Migration status, work conditions and health utilization of female sex workers in three South African cities

Do black women's lives matter? A study of the hidden impact of the barriers to access maternal healthcare for migrant women in South Africa

Background

Studies on the barriers migrant women face when trying to access healthcare services in South Africa have emphasized economic factors, fear of deportation, lack of documentation, language barriers, xenophobia, and discrimination in society and in healthcare institutions as factors explaining migrants' reluctance to seek healthcare. Our study aims to visualize some of the outcome effects of these barriers by analyzing data on maternal death and comparing the local population and black African migrant women from the South African Development Countries (SADC) living in South Africa. The heightened maternal mortality of black migrant women in South Africa can be associated with the hidden costs of barriers migrants face, including xenophobic attitudes experienced at public healthcare institutions.

Methods

Our analysis is based on data on reported causes of death (COD) from the South African Department of Home Affairs (DHA). Statistics South Africa (Stats SA) processed the data further and coded the cause of death (COD) according to the WHO classification of disease, ICD10. The dataset is available on the StatsSA website (http://nesstar.statssa.gov.za:8282/webview/) for research and statistical purposes. The entire dataset consists of over 10 million records and about 50 variables of registered deaths that occurred in the country between 1997 and 2018. For our analysis, we have used data from 2002 to 2015, the years for which information on citizenship is reliably included on the death certificate. Corresponding benchmark data, in which nationality is recorded, exists only for a 10% sample from the population and housing census of 2011. Mid-year population estimates (MYPE) also exist but are not disaggregated by nationality. For this reason, certain estimates of death proportions by nationality will be relative and will not correspond to crude death rates.

Results

The total number of female deaths recorded from the years 2002 to 2015 in the country was 3740.761. Of these, 99.09% (n = 3,707,003) were deaths of South Africans and 0.91% (n = 33,758) were deaths of SADC women citizens. For maternal mortality, we considered the total number of deaths recorded for women between the ages of 15 and 49 years of age and were 1,530,495 deaths. Of these, deaths due to pregnancy-related causes contributed to approximately 1% of deaths. South African women contributed to 17,228 maternal deaths and SADC women to 467 maternal deaths during the period under study. The odds ratio for this comparison was 2.02. In other words, our findings show the odds of a black migrant woman from a SADC country dying of a maternal death were more than twice that of a South African woman. This result is statistically significant as this odds ratio, 2.02, falls within the 95% confidence interval (1.82-2.22).

Conclusion

The study is the first to examine and compare maternal death among two groups of women, women from SADC countries and South Africa, based on Stats SA data available for the years 2002-2015. This analysis allows for a better understanding of the differential impact that social determinants of health have on mortality among black migrant women in South Africa and considers access to healthcare as a determinant of health. As we examined maternal death, we inferred that the heightened mortality among black migrant women in South Africa was associated with various determinants of health, such as xenophobic attitudes of healthcare workers toward foreigners during the study period. The negative attitudes of healthcare workers toward migrants have been reported in the literature and the media. Yet, until now, its long-term impact on the health of the foreign population has not been gaged. While a direct association between the heightened death of migrant populations and xenophobia cannot be established in this study, we hope to offer evidence that supports the need to focus on the heightened vulnerability of black migrant women in South Africa. As we argued here, the heightened maternal mortality among migrant women can be considered hidden barriers in which health inequality and the pervasive effects of xenophobia perpetuate the health disparity of SADC migrants in South Africa.

Estimating the mortality risk correcting for high loss to follow-up among female sex workers with HIV in Durban, South Africa, 2018-2021

PURPOSE

This study assesses risk factors of loss to follow-up (LTFU) and estimates mortality risk among female sex workers (FSW) with HIV in Durban, South Africa, in 2018-2021.

METHODS

We used data from the Siyaphambili trial, which evaluated strategies for improved viral suppression. FSW with HIV aged ≥ 18 years with viral load ≥ 50 copies/mL were followed up for 18 months. LTFU was defined as absence from study or intervention visits for 6 months. We traced LTFU participants by calling/in-person visit attempts to ascertain their vital status. We used Cox regression to determine risk factors of LTFU and inverse probability of tracing weights to correct mortality risk.

RESULTS

Of 777 participants, 10 (1.3%) had died and 578 (74.4%) were initially LTFU. Among those LTFU, 36.3% (210/578) were traced successfully, with 6 additional deaths ascertained. Recent physical and sexual violence, and non-viral suppression were associated with increased LTFU. The unweighted and weighted 18-month mortality risks were 2.4% (95% CI: 0.8%-3.9%) and 3.7% (95% CI: 1.8%-5.9%), respectively.

CONCLUSIONS

LTFU is common among FSW with HIV in South Africa with additional investigation of vital status demonstrating under-ascertained mortality. These data suggest the need for comprehensively addressing risks for mortality among FSW.

A Confounding Discourse Analysis of Vietnamese Sex Workers' Talk in the City of Kaiyuan, China

BACKGROUND

Vietnamese female sex workers (VFSWs) cross the border into Kaiyuan City, Yunnan Province yearly. However, very little is known about both the health and psychological issues VFSWs experience. The objectives of this study were to explore the dominant discourses that emerged from the VFSWs' talk. The interviews occurred between May 2018 and June 2018 with 20 VFSWs who worked in Kaiyuan City, China. The English translated transcripts were analyzed using an eclectic feminist method of discourse analysis. Two discourses emerged. First, "Agency when working in Karaoke Bars and other Indoor Venues", and second, "Negative Impacts on Psychological Well-being and Other Problems from Migration." As for Discourse 1, the VFSWs positioned themselves as having agency over choosing their clientele as well as agency over what they were willing to negotiate with their clients to establish boundaries of their bodies. As for the Discourse 2, while there was a discourse of agency in their work there was also a contrasting, confounding discourse around the negative impact on psychological well-being and reports of stress as a migrant worker. Discourse 1 and Discourse 2 are confounding. When analyzed together, the discourses suggest that the impacts on psychological well-being may be more related to the migrant status of the women, supporting the notion of systemically influenced agency.

Predictors of mobility among women engaged in commercial sex work in Uganda using generalized estimating equations model

BACKGROUND

Women engaged in commercial sex work (WESW) are at a higher risk of acquiring and transmitting HIV. WESW are highly mobile, and their mobility may increase their economic status, and increased access to healthcare and other social services. However, it may also facilitate the spread of HIV infection from higher to lower prevalence regions. This study examined the predictors of mobility among WESW in Uganda using a generalized estimating equations model.

METHODS

We defined and measured mobility as the change in residence by WESW between baseline, 6 months, and 12 months follow-up. Participants who changed places were considered mobile, and those who never changed were non-mobile. We used data from a longitudinal study, which recruited 542 WESW from Southern Uganda aged 18-55 years and constructed a Generalized Estimating Equations Model.

RESULTS

Findings show that 19.6% of WESW changed residence between baseline and 6 months of follow-up and 26.2% (cumulative) between baseline and 12 months of follow-up. Older women (OR = 0.966, 95% CI = 0.935, 0.997) were associated with decreased odds of mobility, whereas WESW who were HIV positive (OR = 1.475, 95% CI = 1.078, 2.018) and those from large households (OR = 1.066, 95% CI = 1.001, 1.134) were associated with increased odds of mobility. WESW residing in rural areas (OR = 0.535, 95% CI = 0.351, 0.817) were associated with decreased odds of mobility compared to those from fishing sites.

