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

A Longitudinal Analysis of Residential Mobility and Experience of Client Violence Among Women Who Exchange Sex in Baltimore

Residential mobility remains an underexplored yet critical construct that may influence the risk of violence among women who exchange sex. This study examined the longitudinal relationship between residential mobility and experience of client-perpetrated physical or sexual violence among women who exchange sex in Baltimore, Maryland. Participants were at least at 18 years of age, were cisgender women, reported having engaged in transactional sex three or more times within the last 3 months, and were willing to be contacted for 6-, 12-, and 18-month follow-up visits. Analyses of responses from 370 women who exchange sex participating in at least one study visit were conducted. Unadjusted and adjusted Poisson regression models of the association over time between residential mobility and recent experience of physical or sexual violence were fit. Generalized estimating equations with an exchangeable correlation structure and robust variance estimation were used to account for clustering of participants' responses over time. Findings demonstrated that those who had lived in at least four places in the past 6 months had a 39% increased risk of client-perpetrated physical violence (aRR: 1.39; 95% CI: 1.07-1.80; p < .05) and a 63% increased risk of sexual violence (aRR: 1.63; 95% CI: 1.14-2.32; p < .01) compared to their less-mobile counterparts. These findings provide necessary evidence of correlations over time between residential mobility and experience of client-perpetrated violence among women who exchange sex. Strengthening our understanding of how residential mobility intersects with violence is critical for the development of public health interventions that are relevant to women's lives and needs. Future interventions should explore including residential mobility, a critical pillar of housing instability, with efforts to address client-perpetrated violence.

Mobility and HIV vulnerabilities among female sex workers in Guinea-Bissau: findings from an integrated bio-behavioral survey

BACKGROUND

Mobility is an important risk determinant for HIV given the potential for intermittent access to HIV services. Mobility may be particularly relevant among female sex workers, (FSW) who have been shown to be at high risk for HIV in settings around the world. Data regarding the role mobility plays in exacerbating HIV risks among FSW across Sub-Saharan Africa remains limited, and data on FSW in Guinea-Bissau is sparse.

METHODS

FSW in four regions of Guinea-Bissau were recruited with a respondent-driven sampling (RDS) method and participated in an integrated bio-behavioral survey between September 27, 2017 and January 26, 2018. Associations between reported general mobility, mobility to or residence in Bissau, and social and HIV vulnerabilities among FSW in Guinea-Bissau were assessed using multivariable logistic regression models. Population proportions were weighted for RDS sampling, while logistic regression models were not.

RESULTS

Survey respondents included 323 individuals in Bissau, 45 in Bissorã, 140 in Bafatá, and 59 in Gabu. Statistical analyses demonstrated that mobility to more than one destination was significantly associated with recent sex without a condom (ie, sex without a condom within the last three sex acts) with both clients (aOR: 2.47 (95% CI: 1.08, 5.64)) and non-paying partners (aOR: 5.39 (95% CI: 2.61, 11.15)) compared to non-mobility. However, mobility to one or more locations was also associated with higher odds of receiving HIV prevention information, and mobility to more than one location was associated with participating in programming with HIV-related organizations.

CONCLUSIONS

These results suggest that while some prevention services including HIV prevention information reach mobile FSW in Guinea-Bissau more than their non-mobile counterparts, the higher rates of condomless sex among mobile FSW suggest that HIV prevention needs may remain unmet for mobile FSW in Guinea-Bissau. Additionally, the results suggest a nuanced relationship between mobility, place of residence, and HIV and social vulnerabilities and prevention indicators.

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.

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.

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.

The Effect of International Travel Arrivals on the New HIV Infections in 15–49 Years Aged Group Among 109 Countries or Territories From 2000 to 2018

Objective

The prevalent international travel may have an impact on new HIV infections, but related studies were lacking. We aimed to explore the association between international travel arrivals and new HIV infections in 15–49 years aged group from 2000 to 2018, to make tailored implications for HIV prevention.

Methods

We obtained the data of new HIV infections from the Joint United Nations Programme on HIV/AIDS and international travel arrivals from the World Bank. Correlation analysis was used to explore the relation briefly. Log-linear models were built to analyze the association between international travel arrivals and new HIV infections.

