contraception use were more likely to be virally suppressed (aPR: 1.19 95% CI: 1.00-1.43). We found vulnerability to be high among FSW living with HIV in South Africa and identified individual and structural determinants associated with viral suppression. Taken together these results suggest optimizing HIV treatment outcomes necessitates supporting younger sex workers and addressing housing instability. Trial registration: NCT03500172.

Injuries and /or trauma due to sexual gender-based violence among survivors in sub-Saharan Africa: a systematic scoping review of research evidence

BACKGROUND

Sexual and gender-based violence (SGBV) is a prevalent issue in sub-Saharan Africa (SSA), causing injuries and trauma with severe consequences for survivors. This scoping review aimed to explore the range of research evidence on injuries and trauma resulting from SGBV among survivors in SSA and identify research gaps.

METHODS

The review employed the Arksey and O'Malley methodological framework, conducting extensive literature searches across multiple electronic databases using keywords, Boolean operators, medical subject heading terms and manual searches of reference lists. It included studies focusing on injuries and trauma from SGBV, regardless of gender or age, published between 2012 and 2023, and involved an SSA countries. Two authors independently screened articles, performed data extraction and quality appraisal, with discrepancies resolved through discussions or a third author. Descriptive analysis and narrative synthesis were used to report the findings.

RESULTS

After screening 569 potentially eligible articles, 20 studies were included for data extraction and analysis. Of the 20 included studies, most were cross-sectional studies (n = 15; 75%) from South Africa (n = 11; 55%), and involved women (n = 15; 75%). The included studies reported significant burden of injuries and trauma resulting from SGBV, affecting various populations, including sexually abused children, married women, visually impaired women, refugees, and female students. Factors associated with injuries and trauma included the duration of abuse, severity of injuries sustained, marital status, family dynamics, and timing of incidents. SGBV had a significant impact on mental health, leading to post-traumatic stress disorder, depression, anxiety, suicidal ideations, and psychological trauma. Survivors faced challenges in accessing healthcare and support services, particularly in rural areas, with traditional healers sometimes providing the only mental health care available. Disparities were observed between urban and rural areas in the prevalence and patterns of SGBV, with rural women experiencing more repeated sexual assaults and non-genital injuries.

CONCLUSION

This scoping review highlights the need for targeted interventions to address SGBV and its consequences, improve access to healthcare and support services, and enhance mental health support for survivors. Further research is required to fill existing gaps and develop evidence-based strategies to mitigate the impact of SGBV on survivors in SSA.

Gender-based violence and associated factors among female sex workers in Ethiopia. Evidence from The National Bio-behavioral Survey, 2020

Background

Gender-based violence (GBV) is usually defined as unequal power relations between men and women, which poses a widespread public health problem. The study evaluated the prevalence and factors associated with GBV among female sex workers (FSWs) in Ethiopia.

Method

We used cross-sectional bio-behavioral data collected using respondent-driven sampling (RDS) in 2020 from 16 towns in Ethiopia. Descriptive statistics was analyzed to summarize the study population characteristics and prevalence of GBV, and a multilevel logistic regression model was applied to identify associated factors for GBV. A p-value of ≤0.05 was used as a threshold for statistical significance.

Result

Of 6,085 participants, 28.1% had experienced GBV during the last 12 months, among which 12.7% and 22.3% experienced physical and sexual violence, respectively. FSWs aged 15-24, and 25-34 than those 35 years or more, had a non-paying than paying partners, had 31-60, 61-90, and over 91 than those had less than 30 paying partners, ever had anal sex than those not, condom failure than those not, mobile female sex workers when compared with those not mobile at different town; 3-5 and ≥ 6 years than those less than 3 years stayed in selling sex, street-based, and multiple places selling sex than those used other venues were significantly associated with GBV.

Conclusion

Gender-based violence is a substantial problem among FSWs in Ethiopia, with significant implications for program planning on prevention and response to mitigate the occurrence and impact of GBV among FSWs.

Violence Against Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review

Women who sell sex (WSS) are vulnerable to violence. We present a scoping review of the last decade of research on the prevalence and incidence of, factors associated with, and services regarding violence against WSS in Eastern and Southern African (ESA). A systematic search of various databases resulted in 20 papers being reviewed. Inclusion criteria, applied by the first two authors, were as follows: empirical papers, key research problem is violence against WSS, and conducted in ESA countries. The lifetime prevalence of violence revealed in the studies ranged from 21% to 82%. A pattern of generalized violence against WSS from paying clients, male partners, strangers, family members, friends/acquaintances, and the authorities emerged. Factors associated with violence included the context within which the sex work occurs, alcohol use, type of sex exchange interactions, and personal factors (low education, low income, marriage, youth, high client volume, time in sex work, forced sexual debut, and internalized sex work stigma). WSS seldom access services after violence. Evaluations of two programs, a woman-focused HIV intervention, and the Diagonal Interventions to Fast-Forward Reproductive Health project, showed improvements in gender-based violence services. Findings suggest that targeted programmes should be paired with improving general health services and focus on promoting collective agency among WSS.