CONCLUSION

The results indicate risk factors for mobility, further research is needed to determine the directionality of these factors in order to design interventions addressing mobility among WESW.

Opportunities and considerations for the design of decentralized delivery of antiretroviral therapy for female sex workers living with HIV in South Africa

BACKGROUND

In South Africa, 60% of female sex workers (FSW) are living with HIV, many of whom experience structural and individual barriers to antiretroviral therapy (ART) initiation and adherence. Community-based decentralized treatment provision (DTP) may mitigate these barriers. To characterize optimal implementation strategies, we explored preferences for DTP among FSW living with HIV in Durban, South Africa.

METHODS

Thirty-nine semi-structured in-depth interviews were conducted with FSW living with HIV (n = 24), and key informants (n = 15) including HIV program implementers, security personnel, and brothel managers. Participants were recruited using maximum variation and snowball sampling. Interviews were conducted in English or isiZulu between September-November 2017 and analyzed using grounded theory in Atlas.ti 8.

RESULTS

DTP was described as an intervention that could address barriers to ART adherence and retention, minimizing transport costs, time and wage loss from clinic visits, and act as a safety net to address FSW mobility and clinic access challenges. Respondents highlighted contextual considerations for DTP and suggested that DTP should be venue-based, scheduled during less busy times and days, and integrate comprehensive health services including psychological, reproductive, and non-communicable disease services. ART packaging and storage were important for community-based delivery, and participants suggested DTP should be implemented by sex work sensitized staff with discrete uniform and vehicle branding.

CONCLUSIONS

Incorporating FSW preferences may support implementation optimization and requires balancing of tensions between preferences and feasibility. These data suggest the potential utility of DTP for FSW as a strategy to address those most marginalized from current ART programs in South Africa.

The HIV Cascade of Care and Service Utilisation at Sex Work Programmes Among Female Sex Workers in South Africa

Female sex workers (FSWs) in South Africa experience a uniquely high prevalence of HIV. We describe the HIV cascade of care (CoC) in FSWs in South Africa, and explored service utilisation at sex work programmes. A cross-sectional, study enrolled FSWs across 12 sites in South Africa. Participants were recruited using chain-referral method. Inclusion criteria: ≥ 18 years, cis-gender female, sold/transacted in sex, HIV positive. 1862 HIV positive FSWs were enrolled. 92% were known positive, 87% were on antiretroviral treatment (ART). Of those on ART, 74% were virally suppressed. Younger FSWs were significantly less likely to be on ART or virally suppressed. Female sex workers using HIV services from specialised programs were 1.4 times more likely to be virally suppressed than non-program users. The pre-COVID-19 pandemic HIV CoC amongst FSWs in South Africa shows striking improvement from previous estimates, and approaches achievement of 90:90:90 goals.

No increased HIV risk in general population near sex work sites: A nationally representative cross-sectional study in Zimbabwe

OBJECTIVES

Sex work sites have been hypothesised to be at the root of the observed heterogeneity in HIV prevalence in sub-Saharan Africa. We determined if proximity to sex work sites is associated with HIV prevalence among the general population in Zimbabwe, a country with one of the highest HIV prevalence in the world.

METHODS

In this cross-sectional study we use a unique combination of nationally representative geolocated individual-level data from 16,121 adults (age 15-49 years) from 400 sample locations and the locations of 55 sex work sites throughout Zimbabwe; covering an estimated 95% of all female sex workers (FSWs). We calculated the shortest distance by road from each survey sample location to the nearest sex work site, for all sites and by type of sex work site, and conducted univariate and multivariate multilevel logistic regressions to determine the association between distance to sex work sites and HIV seropositivity, controlling for age, sex, male circumcision status, number of lifetime sex partners, being a FSW client or being a stable partner of an FSW client.

RESULTS

We found no significant association between HIV seroprevalence and proximity to the nearest sex work site among the general population in Zimbabwe, regardless of which type of site is closest (city site adjusted odds ratio [aOR] 1.010 [95% confidence interval {CI} 0.992-1.028]; economic growth point site aOR 0.982 [95% CI 0.962-1.002]; international site aOR 0.995 [95% CI 0.979-1.012]; seasonal site aOR 0.987 [95% CI 0.968-1.006] and transport site aOR 1.007 [95% CI 0.987-1.028]). Individual-level indicators of sex work were significantly associated with HIV seropositivity: being an FSW client (aOR 1.445 [95% CI 1.188-1.745]); nine or more partners versus having one to three lifetime partners (aOR 2.072 [95% CI 1.654-2.596]).

CONCLUSIONS

Sex work sites do not seem to directly affect HIV prevalence among the general population in surrounding areas. Prevention and control interventions for HIV at these locations should primarily focus on sex workers and their clients, with special emphasis on including and retaining mobile sex workers and clients into services.

Whose role is it anyways: Knowledge generation within the scope of sex work

Research within the context of sex work is challenging. The nature of the subject matter and stigma that surrounds sex work has often privileged a homogenous, academic practice of generating knowledge. Based on the lessons and experiences of an existing sex work programme and a recently completed national public health study with female sex workers (FSWs) in South Africa, we aim to highlight the significance and successes of privileging a bottom-up, community centric approach to the design, data collection, and knowledge generation. A FSW programme provided extensive peer educator skills training and learning opportunities. Lessons were applied to the implementation of a national study on FSW across South Africa. Planning workshops with community members and sites and pre- implementation training of all site staff was undertaken. 3005 FSWs were successfully enrolled and surveyed by their peers, over 6-months. Researchers have a lot to learn from community members and should remain vigilant to the power dynamics that their privilege creates throughout the research process. Those seeking to generate knowledge should practice meaningfully engagement and include population members on the study team in roles that allow them to proactively contribute to the process and create knowledge.

Migration and Mobility: Correlates of Recent HIV Testing Among Substance Using Female Sex Workers at the Mexico-Guatemala Border

The goal of this paper is to determine the association between traveling to engage in sex work in another country and recent access to HIV testing among substance-using female sex workers (FSWs) in the Mexico-Guatemala border region. From 2012 to 2015, through modified time-location sampling and peer referral, 255 FSWs were recruited at Mexico's southern border. Participants completed questionnaires on sociodemographics, migration and mobility experiences, work environment factors, and substance use. A conceptual framework, as depicted by a directed acyclic graph (DAG), guided our analysis. Crude and adjusted logistic regression models were used to evaluate the relationships between mobility experiences and HIV testing in the past year. Overall HIV testing was low (41%); after considering relevant covariates (i.e., interaction with health services and organizations, and sex work characteristics) traveling to engage in sex work in another country was found to be positively associated with HIV testing in the past year. Future efforts need to consider voluntary and non-stigmatizing prevention HIV services and focus on reaching out to less mobile women.

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

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

Structural determinants of HIV/STI prevalence, HIV/STI/sexual and reproductive health access, and condom use among immigrant sex workers globally

OBJECTIVE

Given stark health inequities among precarious and criminalized workers, we aimed to apply a structural determinants framework to systematically review evidence on HIV/sexually transmitted infection (STI) prevalence, access to HIV/STI/SRH services, and condom use among im/migrant sex workers (ISWs) globally.

METHODS

Systematic search of peer-reviewed studies published in English (2009-2019). Eligible studies reported HIV/STI, access to HIV/STI/SRH services, and/or condom use outcomes and/or lived experiences among ISWs. Quantitative and qualitative data were synthesized using a structural determinants framework.