Results

International travel arrivals were positively correlated with new HIV infections (correlation coefficients: 0.916, p < 0.001). After controlling population density, the median age of the total population (years), socio-demographic index (SDI), travel-related mandatory HIV testing, HIV-related restrictions, and antiretroviral therapy coverage, there were 6.61% (95% CI: 5.73, 7.50; p < 0.001) percentage changes in new HIV infections of 15–49 years aged group associated with a 1 million increase in international travel arrivals.

Conclusions

Higher international travel arrivals were correlated with new HIV infections in 15–49 years aged group. Therefore, multipronged structural and effective strategies and management should be implemented and strengthened.

ART uptake and adherence among female sex workers (FSW) globally: A scoping review

We conducted the first scoping literature review on ART uptake and adherence among Female Sex Workers (FSW), following PRISMA-ScR guidelines. Searches were conducted in PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting an ART uptake or adherence result among FSW aged 18 or older; peer-reviewed; published in English between 1996 and 2018. Our search identified 6,735 studies; 30 met eligibility requirements. ART uptake ranges from 0 to 100% and adherence ranges from 50-90%, depending on measurement methods. Uptake and adherence influencing factors are mapped onto a social ecological model (SEM). Knowledge and beliefs, substance use, food insecurity and sex-work engagement were negatively associated, while older age, relationships and social support were positively associated with ART uptake and adherence. Standardised methods to measure uptake and adherence prevalence must be established for data comparison. Evidence regarding ART uptake and adherence barriers and facilitators span multiple SEM levels, although more research is needed regarding structural and occupational level influencers. Results suggest that the multi-level ART uptake and adherence barriers faced by FSW require complex multi-level evidence-based interventions. Study findings can inform ART interventions, future research, and offer guidance to other support services with FSW, such as PrEP interventions.

Intimate Relationships and HIV Infection Risks Among Shan Female Sex Workers From Myanmar in Chiang Mai, Thailand: A Qualitative Study

This study aimed to investigate HIV risks among female sex workers (FSWs) who were from the Shan ethnic group, and how they relate to complex relationships with inconsistent condom use. The study was conducted using in-depth interviews with 17 Shan FSWs (aged 18-45 years old) in Chiang Mai. Intimate relationships between participants and regular clients/steady partners were found to facilitate inconsistent condom use. Participating Shan FSWs sustained intimacy with regular clients not only for economic ends but also for emotional support. Gender norms and male power dominated condom use decision making. Some participants lacked proper HIV preventive knowledge regarding condom breakage and HIV risks. Effective intervention and proper HIV preventive practices should address these intimate contexts. Capacity building among women would assist FSWs to make choices that protect them from HIV/STDs infections. Couples-based HIV interventions addressing emotional intimacy is an urgent need for HIV communication and service delivery in Thailand.

Client-perpetrated gender-based violence among female sex workers in conflict-affected Northern Uganda: a cross-sectional study

STUDY OBJECTIVE

To determine the prevalence and associated factors of client-perpetrated gender-based violence among female sex workers in conflict-affected Northern Uganda.

DESIGN AND SETTINGS

We conducted a cross-sectional study among female sex workers in Gulu district in conflict-affected Northern Uganda.

PARTICIPANTS

The study participants included 300 female sex workers aged 18+ years. The participants were selected using simple random sampling from a database of female sex workers maintained at a national non-governmental organisation in Gulu.

OUTCOME MEASURE

The outcome measure was self-reported exposure to client-perpetrated gender-based violence.

METHODS

We used a pretested semistructured questionnaire to collect data on sociodemographic characteristics, sex work-related characteristics, alcohol use, illicit drug use, HIV status and self-reported exposure to client-perpetrated gender-based violence. Then, data were entered into Epi Info V.7 and analysed using Stata V.14.0.

RESULTS

Among participants, 61.0% reported client-perpetrated gender-based violence. Economic (58.7%) and emotional (52.0%) violence were the most common forms of client-perpetrated gender-based violence in this population. Independently, being: street-based (adjusted OR=9.66, 95% CI 2.78 to 33.5), mobile (adjusted OR=3.21, 95% CI 1.83 to 5.64), HIV-positive (adjusted OR=1.90, 95% CI 1.09 to 3.31) and a low-income earner (<USh200 000 monthly) (adjusted OR=2.26, 95% CI 1.18 to 4.30) were positively associated with exposure to client-perpetrated gender-based violence.