Prevalence of violence victimisation and poly-victimisation among female sex workers in Haiphong, Viet Nam: A cross-sectional study

This cross-sectional study is the first to describe the prevalence of violence and poly-victimisation among 310 female sex workers (FSWs) who were cisgender in Haiphong, Viet Nam. An adapted version of the WHO-Multi-Country Study on Violence against Women Survey Instrument was administered to assess physical, sexual, economic and emotional forms of violence perpetrated by an intimate partner, paying partner/client, and/or others (e.g. relatives, police, strangers and other FSWs) during adulthood. The ACE-Q scale was administered to assess adverse childhood experiences (ACEs) before age 18 years. Our findings showed that FSWs are exposed to high rates of multiple forms of violence by multiple perpetrators. For any male client-perpetrated violence (CPV), lifetime prevalence was 70.0%, with 12-month prevalence 61.3%. Lifetime prevalence of male intimate partner violence (IPV) was 62.1%, and the 12-month prevalence was 58.2%. Lifetime and prior 12-month prevalence of physical and/or sexual violence by other perpetrators (OPV) was 18.1% and 14.2%, respectively. Sixty-five percent of FSWs reported at least one type of ACE. Overall, 21.6 percent of FSWs reported having experienced all three forms of violence (IPV, CPV and OPV) in their lifetime. Policy and programme recommendations for screening and prevention of violence are needed in this setting.

Associations between psychosocial wellbeing and experience of gender-based violence at community, household, and intimate-partner levels among a cross-sectional cohort of young people living with and without HIV during COVID-19 in Cape Town, South Africa

BACKGROUND

Growing evidence indicates that gender-based violence (GBV) increased during COVID-19. We investigated self-reported impact of the pandemic on GBV at community, household and intimate partner (IPV) levels among young people and its associations with psychosocial wellbeing, i.e., COVID-related stressors and mental health.

METHODS

Cross-sectional data were drawn from a survey with young people ages 13-24 (N = 536) living with HIV (YPLWH) and without HIV (YPLWoH), in peri-urban Cape Town, South Africa. The survey, conducted February-October 2021, examined the impact of the initial lockdown on experience and perceived changes in GBV at each level, and pandemic-related psychosocial wellbeing. Descriptive statistics and binomial and multinomial regression analyses were conducted to illustrate exposure and perceived changes in GBV since lockdown, and their association with COVID-related stress factors (e.g., social isolation, anxiety about COVID), mental health (e.g., depression, anxiety), and other risk factors (e.g., age, gender, socioeconomic status) by HIV status.

RESULTS

Participants were 70% women with mean age 19 years; 40% were living with HIV. Since lockdown, YPLWoH were significantly more likely than YPLWH to perceive community violence as increasing (45% vs. 28%, p < 0.001), and to report household violence (37% vs. 23%, p = 0.006) and perceive it as increasing (56% vs. 27%, p = 0.002) (ref: decreasing violence). YPLWoH were also more likely to report IPV experience (19% vs. 15%, p = 0.41) and perception of IPV increasing (15% vs. 8%, p = 0.92). In adjusted models, COVID-related stressors and common mental health disorders were only associated with household violence. However, indicators of economic status such as living in informal housing (RRR = 2.07; 95% CI = 1.12-3.83) and food insecurity (Community violence: RRR = 1.79; 95% CI = 1.00-3.20; Household violence: RRR = 1.72; 95% CI = 1.15-2.60) emerged as significant risk factors for exposure to increased GBV particularly among YPLWoH.

CONCLUSIONS

Findings suggest that for young people in this setting, GBV at community and household levels was more prevalent during COVID-19 compared to IPV, especially for YPLWoH. While we found limited associations between COVID-related stressors and GBV, the perceived increases in GBV since lockdown in a setting where GBV is endemic, and the association of household violence with mental health, is a concern for future pandemic responses and should be longitudinally assessed.

Higher rates of mental health screening of adolescents recorded after provider training using simulated patients in a Kenyan HIV clinic: results of a pilot study

Background

Kenyan adolescent girls and young women (AGYW) experience a dual burden of HIV and common mental disorders (CMD). HIV clinics are a key entry point for AGYW in need of integrated CMD and HIV care; however, rates of screening and referral for CMDs are low. Our objective was to test an evidence-based provider training strategy, simulated patient encounters (SPEs), on CMD service delivery for AGYW in a Kenyan HIV clinic.

Methods

This pilot study was conducted in a public HIV clinic in Thika, Kenya from January to November 2021. The simulated patient encounter (SPE) implementation strategy included case script development from prior qualitative work, patient actor training, and a three-day SPE training including four standardized mock clinical encounters followed by quantitative surveys assessing provider competencies for each encounter. We abstracted medical record data related to HIV and CMDs such as HIV status, reason for visit, CMD screening test performed, and counselling or referral information. We conducted an interrupted time series analysis using abstracted HIV and CMD screening rates from AGYW ages 16-25 years visiting the clinic 7 months before and 3 months after SPE training. We used generalized linear models to assess changes in CMD screening rates after training.

Results

A total of 10 providers participated in the training. Competency ratings improved across four mock encounters (mean score from 8.1 to 13.7) between first and fourth encounters. We abstracted all medical records (n = 1,154) including from 888 (76%) AGYW seeking HIV treatment, 243 (21%) seeking prevention services, and 34 (3%) seeking other services. CMD screening rates increased immediately following training from 8 to 21% [relative risk (RR) = 2.57, 95% confidence interval (CI) = 1.34-4.90, p < 0.01]. The 3 months following the SPE training resulted in an 11% relative increase in CMD screening proportion compared to the 7 months pre-SPE (RR: 1.11, 95% CI: 1.04-1.17, p < 0.01). Finally, 1% of all pre-SPE screens resulted in referral versus 5% of post-SPE screens (p = 0.07).

Conclusion

The SPE model is a promising implementation strategy for improving HIV provider competencies and CMD service delivery for adolescents in HIV clinics. Future research is needed to explore effects on adolescent clinical outcomes in larger trials.