RESULTS

Of 425 studies screened, 29 studies from 15 countries were included. HIV prevalence ranged from 0.3 to 13.6% and varied across settings, with highest prevalence among undocumented ISWs in a high-income country (Portugal). Precarious immigration status was a structural factor associated with poorer HIV/STI outcomes, whereas qualitative narratives showed ISWs' lived experiences as strongly shaped by policing and stigma. Despite disparities, in some settings, HIV and STI prevalence were lower and odds of condom use with clients were higher among ISWs relative to non-im/migrant sex workers. This review identified a paucity of research on SRH and male and gender-diverse ISWs. Across legislative settings, criminalization of SW and im/migrant status, policing, and migration-related marginalization were prominent structural barriers to ISWs' HIV/STI/SRH access.

CONCLUSION

This review identified important inequities and variation in HIV/STI prevalence among ISWs globally. Our findings highlight impacts of the intersections of migration and criminalization, and suggest a need to reform criminalized sex work laws; address punitive policing and immigration enforcement; enable safer indoor work environments; and expand community-based interventions towards promoting HIV/STI/SRH access and health equity among ISWs.

Health service use and health outcomes among international migrant workers compared with non-migrant workers: A systematic review and meta-analysis

OBJECTIVES

The review aimed to synthesise recent evidence on health service use and health outcomes among international migrant workers, compared with non-migrant workers.

METHODS

A search was carried out in MEDLINE, PubMed, Embase, and CINAHL for studies published between Jan 1, 2010, and Feb 29, 2020. Included outcomes were: occupational health service use, fatal occupational injury, HIV, and depression. Two authors independently screened records, extracted data, assessed risk of bias and judged quality of evidence. We meta-analysed estimates and conducted subgroup analyses by sex, geographical origin, geographical destination, and regularity of migration.

RESULTS

Twenty-one studies were included comprising >17 million participants in 16 countries. Most studies investigated regular migrant workers in high-income destination countries. Compared with non-migrant workers, migrant workers were less likely to use health services (relative risk 0·55, 95% confidence interval 0·41 to 0·73, 4 studies, 3,804,131 participants, I2 100%, low quality of evidence). They more commonly had occupational injuries (1·27, 95% confidence interval 1·11 to 1·45, 7 studies, 17,100,626 participants, I2 96%, low quality of evidence). Relative risks differed by geographical origin and/or destination. There is uncertainty (very low quality of evidence) about occupational health service use (0 studies), fatal occupational injuries (5 studies, N = 14,210,820), HIV (3 studies, N = 13,775), and depression (2 studies, N = 7,512).

CONCLUSIONS

Migrant workers may be less likely than non-migrant workers to use health services and more likely to have occupational injuries. More research is required on migrant workers from and in low- and middle-income countries, across migration stages, migrating irregularly, and in the informal economy.

A comparison of the prevalence of sexually transmitted infections among circumcised and uncircumcised adult males in Rustenburg, South Africa: a cross-sectional study

BACKGROUND

South Africa has a persistent burden of sexually transmitted infections (STIs). Male circumcision has been shown to be effective in preventing HIV and STIs, but data are scarce on the protective effect of circumcision in high-risk populations such as migrant miners. The objective of this study was to assess the effect of medical and traditional circumcision on the prevalence of STIs after adjusting for other risk factors in Rustenburg, a mining town in North West Province, South Africa.

METHODS

This cross-sectional study used baseline data collected from a cohort study. Adult males in a mining town were assessed for STIs (gonorrhea, chlamydia, and trichomoniasis) using syndromic assessment. Data on circumcision status and other risk factors for STI syndromes were collected using an interviewer-administered questionnaire. The following symptoms were assessed; penile discharge, painful urination, dyspareunia or penile sores. These symptoms indicate sexually transmitted infection in general since laboratory tests were not performed. Multivariable log binomial regression was used to assess the independent effect of circumcision on STI presence after adjusting for confounders.

RESULTS

A total of 339 participants with a median age of 25 years (IQR 22-29) were included in the study, of whom 116 (34.2%) were circumcised. The overall STIs prevalence was 27.4% (95% CI 22.8 to 32.6%) and was lower in the circumcised participants compared with those who were uncircumcised (15.5% vs 33.6%, respectively, p < 0.001). Both medical (OR 0.57, 95% CI 0.34-0.95, p = 0.030) and traditional circumcision (OR 0.34, 95% CI 0.13-0.86, p = 0.022) were strongly associated with a lower risk of STIs after adjustment for employment and condom use.

CONCLUSION

In this high-risk population in a mining town in South Africa, with a relatively high prevalence of STIs, and where one third of males are circumcised, both medical and traditional circumcision appear to be protective against STIs.

Police Discrimination, Misconduct, and Stigmatization of Female Sex Workers in Kenya: Associations with Delayed and Avoided Health Care Utilization and Lower Consistent Condom Use

Discrimination and violence against sex workers by police are common in many populations and are associated with negative health outcomes, as well as being per se violations of human rights laws and norms. There is a close and mutually reinforcing nexus between legally actionable rights violations and stigma, and reducing human rights violations against sex workers likely requires both legal and societal interventions that address both. In this paper, we first aim to estimate levels of discrimination, violence, and stigma against women sex workers by police in Kenya. Second, we aim to estimate the association between manifestations of discrimination and stigma, on the one hand, and general health care utilization and consistent condom use, on the other. Using data from a survey of Kenyan sex workers, we document widespread discrimination and stigma. Through regression analyses, participants with the highest levels of all three categories of manifestations of discrimination and stigma reported significant lower consistent condom use. Those with the highest levels of witnessed/heard manifestations were significantly more likely to delay or avoid needed health care, and the highest level of experienced manifestations were associated with a marginally significant increase in delay or avoidance. Our findings document a plethora of violations of human rights obligations under Kenyan and international law.

Migrant female sex workers working at the Sino-Vietnamese border for a short time have a higher risk of HIV transmission: a consecutive cross-sectional study

OBJECTIVES

For migrant female sex workers (FSWs) at the Sino-Vietnamese border, the impact of work time in their current location on the spread of HIV/AIDS is not clear.

METHODS

Data were collected from the Sino-Vietnamese border cities of Guangxi, China. Migrant FSWs working in these cities were studied. FSWs who worked less than 6 months in their current location were assigned to the short-term work group (ST FSWs), and FSWs who worked equal to or longer than 6 months in their current location were assigned to the long-term work group (LT FSWs). Logistic regression was performed to examine the impact of work time in the current location and factors associated with HIV infection.

RESULTS

Among the 1667 migrant FSWs, 586 (35.2%) and 1081 (64.9%) were assigned to the ST FSW and LT FSW groups, respectively. Compared to LT FSWs, ST FSWs were more likely to be of Vietnamese nationality, be less than 18 years old when they first engaged in commercial sex work, and have a low-level of HIV-related knowledge and had higher odds of using condoms inconsistently, having more male clients, having no regular male clients, and having a history of male clients who used aphrodisiacs but lower odds of receiving free condoms distribution and education/HIV counselling and testing programme. The analysis of factors associated with HIV infection revealed that Vietnamese FSWs, less than 18 years old when they first engaged in commercial sex work, having no regular male clients, and having lower average charge per sex transaction were correlated with HIV infection.