CONCLUSIONS

There is a high prevalence of client-perpetrated gender-based violence among female sex workers in conflict-affected Northern Uganda. Furthermore, female sex workers who were street-based, mobile, HIV-positive and low-income earners were more likely to experience client-perpetrated gender-based violence. The ministry of health and the development partners need to provide targeted public health interventions to prevent and manage the rampant gender-based violence among this underserved population.

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.

Mobility for sex work and recent experiences of gender-based violence among female sex workers in Iringa, Tanzania: A longitudinal analysis

Female sex workers are highly mobile, which may influence their risk of experiencing physical and sexual violence. However, there remains a paucity of research, particularly longitudinal, from Sub-Saharan Africa exploring mobility and gender-based violence among female sex workers. To address this gap, this study examined the longitudinal relationship between work-related mobility and recent experience of physical or sexual gender-based violence from a client or partner among female sex workers in Iringa, Tanzania. A secondary data analysis was conducted using baseline and 18-month follow-up data from Project Shikamana, a community empowerment-based combination HIV prevention intervention. Responses from 387 female sex workers aged 18 years and older participating in both baseline and follow-up were analyzed. Unadjusted and adjusted Poisson regression models with robust variance estimations, accounting for clustering of female sex workers' responses over time, were fit. Final models adjusted for socio-demographic characteristics and aspects of participants' living situations and work environments. Recent physical or sexual violence from a client or partner was common (baseline: 40%; follow-up: 29%). Twenty-six percent of female sex workers at baseline, and 11% at follow-up, had recently traveled outside of Iringa for sex work. In the final adjusted longitudinal model, female sex workers recently mobile for sex work had a 25% increased risk of any recent experience of physical or sexual gender-based violence when compared with their non-mobile counterparts (adjusted incidence rate ratio: 1.25; 95% CI: 1.03-1.53; p<0.05). Interventions must identify ways-such as mobile support services, linkages and referrals to health and other social services while traveling, or the use of mobile or digital technology-to address mobile female sex workers' unique needs while traveling. Future quantitative and qualitative research is needed to understand the context of female sex workers' mobility and how and why mobility influences risk environments and experiences of gender-based violence.

"A dream come true": Perspectives on long-acting injectable antiretroviral therapy among female sex workers living with HIV from the Dominican Republic and Tanzania

BACKGROUND

Long-acting injectable antiretroviral therapy (LA ART) was found to be non-inferior to daily oral ART in Phase 3 clinical trials. LA ART may offer an important alternative for people living with HIV with challenges adhering to daily oral ART or preferences for non-pill-based regimens.

METHODS

Using a mixed methods approach integrating survey, in-depth interview and biological data from female sex workers (FSW) living with HIV in Tanzania (N = 208) and the Dominican Republic (DR) (N = 201), we assessed factors associated with the potential likelihood of LA ART use if it were available. We conducted multivariate logistic regression and thematic content analysis.

RESULTS

Likelihood of LA ART use was high with 84.92% of FSW from the DR and 92.27% of FSW from Tanzania reporting they would be "likely" or "very likely" to use LA ART if available (p = 0.02). In Tanzania better HIV-related patient-provider communication (AOR 4.58; 95% CI 1.90-11.05) and quality of HIV clinical care (AOR 3.68; 95% CI 1.05-12.86) were positively associated with the high likelihood of LA ART use. In the DR, easier clinic access was associated with a higher likelihood of LA ART use (AOR 3.04; 95% CI 1.41-6.56), as was greater monthly income from sex work (AOR 2.37; 95% CI 1.27-4.41). In both settings, years on ART was significantly associated with a strong likelihood of LA ART use (TZ: AOR 1.16 per year; 95% CI 1.00-1.34/DR: AOR 1.07 per year; 95% CI 1.00-1.14). Qualitative findings underscored enthusiasm for LA ART and reinforced its potential to address sex work-specific barriers to daily oral ART adherence including work-related schedules and substance use.

CONCLUSIONS

We found a high likelihood of LA ART use if available among FSW in two diverse settings and documented barriers to future uptake. Community-driven approaches which include tailored health education and improved patient-provider communication and quality of care, as well as strategies to facilitate appointment adherence are needed to optimize LA ART use among FSW.