Comparing typologies of violence exposure and associations with syndemic health outcomes among cisgender and transgender female sex workers living with HIV in the Dominican Republic

Violence against women research largely excludes transgender women's experiences and violence from perpetrators other than intimate partners. This study compares patterns of violence exposure among cisgender and transgender female sex workers (FSWs) and the associations with syndemic health outcomes. We used cross-sectional surveys from samples of cisgender and transgender FSWs living with HIV in the Dominican Republic (N = 211 and 100, respectively). We used latent class analysis to identify patterns of emotional, physical, and sexual violence and harassment by partners, clients, and police. We assessed sociodemographic and occupational predictors in relation to class membership, and class membership in relation to health (HIV continuum of care outcomes, mental health, substance use), using logistic regression. Two classes were identified in cisgender sample: Low Reported Violence Exposure (Class 1) and Sex Work-related Police Harassment (Class 2). Class 2 participants had greater odds of scoring abnormal or borderline abnormal anxiety on the Hospital Anxiety and Depression Scale (HADS-A) (adjusted OR = 3.97, p<0.01), moderate-to-severe depression per the Patient Health Questionnaire-9 (PHQ-9) (aOR = 5.74, p<0.01), and any illicit drug use in the past six months (aOR = 3.06, p<0.05), compared to Class 1. The transgender sample produced three classes: Low Reported Violence Exposure (Class 1); Sex Work-related Police Harassment (Class 2); and Sex Work-related Violence and Harassment (Class 3). Class 3 participants had greater odds of having anxiety (aOR = 6.65, p<0.01) and depression (aOR = 4.45, p<0.05), while Class 2 participants had greater odds of perfect ART adherence during the previous four days (aOR = 2.78, p<0.05), compared to Class 1. The more diverse and extreme violence patterns uncovered for the transgender sample show this group's heightened risk, while similar patterns across groups regarding police abuse highlight a need for police-focused violence prevention interventions. Each sample's highest violence class was associated with poor mental health, underscoring the need for mental health interventions for all FSWs.

Psychosocial effects of gender-based violence among women in Vhembe district: A qualitative study

Background

The phenomenon of gender-based violence is a pertinent social problem in South Africa. The fear of reporting gender-based violence contributes to its continuation, marginalisation and silencing of victims.

Objectives

The study sought to explore the psychosocial effects of gender-based violence among women in Vhembe district.

Methods

An exploratory phenomenological research design was used and sampling was performed purposively from a population of women who experienced gender-based violence in a low-resource, rural setting of Vhembe district. Semi-structured telephonic interviews were used as the main method of data collection after permissions and informed consent were sought for conducting the study. Thematic content analysis was applied to convert the participants' statements into a meaningful framework to derive the findings.

Results

A total of 15 participants aged from 19 to 35 years participated in the study. Their psychosocial experiences of gender-based violence were depression, worthlessness, social isolation and anger directed towards children.

Conclusion

This research confirms that gender-based violence remains one of the most challenging problems associated with mental health problems in Vhembe district. It affirms the need to focus on awareness in rural areas afflicted by patriarchal attitudes, norms and stereotypes. Gender-based violence should to be viewed as human rights violation for victims' protection.

Contribution

The study contributes to the body of knowledge on the experiences of gender-based violence among marginalised women from rural areas.

Barriers to mental health treatment in primary care practice in low- and middle-income countries in a post-covid era: A systematic review

General primary care workers and family physicians are a crucial work force in managing the mental health of people in any given region. However, the barriers they face in low- and middle-income countries (LMICs) may be worsened by the pandemic. This review aims to bring together evidence about mental health treatment challenges experienced by people in LMICs in primary care settings. The review focuses on the shortage of essential mental healthcare services, stigma and lack of competent primary care professionals in establishing these services and their importance in the COVID-19 pandemic context. The systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and the search strategy included keyword search terms (MeSH) to perform a search across three electronic databases - Critical Appraisal Skills Program assessed PubMed, SpringerLink, and Cochrane and quality of the articles. The articles selected were analyzed through thematic analysis to identify the main themes and conclude our findings. Findings indicate that out of 1792 publications found, 14 studies matched the desired criteria for the studies. Endnotes, database search filters, and Covidence data extraction tools were used to generate the relevant articles in this study. This study shows that primary care institutions have financial and management issues in providing mental health services and a shortage of competent mental health experts in primary care, especially mental health-trained family physicians. The study also identifies community stigma as the most prevalent barrier to seeking mental health therapy, reflecting the lack of community health education in LMICs.

Who Asks About HIV/STI Status?: An Analysis of Women Who Sell Sex and Inject Drugs

Communication about HIV and sexually transmitted infections (STI) is a cornerstone of risk reduction, yet there is a dearth of research that examines communication patterns among persons with dual risks for HIV/STI acquisition, such as women who sell sex and inject drugs (WSSID). We used logistic regression to identify factors associated with WSSID (N = 211) in Baltimore, Maryland always asking new clients about their HIV/STI status. Most WSSID were non-Hispanic White (73%) and 74% reported current homelessness. 50% of WSSID reported always asking new clients about their HIV/STI status. Experiencing depressive symptoms (adjusted odds ratio [aOR]: 0.53; 95% confidence interval [CI]: 0.29, 0.96) and having condomless sex with clients (aOR 0.31; 95% CI: 0.17, 0.57) were inversely associated with WSSID always asking new clients about their HIV/STI status. Recent entry into sex work (aOR 2.99; 95% CI: 1.30, 6.87) was positively associated with always asking new clients about their HIV/STI status. Enhancing HIV/STI communication in combination with engagement in other risk mitigation strategies may decrease disease incidence among WSSID.