CONCLUSION

FSWs with short-term work at the Sino-Vietnamese border had a higher risk of risky sex and were correlated with HIV risk factors. Vietnamese FSWs were at higher risk of HIV infection, and they were more likely to have short-term work. More targeted HIV prevention should be designed for new FSWs who recently began working in a locality to further control the spread of HIV, particularly cross-border FSWs.

Sex work and condom use in Soweto, South Africa: a call for community-based interventions with clients

Despite public health interventions targeting sex workers in an attempt to increase condom use, HIV still remains a significant health issue for those involved in the sex industry in many countries. In this paper, we analyse data collected as part of an ethnographic study of sex work in Soweto, South Africa. We show that the main problems with consistent condom use are clients who threaten violence if sex workers insist on condoms, clients who are 'rough' and refuse to stop intercourse when the condom breaks, and clients who offer to pay more money for unprotected sex. These issues relate to unequal gender norms that disempower female sex workers and dismiss the importance of consent in sexual relationships. The criminalisation of sex work increases vulnerability and reduces sex workers' agency as sex workers are reluctant to report crimes committed against them. Persistent 'whore stigma' adds to this dynamic by dehumanising sex workers. In conclusion, we advocate for decriminalisation and posit that public health interventions aimed at increasing condom use and reducing HIV rates need to specifically engage clients, address unequal gender norms and involve local communities to tackle stigma directed against sex workers.

Facilitators and barriers to incorporating digital technologies into HIV care among cisgender female sex workers living with HIV in South Africa

BACKGROUND

An estimated 44-69% of female sex workers (FSW) in South Africa are living with HIV, among whom 39% are virally suppressed. Digital technologies-increasingly advanced and accessible to marginalized populations-present new opportunities to improve the HIV care continuum. The objective of this study was to explore potential facilitators and barriers to incorporating mobile phones and advanced technologies (e.g., biometric identification methods, mobile phone applications for social media and other uses, and chatbots) to deliver HIV-related interventions to cisgender FSW living with HIV in Durban, South Africa.

METHODS

Four semi-structured, focus group discussions (FGDs) were conducted with 22 cisgender FSWs in December 2018. Participants were recruited from the ongoing Siyaphambili trial using maximum variation sampling to optimize diversity in participant age and sex work venue. FGDs were audio recorded in isiZulu, and translated and transcribed into English. Transcripts were inductively coded using thematic analysis and sub-themes were iteratively refined to connect and evaluate the saliency of codes.

RESULTS

Phone ownership was motivated by a desire to remain safe and to connect with family, peers, and clients. When FSW did not have access to a mobile phone, they reported sharing phones with their peers, though sharing only occurred under specific conditions. Still, to integrate mobile phones into HIV care, FSW identified consistent access to mobile phones as a key barrier. Mobile phone turnover due to frequent selling of phones to meet other financial priorities, substance use, and theft were common. To integrate advanced technologies into HIV care, FSW identified convenience, security, and additional opportunities for social support as the main facilitators. For example, FSW described how biometric identification at clinics could eliminate the need to retain a clinic card. FSW also described how chatbots could easily set medication alarms or be available to assist in emergencies. Barriers for advanced technologies included maintaining privacy, potential threats to security, and cost.

CONCLUSIONS

FSWs were receptive to digital technologies for HIV care and beyond, but they also described many barriers such as inconsistent phone ownership and threats to privacy. As phone ownership grows and HIV programs increasingly leverage digital tools, strong considerations are needed to ensure the most vulnerable are not systematically excluded.

Characterising the relationship between migration and stigma affecting healthcare engagement among female sex workers in Lomé, Togo

Migration in West Africa is common and complicates the sustained delivery of comprehensive HIV care programmes for those with specific vulnerabilities to HIV, including female sex workers (FSW). This study evaluated whether migration potentiates the burden of stigma affecting FSW in Lomé, Togo. Respondent driven sampling identified 354 FSW who completed HIV testing and a questionnaire. Multivariable logistic regression was used to identify factors associated with stigma among FSW. Among study participants, 76.3% (270/354) were migrants, with 30.2% (107/354) reporting stigma. Migrant FSW were less likely to report stigma (aOR 0.40; 95% CI:0.22-0.73). FSW who had an abortion (aOR 3.40; 95% CI:1.79-6.30) and were tested for a sexually transmitted infection (STI) or HIV (aOR 2.03; 95% CI:1.16-3.55) were more likely to report stigma. Among FSW, 59.8% (211/353) disclosed selling sex to a health worker. Disclosure was more common among FSW who had been tested for an STI or HIV (36.7%; 77/210), or both (55.7%; 117/210), and resulted in an attenuated but significant association between STI or HIV testing and stigma, indicating that disclosure partially mediated the relationship. These results highlight the need to mitigate healthcare-related stigma affecting FSW, while also considering decentralised HIV testing approaches, including HIV self-testing.

Effects of Migration on Risky Sexual Behavior and HIV Acquisition in South Africa: A Systematic Review and Meta-analysis, 2000-2017

While human mobility has been implicated in fueling the HIV epidemic in South Africa, the link between migration and HIV has not been systematically reviewed and quantified. We conducted a systematic review of the role of migration in HIV risk acquisition and sexual behaviour based on 29 studies published between 2000 and 2017. Furthermore, we performed a meta-analysis of the association between migration and HIV risk acquisition in four of the studies that used HIV incidence as an outcome measure. The systematic review results show that HIV acquisition and risky sexual behavior were more prevalent among both male and female migrants compared to their non-migrant counterparts. The meta-analysis results demonstrate that migration was significantly associated with increased HIV acquisition risk (aOR = 1.69, 95% CI 1.33-2.14; I² = 35.0%). There is an urgent need for effective combination HIV prevention strategies (comprising biomedical, behavioral and structural interventions) that target migrant populations.

Exploring The Migration Profiles of Primary Healthcare Users in South Africa

South Africa’s public healthcare system responses seldom engage with migration. Our exploratory study investigates migration profiles and experiences of primary healthcare (PHC) users. A cross-sectional survey involving non-probability sampling was conducted with 229 PHC users at six purposively selected PHC clinics in three districts of SA. The survey captured socio-demographic information, migration histories, and PHC experiences. Chi square and Fischer’s exact tests were used to compare categorical variables, whilst Mann–Whitney U tests compared continuous variables between groups. Most PHC users were migrants (22% internal South African; 45% cross-border) who generally move for reasons other than healthcare seeking. Length of time accessing services at a specific clinic was shown to be key in describing experiences of PHC use. Understanding population movement is central to PHC strengthening in SA and requires improved understanding of mobility dynamics in regard to not just nationality, but also internal mobility and length of stay.

Mobility and sex work: why, where, when? A typology of female-sex-worker mobility in Zimbabwe

Sex-worker mobility may have implications for health and access to care but has not been described in sub-Saharan Africa. We described sex-worker mobility in Zimbabwe and a mobility typology using data from 2591 and 2839 female sex workers in 14 sites from 2013 and 2016. We used latent class analysis to identify a typology of mobile sex workers. More women travelled for work in 2016 (59%) than in 2013 (27%), usually to find clients with more money (57% of the journeys), spending a median of 21 (2013) and 24 (2016) days away. A five-class mixture model best fitted the data, with 39% women in an infrequent work-mobility class, 21% in a domestic-high-mobility class, 16% in an international-high-mobility class, 16% in an infrequent opportunistic-non-work-mobility class, and 7% who travel with clients. More-mobile classes were better educated; risk behaviours differed by class. Mobility is increasing among sex worker in Zimbabwe, multi-faceted, and not explained by other vulnerabilities.