Harms of Workplace Inspections for Im/Migrant Sex Workers in In-Call Establishments: Enhanced Barriers to Health Access in a Canadian Setting

Given shifting sex work criminalization and enforcement in Canada, this study examined worrying about workplace inspections by authorities amongst indoor sex workers in Vancouver (2014-2017). Data were drawn from a community-based prospective cohort of sex workers (AESHA). Bivariate and multivariable logistic regression were used to investigate factors associated with worry about inspections. 23.9% of participants experienced workplace inspections; 51.6% worried about inspections. In multivariable analyses, worrying about inspections was associated with recent im/migration [adjusted odds ratio (AOR) 3.13; 95% confidence interval (CI) 1.77-5.53], police harassment (AOR 3.49; 95% CI 1.92-6.34), and workplace violence (AOR 1.66, 95% CI 1.09-2.51). In a multivariable confounder model, worry was independently associated with barriers to health access (AOR 1.45, 95% CI 1.06-1.98). Im/migrant indoor workers are disproportionately impacted by concerns about workplace inspections, which was independently linked to enhanced barriers to health access. Current criminalization measures may exacerbate health inequities among im/migrant sex workers.

Exploring the Association Between Mobility and Access to HIV Services Among Female Sex Workers in Zimbabwe

Female sex workers (FSW) face structural barriers to HIV-service access, however the effect of their mobility is uncertain. Using cross-sectional data from 2839 FSW in 14 sites in Zimbabwe, we explored the association between mobility (number of trips, distance, duration) in the past 12 months and five HIV-service-access outcomes: exposure to community mobilisation, clinic attendance, HIV testing, antiretroviral treatment initiation, and viral suppression (< 1000 copies per mL). We used modified-Poisson regression, and natural-effects models to estimate how the effect of trip frequency was mediated by distance and duration away. Each additional trip in 12 months was associated with increased community-mobilisation-event attendance (adjusted RR 1.08, 95% CI 1.04-1.12) and attending clinic two-or-more times (adjusted RR 1.02, 95% CI 1.00-1.05). There was little evidence of any other associations, or of mediation. Our findings are consistent with literature that found the effects of mobility to vary by context and outcome. This is the first study to consider many FSW-mobility and HIV-service-access measures together. Future research on mobility and health-related behaviour should use a spectrum of measures.

The Effect of Violence and Intersecting Structural Inequities on High Rates of Food Insecurity among Marginalized Sex Workers in a Canadian Setting

Food security is both a basic human right and a public health necessity. Despite known gendered contexts of food insecurity, there is a dearth of research on prevalence and factors driving increased food insecurity for sex workers in a criminalized setting. The current study longitudinally examines the prevalence and structural and individual factors associated with increased odds of food insecurity among street and off-street sex workers in a Canadian urban setting. Prospective analyses drew on data from a community-based longitudinal cohort of cis and trans women in street and off-street sex work in An Evaluation of Sex Workers Health Access (2010-2014). The primary outcome was a time-updated measure of food insecurity, using the Radimer-Cornell scale. We used bivariable and multivariable logistic regression using generalized estimating equations to prospectively model correlates of food insecurity over a five-year period. Of 761 cis and trans women sex workers, 72.4% (n = 551) were food insecure over the study period. Over a third (35.2%, n = 268) identified as Indigenous and a quarter, 25.6% (n = 195) were of a gender/sexual minority. Within the 11.0% (n = 84) of women living with HIV, 96.4% (n = 81) were food insecure over the follow-up period. In multivariable analysis, Indigenous ancestry (AOR = 1.58 [95% CI 1.18, 2.10]), unstable housing (AOR = 1.27 [95% CI 1.03, 1.57]), stimulant use (AOR = 1.97 [95% CI 1.57, 2.45]), heroin use (AOR = 1.72 [95% CI 1.36, 2.19]), mental health diagnosis (AOR = 2.38 [95% CI 1.85, 3.05]), recent violence (AOR = 1.54 [95% CI 1.24, 1.91]), means of food access: reliant on food services only vs. self-sufficient (AOR = 1.78 [95% CI 1.38, 2.29]), and means of food access: both vs. self-sufficient (AOR = 2.29 [95% CI 1.84, 2.86]) were associated with food insecurity. In separate multivariable models, both recent and lifetime physical and/or sexual violence remained independently associated with food insecurity (AOR 1.54 [95% CI 1.24, 1.91]; AOR 4.62 [95% CI 2.99, 7.14], respectively). Almost all study participants living with HIV reported being food insecure. These intersecting risks demonstrate the negative impacts associated with living with HIV, experiencing food insecurity and/or physical or sexual violence. This study also highlights the potential for interventions that address structural inequities (e.g., decriminalizing sex work) to have crosscutting impacts to reduce barriers to accessing necessities (including food) or health and social services (e.g., methadone; primary care).