Psychological pathways to HIV-related posttraumatic stress disorder symptoms among people living with HIV in China: the mediating role of rumination

The occurrence of HIV-related posttraumatic stress disorder (PTSD) compromises the physical and mental health of people living with HIV (PLWH). This study examined the psychological pathways of HIV-related PTSD symptoms considering the influence of rumination in PLWH of China. A cross-sectional survey was conducted in Changsha, China. The data were collected using the PTSD Checklist-Civilian Version, the Ruminative Response Scale, the Multidimensional Scale of Perceived Social Support, and measures of sociodemographic and HIV-related clinic characteristics. A total of 602 PLWH were surveyed. The average score of HIV-related PTSD symptoms was (34.54 ± 13.58). The mediation model showed that perceived social stigma and physical health exhibited direct associations with PTSD symptoms (β = 0.093, -0.145, respectively), while the direct relations of family support, friend support and significant others support to PTSD symptoms were not significant. Rumination mediated the effect of perceived social stigma (β = 0.077), physical health (β = -0.150), family support (β = -0.144) and friend support (β = -0.105) on PTSD symptoms. The study findings underscore the importance of routinely assessing PTSD for PLWH, and developing trauma-focused interventions that alleviate HIV-related PTSD symptoms and reduce rumination while improving social support and physical health and reducing social stigma.

Prevalence of psychological distress among people living with HIV/AIDS: a systematic review and meta-analysis

Although people living with HIV/AIDS (PLWHA) are known to be vulnerable to psychological distress (PD), little is known about the prevalence of PD among PLWHA. A systematic literature search of several databases was conducted from inception to August 2021 focusing on studies reporting on PD symptoms among PLWHA. The overall prevalence estimates were pooled using a random-effects meta-analysis. Differences according to study-level characteristics were examined using stratified meta-analysis. We pooled and analyzed data from 15 studies comprising 5593 PLWHA. The prevalence rate of PD among PLWHA was 43.7% (95% Confidence Interval: 29.9-57.5%). Subgroup analyses by gender, country, CD4 count, employment status and ever attended school found no statistically significant differences in the prevalence of PD. Heterogeneity in the prevalence of PD among PLWHA was partially explained by the assessment tool. Further large-scale studies of high quality are warranted to identify risk factors of PD in PLWHA in their respective socio-cultural contexts.

Mental health challenges and perceived risks among female sex Workers in Nairobi, Kenya

BACKGROUND

Female sex workers (FSWs) in Kenya are at an increased risk of violence, poverty, police arrest, and problematic alcohol and other substance use, all of which are linked to poor mental health and suicidal ideation. Despite the psychological stressors experienced by FSWs, there is no published qualitative methods research investigating their mental health experiences in Kenya. In this paper, we draw on data from in-depth interviews to examine FSWs' lifetime mental health experiences and perceived risk factors.

METHODS

We used baseline in-depth interviews of the Maisha Fiti longitudinal study of FSWs in Nairobi. We randomly selected 40 FSWs from 1003 FSWs who attended a baseline behavioural-biological interview as part of the Maisha Fiti study. The interview guide was semi-structured, and participants were asked to detail their life stories, including narrating specific events such as entry into sex work, experiences of violence, mental health experiences, and use of alcohol and other substances. Interviews were recorded in Kiswahili/ English and transcribed in English. Data were coded and thematically analysed in Nvivo (v.12).

RESULTS

Results indicated that the majority of participants understood 'mental health' as 'insanity', 'stress', 'depression', and 'suicide'; nevertheless, a number described mental health symptomatically, while a few believed that mental health problems were caused by witchcraft. Interestingly, poverty, low levels of education, poor job opportunities, a lack of family support, harmful gender norms, intimate partner violence and subsequent relationship breakdowns, and family bereavement all contributed to poor mental health and subsequent entry into sex work. In addition, the consequences of sex work such as sexual risks, and ongoing violence from police and clients, further exacerbated poor mental health.

CONCLUSIONS

There is a need for both micro- and macro interventions to address poverty and violence against FSWs in Kenya, thereby reducing mental health problems. Addressing violence against women and girls may also reduce entry into sex work. Improving mental health literacy and providing mental health intervention services for 'at-risk' populations such as FSWs should enhance coping strategies and help-seeking efficacy.

Exposure to job-related violence among young female sex workers in urban slums of Southwest Nigeria

Background

In Nigeria, many young girls are engaged in commercial sex work as a means of livelihood and support of dependent relatives. Although studies have documented some of the violence related issues among commercial sex workers, the plight of adolescent and young sex workers particularly in urban slums may be different in context and depth.

Objective

This study explored the lived experiences of violence and health related harm among vulnerable young female sex workers in urban slums in Ibadan and Lagos, Southwest Nigeria. It also analyzed their coping strategies and survival mechanisms.

Design

The study is cross-sectional and applied an interpretive phenomenological approach to this qualitative study through in-depth interviews.

Participants

Young female sex workers ages (15–24 years) who reported having experienced violence were recruited for the study. Twelve participants completed the interviews out the 20 initially contacted.

Data collection and analysis

Primary data were collected using in-depth interviews (IDIs). Data were transcribed using a phenomenological framework analysis. Participants’ reports based on life experiences were identified: lived experience “daily brothel life experience”; sources of violence such as law enforcement agents’ intermittent raids; violence experience with clients who often demanded sexual acts beyond the agreed scope; and coping strategies employed to mitigate the challenges.

Settings

The study was conducted in brothels of two selected slum areas in Ibadan and Lagos, Southwest Nigeria.