Migration and cognitive function: a conceptual framework for Global Health Research

BACKGROUND

Migration is a fundamental demographic process that has been observed globally. It is suggested that migration is an issue of global health importance that can have an immediate and lasting impact on an individual's health and well-being. There is now an increasing body of evidence linking migration with cognitive function in older adults. In this paper, we synthesized the current evidence to develop a general conceptual framework to understand the factors contributing to the association between migration and cognitive function.

METHODS

A comprehensive review of the literature was conducted on the associations between migration and cognition among middle-aged and older adults.

RESULTS

Five potential mechanisms were identified from the literature: 1) socioeconomic status-including education, occupation, and income; 2) psychosocial factors-including social networks, social support, social stressors, and discrimination; 3) behavioral factors-including smoking, drinking, and health service utilization; 4) physical and psychological health status-including chronic conditions, physical function, and depression; and 5) environmental factors-including both physical and social environment. Several underlying factors were also identified-including early-life conditions, gender, and genetic factors.

CONCLUSIONS

The factors linking migration and cognitive function are multidimensional and complex. This conceptual framework highlights potential implications for global health policies and planning on healthy aging and migrant health. Additional studies are needed to further examine these mechanisms to extend and refine our general conceptual framework.

Feasibility, acceptability and potential sustainability of a 'diagonal' approach to health services for female sex workers in Mozambique

Background

Female sex workers (FSWs) in many settings have restricted access to sexual and reproductive health (SRH) services. We therefore conducted an implementation study to test a ‘diagonal’ intervention which combined strengthening of FSW-targeted services (vertical) with making public health facilities more FSW-friendly (horizontal). We piloted it over 18 months and then assessed its performance.

Methods

Applying a convergent parallel mixed-methods design, we triangulated the results of the analysis of process indicators, semi-structured interviews with policy makers and health managers, structured interviews with health care providers and group discussions with peer outreach workers. We then formulated integrated conclusions on the interventions’ feasibility, acceptability by providers, managers and policy makers, and potential sustainability.

Results

The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure FSWs have access to SRH services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society.

Conclusions

In the current Mozambican context, a ‘diagonal’ approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component.

Prevalence and patterns of victimization and polyvictimization among female sex workers in Soweto, a South African township: a cross-sectional, respondent-driven sampling study

Background: Female sex workers (FSWs) are disproportionately affected by violence from multiple partner categories. This increases their vulnerability to HIV.

Objectives: To describe patterns of violence and polyvictimization among female SWs in Soweto.

Methods: A respondent-driven sampling (RDS) recruitment methodology was used to enrol 508 Soweto-based FSWs using a survey instrument. Raw and RDS adjusted data were descriptively analysed, Spearman’s correlation and chi² test of association were used to show associations. Polyvictimization patterns are shown within a modified Venn diagram.

Results: The median age of FSWs in Soweto was 31 years, and most had an incomplete education (74.2%). The prevalence of exposure to physical/sexual intimate partner violence (IPV) in the past year was 53.8%, 46.8% by clients, and 18.5% by police. Past year prevalence of sexual/physical violence by any perpetrator category was 70.8% and lifetime exposure was 76.0%. Childhood sexual violence was reported by 44.3%. Lifetime non-partner rape was 55.5% and all rape exposure was 62.4%. As a result of engaging in sex work in the past year, 65.2% women had been discriminated against. Client, police, IPV, and childhood trauma were all significantly associated with one another, with IPV being the most common co-occurrence. Polyvictimization was seen in almost two-thirds of FSWs, and increased with exposure to discrimination.

Conclusion: In Soweto, FSWs are exposed to high rates of violence in multiple forms across their lifetime. Our findings show that violence continues unabated into adulthood at levels far higher than in the general population and overall at higher levels than previously recorded among SWs in South Africa. We argue that violence against FSWs is rooted in discrimination. The disparate burden of violence on FSWs requires urgent interventions to proactively address and reframe the normalisation of violence against all women.

Sexual transactions between long distance truck drivers and female sex workers in South Africa

Background: Female sex workers (FSWs) and long distance truck drivers (LDTDs) are considered key populations at high risk for HIV transmission due to high prevalence. The intersection of these mobile populations presents unique challenges in the fight against HIV and the movement towards reducing new infections.

Objective: The purpose of this study was to explore the nature of sex trade along a particular transport route. Sexual transactions and the vulnerabilities that exist between these two groups with regards to HIV/AIDS are described, with the purpose of furthering the agenda for targeted interventions.

Methods: Qualitative in-depth interviews were conducted with 14 participants, seven FSWs and seven LDTDs. We recruited FSWs through snowballing, and LDTDs through intercepts at truck stops. Semi-structured interview guides were used for data collection, and thematic analysis was conducted.

Results: The sex trade in this study is characterized by competition, fuelled by money-driven and age-disparate rivalry. Despite widespread HIV knowledge, FSWs contend with persistent challenges regarding condom use negotiation, induced by more money in the exchange for unsafe sex. Despite the placement of wellness centres in truck stops along the highway, LDTDs face stigma related challenges with regards to testing for HIV and personal acknowledgement of their involvement in the sex trade.

Conclusion: The nature of the sex trade along the highway continues to be risky despite the availability of HIV testing and antiretroviral treatment (ART). The sex trade is perceived to be increasing along trucking routes, in spite of measures instituted to limit access to FSWs. FSWs struggle to cope with the pressure of unprotected sex because of the need to generate more income, as well as avoid incidents of violence and threats. Interventions along transport routes need to be inclusive of FSWs who could play a vital role in stigma reduction amongst LDTDs through peer education.

Impacts of Climate Change on Health and Wellbeing in South Africa

Given its associated burden of disease, climate change in South Africa could be reframed as predominately a health issue, one necessitating an urgent health-sector response. The growing impact of climate change has major implications for South Africa, especially for the numerous vulnerable groups in the country. We systematically reviewed the literature by searching PubMed and Web of Science. Of the 820 papers screened, 34 were identified that assessed the impacts of climate change on health in the country. Most papers covered effects of heat on health or on infectious diseases (20/34; 59%). We found that extreme weather events are the most noticeable effects to date, especially droughts in the Western Cape, but rises in vector-borne diseases are gaining prominence. Climate aberration is also linked in myriad ways with outbreaks of food and waterborne diseases, and possibly with the recent Listeria epidemic. The potential impacts of climate change on mental health may compound the multiple social stressors that already beset the populace. Climate change heightens the pre-existing vulnerabilities of women, fishing communities, rural subsistence farmers and those living in informal settlements. Further gender disparities, eco-migration and social disruptions may undermine the prevention-but also treatment-of HIV. Our findings suggest that focused research and effective use of surveillance data are required to monitor climate change's impacts; traditional strengths of the country's health sector. The health sector, hitherto a fringe player, should assume a greater leadership role in promoting policies that protect the public's health, address inequities and advance the country's commitments to climate change accords.