Sex workers' experiences and occupational conditions post-implementation of end-demand criminalization in Metro Vancouver, Canada

OBJECTIVES

In 2014, Canada introduced end-demand criminalization (the Protection of Communities and Exploited Persons Act (PCEPA)), criminalizing purchase of sexual services while leaving the sale of sex legal. We assessed factors correlated with self-reported changes in working conditions post-PCEPA among sex workers (SWs) in Metro Vancouver.

METHODS

Post-PCEPA data for one year were drawn from a community-based cohort of SWs. We analyzed self-reported changes in working conditions among 299 participants who worked prior to PCEPA and were asked about working conditions post-PCEPA. Multivariate GEE analysis evaluated factors correlated with negative changes post-PCEPA, including reduced capacity to screen clients and reduced access to workspaces/clients.

RESULTS

Most (72.2%) experienced no change in working conditions, and 26.4% reported negative changes (e.g., reduced ability to screen clients or reduced access to workspaces/clients). Reporting negative changes was correlated with being an im/migrant to Canada (adjusted odds ratio (AOR) 2.79, 95% CI 1.59-4.92) and recent physical workplace violence (AOR 4.01, 95% CI 1.12-14.40). In sub-analysis, physical/sexual workplace violence (AOR 3.77, 95% CI 1.17-12.16) and living in the suburbs of Richmond/Burnaby (AOR 2.81, 95% CI 1.15-6.84) correlated with reduced screening capacity; incarceration (AOR 2.98, 95% CI 1.04-8.57) and being an im/migrant (AOR 2.39, 95% CI 1.14-4.99) correlated with reduced access to workspaces/clients.

CONCLUSIONS

Most SWs reported no change in working conditions and one quarter reported negative changes, suggesting that PCEPA may be failing to advance sex workers' safety. Im/migrants, women experiencing workplace violence, and those facing criminalization were most likely to report negative impacts. Decriminalization of all aspects of sex work is needed to support well-being, health, and safety.

Preventing sexually transmitted and blood borne infections (STBBIs) among sex workers: a critical review of the evidence on determinants and interventions in high-income countries

Background

Across diverse regions globally, sex workers continue to face a disproportionate burden of HIV and other sexually transmitted and blood borne infections (STBBIs). Evidence suggests that behavioural and biomedical interventions are only moderately successful in reducing STBBIs at the population level, leading to calls for increased structural and community-led interventions. Given that structural approaches to mitigating STBBI risk beyond HIV among sex workers in high-income settings remain poorly understood, this critical review aimed to provide a comprehensive synthesis of the global research and literature on determinants of HIV and other STBBIs and promising intervention practices for sex workers of all genders in high-income countries.

Methods

We searched for publications over the last decade (January 2005–March 2016) among sex workers (cis women, cis men, and trans individuals). Data obtained from quantitative peer-reviewed studies were triangulated with publicly available reports and qualitative/ethnographic research where quantitative evidence was limited.

Results

Research demonstrates consistent evidence of the direct and indirect impacts of structural factors (e.g., violence, stigma, criminalization, poor working conditions) on increasing risk for STBBIs among sex workers, further compounded by individual and interpersonal factors (e.g., mental health, substance use, unprotected sex). Sub-optimal access to health and STBBI prevention services remains concerning. Full decriminalization of sex work has been shown to have the largest potential to avert new infections in sex work, through reducing workplace violence and increasing access to safer workspaces. Promising practices and strategies that should be scaled-up and evaluated to prevent STBBIs are highlighted.

Conclusions

The high burden of STBBIs among sex workers across high-income settings is of major concern. This review uniquely contributes to our understanding of multilevel factors that potentiate and mitigate STBBI risk for sex workers of all genders. Research suggests that multipronged structural and community-led approaches are paramount to addressing STBBI burden, and are necessary to realizing health and human rights for sex workers. Given the heterogeneity of sex worker populations, and distinct vulnerabilities faced by cis men and trans sex workers, further research utilizing mixed-methods should be implemented to delineate the intersections of risk and ameliorate critical health inequalities.