Results

The results showed that the major motivation for engaging in commercial sex work was for economic reasons. However, there are inherent risks involved particularly for the vulnerable young people. Stigmatization from the community, clients’ uncontrolled-aggressive behavior and harassment from law enforcement agents are some of the frequent violence experiences reported. Self-help coping strategies are usually employed to prevent or mitigate the challenges.

Conclusion

The plight of this young people required policy and program attention towards alternative economic empowerment to rehabilitate those willing to leave the profession. Also the need to develop arm reduction interventions towards protection of young sex workers against violence.

Supplementary information

The online version contains supplementary material available at 10.1186/s12889-022-13440-1.

The Intersection of Intimate Partner Violence Perpetration and Sexual Risk Behavior Among Young Men in Tanzania: A Latent Class Analysis of Patterns and Outcomes

Few studies of intimate partner violence (IPV) perpetration and sexual risk behavior among men have examined how multiple dimensions of these behaviors intersect in ways that may uniquely elevate health risks. The current study used latent class analysis to: (1) identify distinct patterns of IPV and sexual risk behavior in a sample of Tanzanian men (n = 985) and (2) examine associations between identified patterns and health outcomes. Four classes were identified: normative (64% of the sample), IPV only (14%), sexual risk only (13%), and comorbid IPV/sexual risk (5%). Compared to men in the normative subgroup, men in the comorbid group had significantly higher odds of STI infection, higher perceived HIV risk, and greater odds of substance use. Findings provide evidence that engaging in IPV and multiple sexual partnerships (i.e., a comorbid pattern) denotes elevated health risks across a range of indicators, suggesting the importance of targeted treatment and prevention efforts for men in this subgroup.

Gender-based violence and depressive symptoms among female entertainment workers in Cambodia: A cross-sectional study

Female entertainment workers (FEWs) are at higher risk of gender-based violence (GBV) than the general population. The prolonged stress and fear caused by GBV increase the likelihood of depression, a major mental health problem among FEWs. However, their mental health issue has received limited attention and remains poorly researched in the context of GBV. We examined the association between GBV and depressive symptoms among FEWs in Cambodia. We conducted this cross-sectional study in 2017. We used a two-stage cluster random sampling method to select FEWs from the municipality and six provinces for face-to-face interviews. We used the Centre for Epidemiologic Studies Depression Scale (CES-D) to measure depressive symptoms. We conducted a multivariable logistic regression analysis to identify factors associated with depressive symptoms. We included a total of 645 FEWs in data analyses. The proportions of FEWs experiencing emotional, physical, and sexual violence were 36.1%, 11.6%, and 17.2%, respectively. Of the total participants, 65.9% had high levels of depressive symptoms. The adjusted odds of having high levels of depressive symptoms were higher among FEWs who engaged in transactional sex (AOR 1.79, 95% CI 1.09-2.94), experienced emotional abuse (AOR 3.15, 95% CI 1.90-5.23), and experienced two (AOR 7.89, 95% CI 3.28-18.99) and three overlapping types of GBV (AOR 12.12, 95% CI 2.47-59.25) than those who did not. FEWs in this study experienced high levels and overlapping types of GBV associated with high levels of depressive symptoms. Policy interventions and services should be designed to prevent GBV and support the victims of GBV to mitigate depressive symptoms among FEWs in Cambodia.

Longitudinal experiences and risk factors for common mental health problems and suicidal behaviours among female sex workers in Nairobi, Kenya

BACKGROUND

Female sex workers (FSWs) are at high risk of mental health problems and suicide risk. Few longitudinal studies have examined risk factors for poor mental health among FSWs.

METHODS

Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme clinics across Nairobi. Behavioural-biological survey data were collected at baseline (n = 1003, June-December 2019), midline (n = 366) (Jan-March 2020) and endline (n = 877) (June 2020-Jan 2021). Women reporting mental health problems were offered counselling services. Multivariable mixed logistic regression models were used to examine factors associated with mental health problems and suicidal behaviours.

RESULTS

There was a decline in the proportion of women reporting any mental health problem (depression and/or anxiety and/or PTSD) (baseline: 29.9%, midline: 13.3%, endline: 11.8%). There was strong evidence that any mental health problem was associated with recent hunger (aOR 1.99; 95% CI 1.37-2.88) and recent violence from non-intimate partners (2.23; 95% CI 1.55-3.19). Recent suicidal behaviour prevalence was similar across survey rounds (baseline: 10.2%; midline: 10.2%; endline: 10.4%), and was associated with recent violence from non-intimate partners (aOR 1.96; 95% CI 1.31-2.95), recent hunger (aOR 1.69; 95% CI 1.15-2.47) and having an additional employment to sex work (aOR 1.50; 95% CI 1.00-2.23).

CONCLUSIONS

Our study found a decline in mental health problems but high levels of persistent suicidal behaviours among FSWs. Syndemic risk factors including food insecurity and violence were longitudinally associated with mental health problems and recent suicidal behaviours. There is a need for accessible mental health services for FSWs, alongside structural interventions addressing poverty and violence.

Prevalence of suicidality, depression, post-traumatic stress disorder, and anxiety among female sex workers: a systematic review and meta-analysis

The purpose was to assess prevalence of suicidality, depression, post-traumatic stress disorder (PTSD), and anxiety among female sex workers (FSW). A systematic review and meta-analysis was performed. Search strategy was performed in MEDLINE, Scopus, Web of Science, EMBASE, Ovid and Cochrane Central Database from inception until March 2020. Considered for inclusion were cross-sectional studies performed on FSW that assessed prevalence of any of the following: suicide attempt or suicidal ideation, depression, PTSD, or anxiety. Five reviewers, independently and in duplicate, selected all eligible articles in an abstract and full-text screening phase and, moreover, extracted information from each study. A binomial-normal generalized linear mixed model was employed to estimate prevalence of the conditions. From 8035 studies yielded in the search strategy, 55 were included for analysis. The overall prevalence of suicidal ideation and attempt was 27% (95% C.I. 18-39%) and 20% (95% C.I. 13-28%), respectively. Furthermore, overall prevalence of depression and PTSD was 44% (95% C.I. 35-54%) and 29% (95% C.I. 18-44%), respectively. Eleven studies were classified as high quality. Findings indicate that there is an overall high prevalence of suicidality, depression, and PTSD among FSW. Development of accessible large-scale interventions that assess mental health among this population remains critical.