The effect of mobility on HIV-related healthcare access and use for female sex workers: A systematic review

Female sex workers (FSW) experience a high HIV burden and are often mobile. FSW access to HIV-related healthcare is essential for equitable welfare and to reduce new HIV infections. We systematically reviewed the literature on mobility and HIV-related healthcare access and use among FSW. Outcome measures included: HIV/STI testing, STI treatment, PrEP (initiation or adherence), and ART (initiation or adherence). We summarised the results with a narrative synthesis. From 7417 non-duplicated citations, nine studies from Canada (3), Guatamala, Honduras (2), India, South Africa, and Vietnam were included. Only one of the studies was designed to address mobility and healthcare access, and only six reported adjusted effect estimates. Mobility was measured over four time-frames (from 'current' to 'ever'), as having lived or worked elsewhere or in another town/province/country. Three studies from Canada, Guatemala, and India found mobility associated with increased odds of poor initial access to healthcare (adjusted odds ratios (AOR) from 1.33, 95% CI 1.02, 1.75, to 2.27, 95% CI 1.09, 4.76), and one from Vietnam found no association (odds ratio (OR): 0.92, 95% CI 0.65, 1.28). The study from South Africa found no association with initiating ART (risk ratio: 0.86, 95% CI 0.65, 1.14). Two studies from Canada and Honduras found increased odds of ART interruption (AOR 2.74, 95% CI 0.89, 8.42; 5.19, 95% CI 1.38, 19.56), while two other studies from Canada and Honduras found no association with detectable viral load (OR 0.84, 95% CI 0.08, 8.33; AOR 0.79, 95% CI 0.41, 1.69). We found that mobility is associated with reduced initial healthcare access and interruption of ART, consistent with literature from the general population. Discordance between effects on adherence and viral load may be due to measurement of mobility. Future research should carefully construct measures of mobility and consider a range of HIV-related healthcare outcomes.

Opportunities for Enhanced Strategic Use of Surveys, Medical Records, and Program Data for HIV Surveillance of Key Populations: Scoping Review

BACKGROUND

Normative guidelines from the World Health Organization recommend tracking strategic information indicators among key populations. Monitoring progress in the global response to the HIV epidemic uses indicators put forward by the Joint United Nations Programme on HIV/AIDS. These include the 90-90-90 targets that require a realignment of surveillance data, routinely collected program data, and medical record data, which historically have developed separately.

OBJECTIVE

The aim of this study was to describe current challenges for monitoring HIV-related strategic information indicators among key populations ((men who have sex with men [MSM], people in prisons and other closed settings, people who inject drugs, sex workers, and transgender people) and identify future opportunities to enhance the use of surveillance data, programmatic data, and medical record data to describe the HIV epidemic among key populations and measure the coverage of HIV prevention, care, and treatment programs.

METHODS

To provide a historical perspective, we completed a scoping review of the expansion of HIV surveillance among key populations over the past three decades. To describe current efforts, we conducted a review of the literature to identify published examples of SI indicator estimates among key populations. To describe anticipated challenges and future opportunities to improve measurement of strategic information indicators, particularly from routine program and health data, we consulted participants of the Third Global HIV Surveillance Meeting in Bangkok, where the 2015 World Health Organization strategic information guidelines were launched.

RESULTS

There remains suboptimal alignment of surveillance and programmatic data, as well as routinely collected medical records to facilitate the reporting of the 90-90-90 indicators for HIV among key populations. Studies (n=3) with estimates of all three 90-90-90 indicators rely on cross-sectional survey data. Programmatic data and medical record data continue to be insufficiently robust to provide estimates of the 90-90-90 targets for key populations.

CONCLUSIONS

Current reliance on more active data collection processes, including key population-specific surveys, remains warranted until the quality and validity of passively collected routine program and medical record data for key populations is optimized.

Influence of indoor work environments on health, safety, and human rights among migrant sex workers at the Guatemala-Mexico Border: a call for occupational health and safety interventions

BACKGROUND

Migrant women are over-represented in the sex industry, and migrant sex workers experience disproportionate health inequities, including those related to health access, HIV and sexually transmitted infections (STIs), and violence. Despite calls for occupational sex work interventions situated in labour rights frameworks, there remains a paucity of evidence pertaining to migrant sex workers' needs and realities, particularly within Mexico and Central America. This study investigated migrant sex workers' narratives regarding the ways in which structural features of work environments shape vulnerability and agency related to HIV/STI prevention and violence at the Guatemala-Mexico border.

METHODS

Drawing on theoretical perspectives on risk environments and structural determinants of HIV in sex work, we analyzed in-depth interviews, focus groups, and ethnographic fieldwork conducted with 39 migrant sex workers in indoor work environments between 2012 and 2015 in Tecún Umán, Guatemala.

RESULTS

Participant narratives revealed the following intersecting themes to be most closely linked to safety and agency to engage in HIV/STI prevention: physical features of indoor work environments (e.g., physical layout of venue, proximity to peers and third parties); social norms and practices for alcohol use within the workplace; the existence and nature of management practices and policies on health and safety practices; and economic influences relating to control over earnings and clients. Across work environments, health and safety were greatly shaped by human rights concerns stemming from workplace interactions with police, immigration authorities, and health authorities.

CONCLUSIONS

Physical isolation, establishment norms promoting alcohol use, restricted economic agency, and human rights violations related to sex work policies and immigration enforcement were found to exacerbate risks. However, some establishment policies and practices promoted 'enabling environments' for health and safety, supporting HIV/STI prevention, economic agency, and protection from violence and exploitation; these practices and policies were especially crucial for recent migrants. Policy reforms and structural workplace interventions tailored to migrant sex workers' needs are recommended to promote improved working conditions and migrant sex workers' health, safety, and human rights.

Health Services Use and HIV Prevalence Among Migrant and National Female Sex Workers in Portugal: Are We Providing the Services Needed?

This cross-sectional bio-behavioral survey conducted with 853 female sex workers (FSW) aimed to examine differences in use of HIV health services, testing and prevalence among migrant and national FSW. A quarter of undocumented FSW had never used National Health Service (NHS) and 15 % never tested for HIV, significantly more than nationals (p < 0.001 and p = 0.024, respectively). HIV infection was self-reported by 11.9 % of nationals, 1.8 % of documented and 0.8 % of undocumented migrants (p < 0.001). The HIV rapid test was reactive in 13.6 % of undocumented, 8.0 % of nationals and 2.3 % of documented. A higher proportion of migrants were unaware of their positive serostatus compared to nationals. Ever had HIV testing was less likely among undocumented, who never used the NHS and who didn't know where to go if suspected being HIV-infected. Promoting early diagnosis with linkage to care among migrant FSW should be supported, while developing health services better tailored to their needs.

Sexual and reproductive health outcomes among female sex workers in Johannesburg and Pretoria, South Africa: Recommendations for public health programmes

BACKGROUND

The sexual and reproductive health (SRH) status of female sex workers is influenced by a wide range of demographic, behavioural and structural factors. These factors vary considerably across and even within settings. Adopting an overly standardised approach to sex worker programmes may compromise its impact on some sub-groups in local areas.

METHODS

Records of female sex workers attending clinic-, community-, or hotel-based health services in Johannesburg (n = 1422 women) and Pretoria (n = 408 women), South Africa were analysed. We describe the population's characteristics and identified factors associated with sexual and reproductive health outcomes, namely HIV status; previous symptomatic sexually transmitted infection (STI); modern contraceptive use and number of child dependents.