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.

Work-related mobility and experiences of gender-based violence among female sex workers in Iringa, Tanzania: a cross-sectional analysis of baseline data from Project Shikamana

OBJECTIVES

To examine how work-related mobility among female sex workers (FSWs) is associated with gender-based violence (GBV) in Iringa, Tanzania.

DESIGN

Cross-sectional analyses were conducted on baseline data gathered between October 2015 and April 2016 from FSWs participating in Project Shikamana, a community empowerment-based combination HIV prevention intervention.

SETTING

Participants were recruited for the baseline study using venue-based time-location sampling in two communities in Iringa, Tanzania.

PARTICIPANTS

FSWs were eligible for participation if they were 18 years or older and had exchanged sex for money within the past month. Four-hundred ninety-six FSWs participated in the baseline survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Any recent experience of GBV was examined by recent work-related mobility among FSWs. Any recent experience of GBV was also disaggregated by severity for analyses. All bivariate and multivariate binary and multinomial logistic regressions adjusted for intraclass correlations among women recruited from the same venues.

RESULTS

Forty per cent of participants experienced recent physical or sexual violence, and 30% recently experienced severe physical or sexual violence. Thirty-three per cent of participants recently exchanged sex for money outside of their district or region, and 12% were both intraregionally and inter-regionally mobile for sex work. Intraregionally and inter-regionally mobile FSWs had 1.9 times greater odds of reporting recent GBV (adjusted OR: 1.89; 95% CI: 1.06 to 3.38; p=0.031) compared with non-mobile FSWs and a 2.5 times higher relative risk for recent experience of severe GBV relative to no recent GBV (relative risk ratio: 2.51; 95% CI: 1.33 to 4.74; p=0.005).

CONCLUSIONS

Mobility for sex work may increase FSWs' exposure to GBV, particularly more severe GBV. The vulnerability of mobile FSWs to violence, particularly severe forms, demands inclusive services that are accessible to mobile FSWs.

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.

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.

Influence of peer support on HIV/STI prevention and safety amongst international migrant sex workers: A qualitative study at the Mexico-Guatemala border

BACKGROUND

Migrant women engaged in precarious employment, such as sex work, frequently face pronounced social isolation alongside other barriers to health and human rights. Although peer support has been identified as a critical HIV and violence prevention intervention for sex workers, little is known about access to peer support or its role in shaping health and social outcomes for migrant sex workers. This article analyses the role of peer support in shaping vulnerability and resilience related to HIV/STI prevention and violence among international migrant sex workers at the Mexico-Guatemala border.

METHODS

This qualitative study is based on 31 semi-structured interviews conducted with international migrant sex workers in the Mexico-Guatemala border communities of Tapachula, Mexico and Tecún Umán and Quetzaltenango, Guatemala.

RESULTS

Peer support was found to be critical for reducing social isolation; improving access to HIV/STI knowledge, prevention and resources; and mitigating workplace violence, particularly at the initial stages of migration and sex work. Peer support was especially critical for countering social isolation, and peers represented a valuable source of HIV/STI prevention knowledge and resources (e.g., condoms), as well as essential safety supports in the workplace. However, challenges to accessing peer support were noted, including difficulties establishing long-lasting relationships and other forms of social participation due to frequent mobility, as well as tensions among peers within some work environments. Variations in access to peer support related to country of work, work environment, sex work and migration stage, and sex work experience were also identified.

CONCLUSIONS

Results indicate that peer-led and community empowerment interventions represent a promising strategy for promoting the health, safety and human rights of migrant sex workers. Tailored community empowerment interventions addressing the unique migration-related contexts and challenges faced by migrant sex workers should be a focus of future community-based research, alongside promotion of broader structural changes.

Burden and correlates of mental health diagnoses among sex workers in an urban setting

Background

Women involved in both street-level and off-street sex work face disproportionate health and social inequities compared to the general population. While much research has focused on HIV and sexually transmitted infections (STIs) among sex workers, there remains a gap in evidence regarding the broader health issues faced by this population, including mental health. Given limited evidence describing the mental health of women in sex work, our objective was to evaluate the burden and correlates of mental health diagnoses among this population in Vancouver, Canada.