Prevalence and correlates of common mental health problems and recent suicidal thoughts and behaviours among female sex workers in Nairobi, Kenya

BACKGROUND

Adverse childhood experiences (ACEs), poverty, violence and harmful alcohol/substance use are associated with poor mental health outcomes, but few studies have examined these risks among Female Sex Workers (FSWs). We examine the prevalence and correlates of common mental health problems including suicidal thoughts and behaviours among FSWs in Kenya.

METHODS

Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme (SWOP) clinics across Nairobi. Baseline behavioural-biological survey (n = 1003) data were collected June-December 2019. Mental health problems were assessed using the Patient Health Questionnaire (PHQ-9) for depression, the Generalised Anxiety Disorder tool (GAD-7) for anxiety, the Harvard Trauma Questionnaire (HTQ-17) for Post-Traumatic Stress Disorder (PTSD) and a two-item tool to measure recent suicidal thoughts/behaviours. Other measurement tools included the WHO Adverse Childhood Experiences (ACE) score, WHO Violence Against Women questionnaire, and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Descriptive statistics and multivariable logistic regression were conducted using a hierarchical modelling approach.

RESULTS

Of 1039 eligible FSWs, 1003 FSWs participated in the study (response rate: 96%) with mean age 33.7 years. The prevalence of moderate/severe depression was 23.2%, moderate/severe anxiety 11.0%, PTSD 14.0% and recent suicidal thoughts/behaviours 10.2% (2.6% suicide attempt, 10.0% suicidal thoughts). Depression, anxiety, PTSD and recent suicidal thoughts/behaviours were all independently associated with higher ACE scores, recent hunger (missed a meal in last week due to financial difficulties), recent sexual/physical violence and increased harmful alcohol/substance. PTSD was additionally associated with increased chlamydia prevalence and recent suicidal thoughts/behaviours with low education and low socio-economic status. Mental health problems were less prevalent among women reporting social support.

CONCLUSIONS

The high burden of mental health problems indicates a need for accessible services tailored for FSWs alongside structural interventions addressing poverty, harmful alcohol/substance use and violence. Given the high rates of ACEs, early childhood and family interventions should be considered to prevent poor mental health outcomes.

The use of PSA as a biomarker of recent semen exposure in female reproductive health studies

Semen contains potent soluble proteins, bacteria, viruses, activated immune cells as well as anti- and pro-inflammatory cytokines that may influence the inflammatory response and alter microbial composition of the female genital tract. The presence of semen in the female genital mucosa may be a significant confounder that most studies have failed to control for in their analysis. Prostate-specific antigen (PSA), a protein secreted by the prostate into the urethra during ejaculation, is a well-established biomarker of semen exposure. Several studies have demonstrated discordance between self-reports of sexual behavior and the presence of PSA. Recent semen exposure has been shown to promote pro-inflammatory responses, stimulate the recruitment of activated immune cells and decrease Lactobacilli abundance in the female genital mucosa. As a result, it is important to understand the concordance between self-reported consistent condom use and the presence of semen biomarkers. Furthermore, to ensure that the interpretation of data in clinical studies of the immunological and microbial environment in the female genital mucosa are accurate, it is essential to establish whether semen is present in the vaginal fluid. This review explores the impact of semen exposure on the mucosal microenvironment and assesses the use of the PSA as an objective biomarker of semen exposure to reduce reliance on self-reported sexual intercourse.

Intimate partner and client-perpetrated violence are associated with reduced HIV pre-exposure prophylaxis (PrEP) uptake, depression and generalized anxiety in a cross-sectional study of female sex workers from Nairobi, Kenya

INTRODUCTION

UNAIDS has identified female sex workers (FSW) as a key HIV at-risk population. FSW disproportionately experience gender-based violence, which compounds their risk of HIV acquisition and may contribute to adverse mental health outcomes. Pre-exposure prophylaxis (PrEP) is a powerful but underused HIV prevention tool for these women. This study explored the associations between intimate partner violence (IPV) and client-perpetrated violence against FSW, mental health outcomes and PrEP use.

METHODS

An anonymous questionnaire was administered to a convenience sample of 220 Nairobi FSW attending dedicated clinics from June to July 2019, where PrEP was available free of charge. A modified version of the WHO Violence Against Women Instrument assessed IPV and client-perpetrated violence, and the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) assessed depressive and anxiety symptoms respectively. Multivariable logistic regressions evaluated predictors of depression, generalized anxiety and PrEP use.