RESULTS

The women in Johannesburg were less likely than those in Pretoria to have HIV (42.2% vs 52.9%), or previous symptomatic STIs (44.3% vs. 8.3%), and were 1.4 fold less likely to have child dependents (20.1% vs. 15.3%). About 43% of women in Johannesburg were Zimbabwean and 40% in Pretoria. Of concern, only about 15% of women in both sites were using modern contraceptives. Johannesburg women were also more likely to access health services at a hotel (85.0% vs. 80.6%) or clinic (5.7% vs. 0.5%), to have completed secondary education (57.1% vs. 36.0%), and moved house more than twice during the past year (19.6 vs. 2.0%). In both cities, risk of HIV rose rapidly with age (23.8%-58.2% vs. 22.0%-64.8%). Of interest, HIV prevalence was considerably higher in those with consistent condom use with one's main partner than inconsistent users.

CONCLUSIONS

Sex worker populations are heterogeneous. Local health programmes must prioritise services that reflect the variety and complexity of sex worker needs and behaviours, and should be designed in consultation with sex workers. Segmenting sex worker populations according to age, country of origin and place of service delivery, and training healthcare providers accordingly, could help prevent new HIV infections, improve adherence to antiretroviral treatment and increase uptake of SRH services.

Condoms and sexual health education as evidence: impact of criminalization of in-call venues and managers on migrant sex workers access to HIV/STI prevention in a Canadian setting

Background

Despite a large body of evidence globally demonstrating that the criminalization of sex workers increases HIV/STI risks, we know far less about the impact of criminalization and policing of managers and in-call establishments on HIV/STI prevention among sex workers, and even less so among migrant sex workers.

Methods

Analysis draws on ethnographic fieldwork and 46 qualitative interviews with migrant sex workers, managers and business owners of in-call sex work venues in Metro Vancouver, Canada.

Results

The criminalization of in-call venues and third parties explicitly limits sex workers’ access to HIV/STI prevention, including manager restrictions on condoms and limited onsite access to sexual health information and HIV/STI testing. With limited labour protections and socio-cultural barriers, criminalization and policing undermine the health and human rights of migrant sex workers working in –call venues.

Conclusions

This research supports growing evidence-based calls for decriminalization of sex work, including the removal of criminal sanctions targeting third parties and in-call venues, alongside programs and policies that better protect the working conditions of migrant sex workers as critical to HIV/STI prevention and human rights.

International migration from non-endemic settings as a protective factor for HIV/STI risk among female sex workers in Vancouver, Canada

Given heterogeneous evidence regarding the impacts of migration on HIV/sexually transmitted infections (STIs) among female sex workers (FSWs), we explored factors associated with international migration among FSWs in Vancouver, Canada. We draw on baseline questionnaire and HIV/STI testing data from a community-based cohort, AESHA, from 2010-2012. Logistic regression identified correlates of international migration. Of 650 FSWs, 163 (25.1%) were international migrants, who primarily worked in formal indoor establishments. HIV/STI prevalence was lower among migrants than Canadian-born women (5.5 vs. 25.9%). In multivariate analysis, international migration was positively associated with completing high school, supporting dependents, and paying a third party, and negatively associated with HIV, injecting drugs and inconsistent condom use with clients. Although migrants experience lower workplace harms and HIV risk than Canadian-born women, they face concerning levels of violence, police harassment, and HIV/STIs. Research exploring structural and socio-cultural factors shaping risk mitigation and migrants' access to support remains needed.

HIV prevention and care-seeking behaviour among female sex workers in four cities in India, Kenya, Mozambique and South Africa

OBJECTIVE

To identify gaps in the use of HIV prevention and care services and commodities for female sex workers, we conducted a baseline cross-sectional survey in four cities, in the context of an implementation research project aiming to improve use of sexual and reproductive health services.

METHODS

Using respondent-driven sampling, 400 sex workers were recruited in Durban, 308 in Tete, 400 in Mombasa and 458 in Mysore and interviewed face-to-face. RDS-adjusted proportions were estimated by nonparametric bootstrapping and compared across cities using post hoc pairwise comparison.

RESULTS

Condom use with last client ranged from 88.3% to 96.8%, ever female condom use from 1.6% to 37.9%, HIV testing within the past 6 months from 40.5% to 70.9%, receiving HIV treatment and care from 35.5% to 92.7%, care seeking for last STI from 74.4% to 87.6% and having had at least 10 contacts with a peer educator in the past year from 5.7% to 98.1%. Many of the differences between cities remained statistically significant (P < 0.05) after adjusting for differences in FSWs' socio-demographic characteristics.

CONCLUSION

The use of HIV prevention and care by FSWs is often insufficient and differed greatly between cities. Differences could not be explained by variations in socio-demographic sex worker characteristics. Models to improve use of condoms and HIV prevention and care services should be tailored to the specific context of each site. Programmes at each site must focus on improving availability and uptake of those services that are currently least used.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Universal Coverage without Universal Access: Institutional Barriers to Health Care among Women Sex Workers in Vancouver, Canada

Background

Access to health care is a crucial determinant of health. Yet, even within settings that purport to provide universal health coverage (UHC), sex workers’ experiences reveal systematic, institutionally ingrained barriers to appropriate quality health care. The aim of this study was to assess prevalence and correlates of institutional barriers to care among sex workers in a setting with UHC.

Methods

Data was drawn from an ongoing community-based, prospective cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers’ Health Access). Multivariable logistic regression analyses, using generalized estimating equations (GEE), were employed to longitudinally investigate correlates of institutional barriers to care over a 44-month follow-up period (January 2010-August 2013).

Results

In total, 723 sex workers were included, contributing to 2506 observations. Over the study period, 509 (70.4%) women reported one or more institutional barriers to care. The most commonly reported institutional barriers to care were long wait times (54.6%), limited hours of operation (36.5%), and perceived disrespect by health care providers (26.1%). In multivariable GEE analyses, recent partner- (adjusted odds ratio [AOR] = 1.46, % 95% Confidence Interval [CI] 1.10–1.94), workplace- (AOR = 1.31, 95% CI 1.05–1.63), and community-level violence (AOR = 1.41, 95% CI 1.04–1.92), as well as other markers of vulnerability, such as self-identification as a gender/sexual minority (AOR = 1.32, 95% CI 1.03–1.69), a mental illness diagnosis (AOR = 1.66, 95% CI 1.34–2.06), and lack of provincial health insurance card (AOR = 3.47, 95% CI 1.59–7.57) emerged as independent correlates of institutional barriers to health services.

Discussion

Despite Canada’s UHC, women sex workers in Vancouver face high prevalence of institutional barriers to care, with highest burden among most marginalized women. These findings underscore the need to explore new models of care, alongside broader policy changes to fulfill sex workers’ health and human rights.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Retention and risk factors for loss to follow-up of female and male sex workers on antiretroviral treatment in Ivory Coast: a retrospective cohort analysis

BACKGROUND

Antiretroviral therapy (ART) for HIV-infected sex workers is an important HIV prevention strategy. However, sex workers may have additional challenges for retention in ART care. The objectives of this study were to assess retention of sex workers on ART in a routine setting in Ivory Coast and identify risk factors for loss to follow-up (LTFU).

METHODS

The design was a retrospective cohort study. An analysis of clinic files was conducted in 2 sites providing ART services to sex workers in Ivory Coast. Demographic, behavior, and clinical data of female and male sex workers on ART were abstracted onto a standardized anonymous data collection form. Data collection took place between May 11 and 28, 2010.