Methods

An Evaluation of Sex Workers Health Access (AESHA) is a prospective, community-based cohort of on- and off-street women in sex work in Vancouver, Canada. Participants complete interviewer-administered questionnaires semi-annually. We analyzed the lifetime burden and correlates of self-reported mental health diagnoses using bivariate and multivariable logistic regression.

Results

Among 692 sex workers enrolled between January 2010 and February 2013, 338 (48.8%) reported ever being diagnosed with a mental health issue, with the most common diagnoses being depression (35.1%) and anxiety (19.9%). In multivariable analysis, women with mental health diagnoses were more likely to identify as a sexual/gender minority (LGBTQ) [AOR=2.56, 95% CI: 1.72—3.81], to use non-injection drugs [AOR=1.85, 95% CI: 1.12—3.08], to have experienced childhood physical/sexual trauma [AOR=2.90, 95% CI: 1.89—4.45], and work in informal indoor [AOR=1.94, 95% CI: 1.12 – 3.40] or street/public spaces [AOR=1.76, 95% CI: 1.03–2.99].

Conclusions

This analysis highlights the disproportionate mental health burden experienced by women in sex work, particularly among those identifying as a sexual/gender minority, those who use drugs, and those who work in informal indoor venues and street/public spaces. Evidence-informed interventions tailored to sex workers that address intersections between trauma and mental health should be further explored, alongside policies to foster access to safer workspaces and health services.

Risk Environments and Substance Use Among Mexican Female Sex Work on the U.S.-Mexico Border

We use a risk environment framework to qualitatively examine pathways into substance use and abuse among Mexican female sex workers on the U.S.-Mexico border. Life history interviews and ethnographic observations were conducted with female sex workers to uncover how the border context shapes patterns of substance use. The findings illustrate that, for many women, initiation into sex work is contextualized within immigration, the global economy, and demands and desire for financial autonomy. Paradoxically, many find autonomy within sex work as they increase their ability to support their families and themselves. As women become more entrenched in sex work, however, they are put on a path toward substance abuse beginning with alcohol then cocaine and heroin. This identification of specific substance use pathways and trajectories has important implications for the development of prevention and intervention programs that can help curtail problematic drug use that can lead to negative health consequences.

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.

Recent im/migration to Canada linked to unmet health needs among sex workers in Vancouver, Canada: Findings of a longitudinal study

Despite universal health care in Canada, sex workers (SWs) and im/migrants experience suboptimal health care access. In this analysis, we examined the correlates of unmet health needs among SWs in Metro Vancouver over time. Data from a longitudinal cohort of women SWs (An Evaluation of Sex Workers Health Access [AESHA]) were used. Of 742 SWs, 25.5% reported unmet health needs at least once over the 4-year study period. In multivariable logistic regression using generalized estimating equations, recent im/migration had the strongest impact on unmet health needs; long-term im/migration, policing, and trauma were also important determinants. Legal and social supports to promote im/migrant SWs' access to health care are recommended.

Food Insecurity Increases HIV Risk Among Young Sex Workers in Metro Vancouver, Canada

This research aimed to determine the effect of food insecurity on sexual HIV risk with clients among youth sex workers (YSWs) <30 years in Metro Vancouver, Canada. Data were drawn from a prospective community cohort of sex workers (2010-2013). We examined the independent relationship between YSWs' food insecurity and being pressured into sex without a condom by clients ("client condom refusal"). Of 220 YSWs, 34.5 % (n = 76) reported client condom refusal over the 3.5-year study period and 76.4 % (n = 168) reported any food insecurity. Adjusting for other HIV risk pathways, food insecurity retained an independent effect on client condom refusal (AOR 2.08, 95 % CI 1.23-3.51), suggesting that food insecurity is significantly associated with HIV risk among YSWs. This study indicates a critical relationship between food insecurity and HIV risk, and demonstrates YSWs' particular vulnerability. Public policies for food assistance as a harm reduction measure may be key to addressing this disparity.

Structural Determinants of Health among Im/Migrants in the Indoor Sex Industry: Experiences of Workers and Managers/Owners in Metropolitan Vancouver

Background

Globally, im/migrant women are overrepresented in the sex industry and experience disproportionate health inequities. Despite evidence that the health impacts of migration may vary according to the timing and stage of migration (e.g., early arrival vs. long-term migration), limited evidence exists regarding social and structural determinants of health across different stages of migration, especially among im/migrants engaged in sex work. Our aim was to describe and analyze the evolving social and structural determinants of health and safety across the arrival and settlement process for im/migrants in the indoor sex industry.