RESULTS

Of the total 220 women (median [IQR] age 32 [27-39]), 56.8% (125/220) reported depression (PHQ-9 ≥ 10) and 39.1% (86/220) reported anxiety (GAD-7 ≥ 10). Only 41.4% (91/220) reported optimal use of PrEP (taken correctly six to seven days/week) despite the cohort pursuing sex work for a median of 7 (4 to 12) years. Most women reported experiencing any violence in the past 12 months (90%, 198/220). Any recent IPV was frequent (78.7%, 129/164), particularly emotional IPV (66.5%, 109/164), as was any client-perpetrated violence in the past 12 months (80.9%, 178/220). Regression analyses found that violence was independently associated with depression (adjusted OR [aOR] 9.39, 95% CI 2.90 to 30.42, p = 0.0002) and generalized anxiety (aOR 3.47, 95% CI 1.10 to 10.88, p = 0.03), with the strongest associations between emotional IPV and both depression and anxiety. Recent client-perpetrated emotional violence (aOR 0.23, 95% CI 0.07 to 0.71, p = 0.01) was associated with decreased PrEP use, whereas client-perpetrated physical violence was associated with increased PrEP use (aOR 3.01, 95% CI 1.16 to 7.81, p = 0.02).

CONCLUSIONS

There was a high prevalence of recent violence by different perpetrators as well as depression and anxiety among FSW from Nairobi. PrEP use was relatively infrequent, and recent client-perpetrated emotional violence was associated with PrEP non-use. Interventions to reduce gender-based violence may independently enhance HIV prevention and reduce the mental health burden in this community.

Increase in HIV incidence in women exposed to rape

OBJECTIVE

To determine the incidence of HIV acquisition in women postrape compared with a cohort of women who had not been raped.

DESIGN

A prospective cohort study.

METHODS

The Rape Impact Cohort Evaluation study based in Durban, South Africa, enrolled women aged 16-40 years from postrape care services, and a control group of women from Primary Healthcare services. Women who were HIV negative at baseline (441 in the rape-exposed group and 578 in the control group) were followed for 12-36 months with assessments every 3 months in the first year and every 6 months thereafter. Multivariable Cox regression models adjusted for baseline and time varying covariates were used to investigate the effect of rape exposure on HIV incidence over follow-up.

RESULTS

Eighty-six women acquired HIV during 1605.5 total person-years of follow-up, with an incident rate of 6.6 per 100 person-years [95% confidence interval (CI): 4.8-9.1] among the rape exposed group and 4.7 per 100 person-years (95% CI: 3.5-6.2) among control group. After controlling for confounders (age, previous trauma, social support, perceived stress, multiple partners and transactional sex with a casual partner), women exposed to rape had a 60% increased risk of acquiring HIV [adjusted hazard ratio: 1.59 (95% CI: 1.01-2.48)] compared with those not exposed. Survival analysis showed difference in HIV incident occurred after month 9.

CONCLUSION

Rape is a long-term risk factor for HIV acquisition. Rape survivors need both immediate and long-term HIV prevention and care.

Intimate partner violence and factors associated with sexually transmitted infections among Thai women attending gynecology clinics

Intimate partner violence (IPV) and sexually transmitted infections (STIs) are significant public health problems worldwide. However, most research on this association and risk of STIs has been conducted in Western countries and may not be generalizable to women living in different contexts, such as Thailand. We aimed to examine prevalence of IPV and identify factors associated with STIs among Thai women. Participants were patients aged 15-49 years attending two gynecology clinics at a university hospital in Bangkok, Thailand. Data were collected through an anonymous structured questionnaire, including sociodemographic characteristics, IPV, childhood abuse (CA), sexual risk behaviors, alcohol use, depressive symptoms, and self-reported STI diagnosis. Multivariate logistic regression analyses were used to examine factors associated with STI diagnosis. Among 400 participants, 84 (21%) had ever experienced at least one type of IPV in the past year. IPV, CA, age at first sex, multiple sexual partners, and alcohol use were significantly associated with STI-positive. Women who reported IPV (OR = 2.65, 95% CI = 1.11-6.28), experienced CA (OR = 5.59, 95% CI = 1.08-28.99), and had multiple sexual partners (OR = 1.39, 95% CI = 1.08-1.79) were significantly more likely to have an STI. Incorporation of IPV screening into general STIs screening is needed for this population to prevent and decrease IPV and STI consequences. Further research is also needed to understand the pathways linking IPV and STI risk to optimize the design of effective prevention interventions.

Mental health problems among female sex workers in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

The psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs). Key risk factors include poverty, low education, violence, alcohol and drug use, human immunodeficiency virus (HIV), and stigma and discrimination. This systematic review and meta-analysis aimed to quantify the prevalence of mental health problems among FSWs in LMICs, and to examine associations with common risk factors.

METHOD AND FINDINGS

The review protocol was registered with PROSPERO, number CRD42016049179. We searched 6 electronic databases for peer-reviewed, quantitative studies from inception to 26 April 2020. Study quality was assessed with the Centre for Evidence-Based Management (CEBM) Critical Appraisal Tool. Pooled prevalence estimates were calculated for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal behaviour. Meta-analyses examined associations between these disorders and violence, alcohol/drug use, condom use, and HIV/sexually transmitted infection (STI). A total of 1,046 studies were identified, and 68 papers reporting on 56 unique studies were eligible for inclusion. These were geographically diverse (26 countries), representing all LMIC regions, and included 24,940 participants. All studies were cross-sectional and used a range of measurement tools; none reported a mental health intervention. Of the 56 studies, 14 scored as strong quality, 34 scored as moderate, and 8 scored as weak. The average age of participants was 28.9 years (age range: 11-64 years), with just under half (46%) having up to primary education or less. The pooled prevalence rates for mental disorders among FSWs in LMICs were as follows: depression 41.8% (95% CI 35.8%-48.0%), anxiety 21.0% (95% CI: 4.8%-58.4%), PTSD 19.7% (95% CI 3.2%-64.6%), psychological distress 40.8% (95% CI 20.7%-64.4%), recent suicide ideation 22.8% (95% CI 13.2%-36.5%), and recent suicide attempt 6.3% (95% CI 3.4%-11.4%). Meta-analyses found significant associations between violence experience and depression, violence experience and recent suicidal behaviour, alcohol use and recent suicidal behaviour, illicit drug use and depression, depression and inconsistent condom use with clients, and depression and HIV infection. Key study limitations include a paucity of longitudinal studies (necessary to assess causality), non-random sampling of participants by many studies, and the use of different measurement tools and cut-off scores to measure mental health problems and other common risk factors.