RESULTS

A total of 376 female and 38 male sex workers were included in the analysis. The retention probability was 75% at 6 months, 68% at 12 months, 55% at 24 months, and 47% at 36 months. Attrition was mainly because of LTFU. Factors significantly associated with LTFU in bivariate analysis were lower schooling level, later calendar year of starting ART, and not receiving initial adherence counseling. Later year of starting ART and not receiving adherence counseling at ART initiation remained significantly associated with LTFU in a multivariate Cox regression model.

CONCLUSIONS

To improve the retention of sex workers on ART, there is a need for more in-depth investigation of the role of pre-ART counseling and the increasing rates of LTFU with each calendar year.

Images of Place: Visuals from Migrant Women Sex Workers in South Africa

Many migrants in inner-city Johannesburg survive through unconventional and sometimes criminalized livelihood activities. In this article, we draw on data from a study that applied a participatory visual methodology to work with migrant women who sell sex, and explored the suitability of this approach as a way to engage with a presumed 'hard to reach' urban population. The lived experiences of migrant women sex workers were documented by combining participatory visual methods with a more traditional ethnographic approach, and this approach led us to new ways of seeing their worlds. This methodological approach raises important considerations for working with marginalized and criminalized urban groups.

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.

Gaps in the hepatitis C continuum of care among sex workers in Vancouver, British Columbia: Implications for voluntary hepatitis C virus testing, treatment and care

BACKGROUND

Hepatitis C virus (HCV) eradication leads to reduced morbidity, mortality and transmission. Despite the disproportionate burden of HCV among sex workers, data regarding the HCV care continuum in this population remain negligible.

METHODS

Using baseline data from an ongoing cohort of women sex workers in Vancouver (An Evaluation of Sex Workers' Health Access, January 2010 to August 2013), the authors assessed HCV prevalence and engagement in the HCV care continuum within the past year. Multivariable logistic regression analyses were used to evaluate associations with recent (ie, in the past year) HCV testing.

RESULTS

Among 705 sex workers, 302 (42.8%) were HCV seropositive. Of these, 22.5% were previously unaware of their HCV status, 41.7% had accessed HCV-related care, 13.9% were offered treatment and only 1.0% received treatment. Among 552 HCV-seronegative sex workers, only one-half (52.9%) reported a recent HCV test. In multivariable analysis, women who self-identified as a sexual⁄gender minority (adjusted OR [aOR] 1.89 [95% CI 1.11 to 3.24]), resided in the inner city drug use epicentre (aOR 3.19 [95%CI 1.78 to 5.73]) and used injection (aOR 2.00 [95% CI 1.19 to 3.34]) or noninjection drugs (aOR 1.95 [95% CI 1.00 to 3.78]) had increased odds of undergoing a recent HCV test, while immigrant participants (aOR 0.24 [95% CI 0.12 to 0.48]) had decreased odds.

CONCLUSIONS

Despite a high burden of HCV among sex workers, large gaps in the HCV care continuum remain. Particularly concerning are the low access to HCV testing, with one-fifth of women living with HCV being previously unaware of their status, and the exceptionally low prevalence of HCV treatment. There is a critical need for further research to better understand and address barriers to engage in the HCV continuum for sex workers.

HIV prevalence and risk behaviours among foreign migrant women residing in Cape Town, South Africa

HIV prevalence and risk behaviour among foreign migrants in South Africa has not been explored. This paper describes the effectiveness of respondent-driven sampling (RDS) to recruit foreign migrant women residing in Cape Town, reports HIV prevalence, and describes key characteristics among them. We conducted a biological and behavioural surveillance survey using RDS. After written informed consent, participants completed an audio computer assisted self-interview and provided a dried blood sample for HIV analysis. HIV prevalence was estimated to be 7 % (CI 4.9-9.5) among 935 women. HIV sero-positivity was associated with older age (p = 0.001), country of origin (p < 0.000), being unmarried (p < 0.000), having lived in South Africa for 3-5 years (p = 0.023), sexual debut at ≥15 years (p = 0.047), and having used a condom at last sex with a main partner (p = 0.007). Few women reported early sexual debut, or multiple sexual partners. RDS was successful in recruiting foreign migrant women.

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.

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

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

Systematic review of facility-based sexual and reproductive health services for female sex workers in Africa

Background

Several biological, behavioural, and structural risk factors place female sex workers (FSWs) at heightened risk of HIV, sexually transmitted infections (STIs), and other adverse sexual and reproductive health (SRH) outcomes. FSW projects in many settings have demonstrated effective ways of altering this risk, improving the health and wellbeing of these women. Yet the optimum delivery model of FSW projects in Africa is unclear. This systematic review describes intervention packages, service-delivery models, and extent of government involvement in these services in Africa.

Methods

On 22 November 2012, we searched Web of Science and MEDLINE, without date restrictions, for studies describing clinical and non-clinical facility-based SRH prevention and care services for FSWs in low- and middle-income countries in Africa. We also identified articles in key non-indexed journals and on websites of international organizations. A single reviewer screened titles and abstracts, and extracted data from articles using standardised tools.

Results

We located 149 articles, which described 54 projects. Most were localised and small-scale; focused on research activities (rather than on large-scale service delivery); operated with little coordination, either nationally or regionally; and had scanty government support (instead a range of international donors generally funded services). Almost all sites only addressed HIV prevention and STIs. Most services distributed male condoms, but only 10% provided female condoms. HIV services mainly encompassed HIV counselling and testing; few offered HIV care and treatment such as CD4 testing or antiretroviral therapy (ART). While STI services were more comprehensive, periodic presumptive treatment was only provided in 11 instances. Services often ignored broader SRH needs such as family planning, cervical cancer screening, and gender-based violence services.

Conclusions

Sex work programmes in Africa have limited coverage and a narrow scope of services and are poorly coordinated with broader HIV and SRH services. To improve FSWs’ health and reduce onward HIV transmission, access to ART needs to be addressed urgently. Nevertheless, HIV prevention should remain the mainstay of services. Service delivery models that integrate broader SRH services and address structural risk factors are much needed. Government-led FSW services of high quality and scale would markedly reduce SRH vulnerabilities of FSWs in Africa.

Concentrated HIV subepidemics in generalized epidemic settings

PURPOSE OF REVIEW

A relatively neglected topic to date has been the occurrence of concentrated epidemics within generalized epidemic settings and the potential role of targeted interventions in such settings. We review recent studies in high-risk groups as well as findings relating to geographical heterogeneity and the potential for targeting 'high-transmission zones' in the 10 countries with highest HIV prevalence.

RECENT FINDINGS

Our review of recent studies confirmed earlier findings that, even in the context of generalized epidemics, MSM have a substantially higher prevalence than the general population. Estimates of prevalence of HIV among people who inject drugs (PWID) in sub-Saharan African countries are rarely available and, when they are, often outdated. We identified recent studies of sex workers in Kenya and Uganda. In all three cases - MSM, PWID, and sex workers - HIV prevalence estimates are mostly based on convenience. Moreover, good estimates of the total size of these populations are not available. Our review of recent studies of high-risk populations defined on the basis of geography showed high levels of both new and existing infections in Kenya (slums), South Africa (peri-urban communities), and Uganda (fishing villages).

SUMMARY

Recent empirical findings combined with evidence from phylogenetic studies and supported by mathematical models provide a clear rationale for testing the feasibility, acceptability, and effectiveness of targeted HIV prevention approaches in hyperendemic populations to supplement measures aimed at the general population.