CONCLUSIONS

In this study, we found that mental health problems are highly prevalent among FSWs in LMICs and are strongly associated with common risk factors. Study findings support the concept of overlapping vulnerabilities and highlight the urgent need for interventions designed to improve the mental health and well-being of FSWs.

Characterizing the role of intersecting stigmas and sustained inequities in driving HIV syndemics across low-to-middle-income settings

PURPOSE OF REVIEW

In 2020, key populations around the world still have disproportionate risks for HIV acquisition and experiencing HIV-related syndemics. This review presents current data around HIV-related syndemics among key populations globally, and on the role of intersecting stigmas in producing these syndemics in low-to-middle-income settings.

RECENT FINDINGS

Sex workers, sexual and gender minorities, prisoners, and people who use drugs experience high burdens of tuberculosis, sexually transmitted infections, viral hepatitis, and violence linked to heightened HIV-related risks or acquisition. Adverse sexual, reproductive, and mental health outcomes are also common and similarly amplify HIV acquisition and transmission risks, highlighting the need for psychosocial and reproductive health services for key populations.

SUMMARY

Achieving the promise of biomedical interventions to support HIV care and prevention requires action towards addressing syndemics of HIV, and the stigmas that reproduce them, among those most marginalized globally.

Creating HIV risk profiles for men in South Africa: a latent class approach using cross-sectional survey data

INTRODUCTION

Engaging at-risk men in HIV prevention programs and services is a current priority, yet there are few effective ways to identify which men are at highest risk or how to best reach them. In this study we generated multi-factor profiles of HIV acquisition/transmission risk for men in Durban, South Africa, to help inform targeted programming and service delivery.

METHODS

Data come from surveys with 947 men ages 20 to 40 conducted in two informal settlements from May to September 2017. Using latent class analysis (LCA), which detects a small set of underlying groups based on multiple dimensions, we identified classes based on nine HIV risk factors and socio-demographic characteristics. We then compared HIV service use between the classes.

RESULTS

We identified four latent classes, with good model fit statistics. The older high-risk class (20% of the sample; mean age 36) were more likely married/cohabiting and employed, with multiple sexual partners, substantial age-disparity with partners (eight years younger on-average), transactional relationships (including more resource-intensive forms like paying for partner's rent), and hazardous drinking. The younger high-risk class (24%; mean age 27) were likely unmarried and employed, with the highest probability of multiple partners in the last year (including 42% with 5+ partners), transactional relationships (less resource-intensive, e.g., clothes/transportation), hazardous drinking, and inequitable gender views. The younger moderate-risk class (36%; mean age 23) were most likely unmarried, unemployed technical college/university students/graduates. They had a relatively high probability of multiple partners and transactional relationships (less resource-intensive), and moderate hazardous drinking. Finally, the older low-risk class (20%; mean age 29) were more likely married/cohabiting, employed, and highly gender-equitable, with few partners and limited transactional relationships. Circumcision (status) was higher among the younger moderate-risk class than either high-risk class (p < 0.001). HIV testing and treatment literacy score were suboptimal and did not differ across classes.

CONCLUSIONS

Distinct HIV risk profiles among men were identified. Interventions should focus on reaching the highest-risk profiles who, despite their elevated risk, were less or no more likely than the lower-risk to use HIV services. By enabling a more synergistic understanding of subgroups, LCA has potential to enable more strategic, data-driven programming and evaluation.

Structural interventions and social suffering: Responding to amphetamine-type stimulant use among female entertainment and sex workers in Cambodia

BACKGROUND

In Cambodia, HIV infection remains high among female entertainment and sex workers (FESW) and the use of amphetamine-type stimulants (ATS) is an independent risk factor for unprotected sex and sexually transmitted infections among this group. For decades public health approaches to HIV prevention in low and middle income countries (LMIC) have attempted to target the macro-power relations that shape risk behaviour with structural interventions. Recent research has highlighted that interventions that combine ATS risk reduction, in the form of financial incentives for abstinence, with existing HIV prevention programmes, may also play an important role. However, whether this approach goes far enough as a response to structural drivers of risk requires further examination.

METHODS

Semi-structured in-depth interviews were conducted with 30 FESW (mean age 25 years) from five provinces in Cambodia, as part of formative research for the implementation of the Cambodia Integrated HIV and Drug Prevention (CIPI) trial. The aim was to explore the contexts and drivers of ATS use. Data were analysed using grounded theory.

RESULTS

In addition to increasing occupational functionality, ATS were used to control pervasive feelings of 'sadness' in relation to the lived experience of poverty, family and relationship problems. Feeling sad could be viewed as an expression of social suffering, in response to competing priorities and seemingly inescapable constraints imposed by a lack of options for income generation, gender inequalities and stigma. Participants expressed interest in microenterprise (ME) opportunities, particularly vocational training, that could create new work opportunities beyond sex work and ATS use.

CONCLUSION

In addition to reducing ATS use, HIV prevention interventions need to target sources of sadness and social suffering as drivers of risk among FESW in this context. The inclusion of ME opportunities in HIV prevention, to alleviate social suffering, warrants further investigation through qualitative and ethnographic research.