Methods

We analyzed qualitative interviews conducted with 44 im/migrant sex workers and managers/owners working in indoor sex establishments (e.g., massage parlours, micro-brothels) in Metropolitan Vancouver, Canada in 2011; quantitative data from AESHA, a larger community-based cohort, were used to describe socio-demographic and social and structural characteristics of im/migrant sex workers.

Results

Based on quantitative data among 198 im/migrant workers in AESHA, 78.3% were Chinese-born, the median duration in Canada was 6 years, and most (86.4%) serviced clients in formal indoor establishments. Qualitative narratives revealed diverse pathways into sex work upon arrival to Canada, including language barriers to conventional labour markets and the higher pay and relative flexibility of sex work. Once engaged in sex work, fear associated with police raids (e.g., immigration concerns, sex work disclosure) and language barriers to sexual negotiation and health, social and legal supports posed pervasive challenges to health, safety and human rights during long-term settlement in Canada.

Conclusions

Findings highlight the critical influences of criminalization, language barriers, and stigma and discrimination related to sex work and im/migrant status in shaping occupational health and safety for im/migrants engaged in sex work. Interventions and policy reforms that emphasize human rights and occupational health are needed to promote health and wellbeing across the arrival and settlement process.

Effects of In-country and Cross-Border Mobility on Condom Use Among Transgender Women (hijras) in Bangladesh: A Cross-Sectional Study

In Bangladesh transgender women (hijras) are thought to be highly mobile that may be an impediment to condom use. This cross-sectional study was conducted to determine the extent of mobility of hijras, in-country and cross-border, and whether mobility affects condom use in anal intercourse. Hijras ≥15 years of age, receiving services from the Global Fund supported HIV prevention program were enrolled. A behavioral questionnaire was administered and blood was tested for antibodies to HIV and syphilis. Of 889 hijras sampled, 41.3 % never traveled, 26.4 % traveled in-country and 32.3 % crossed the border in the last year. HIV and active syphilis was at 0.8 and 1.8 % respectively. Among hijras who crossed the border condom use was less likely in last anal intercourse (AOR 0.68; 95 % CI 0.48-0.96), and consistently with new (AOR 0.59; 95 % CI 0.34-1.01) and regular clients (AOR 0.45; 95 % CI 0.27-0.76) in the last week. This study concludes that in Bangladesh hijras are highly mobile and cross-border mobility negatively affects condom use.

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.

Structural Barriers to Antiretroviral Therapy Among Sex Workers Living with HIV: Findings of a Longitudinal Study in Vancouver, Canada

In light of limited data on structural determinants of access and retention in antiretroviral therapy (ART) among sex workers, we examined structural correlates of ART use among sex workers living with HIV over time. Longitudinal data were drawn from a cohort of 646 female sex workers in Vancouver, Canada (2010-2012) and linked pharmacy records on ART dispensation. We used logistic regression with generalized estimating equations (GEE) to examine correlates of gaps in ART use (i.e., treatment interruptions or delayed ART initiation), among HIV seropositive participants (n = 74). Over a 2.5-year period, 37.8 % of participants experienced gaps in ART use (i.e., no ART dispensed in a 6-month period). In a multivariable GEE model, younger age, migration/mobility, incarceration, and non-injection drug use independently correlated with gaps in ART use. In spite of successes scaling-up ART in British Columbia, younger, mobile, or incarcerated sex workers face persistent gaps in access and retention irrespective of drug use. Community-based, tailored interventions to scale-up entry and retention in ART for sex workers should be further explored in this setting.

Occupational and demographic factors associated with drug use among female sex workers at the China-Myanmar border

BACKGROUND

Within the last decade, the use of amphetamine type stimulants (ATS) has swelled in Myanmar. Regionally, female sex workers have reported turning to ATS for occupational reasons. In doing so, drug-using female sex workers (FSW) face compounded risks for HIV and other sexually transmitted infections (STI). Here, we examine the factors that impact FSW drug use in Muse, a town along the China-Myanmar border.

METHODS

In 2012, 101 FSW were recruited from entertainment venues and brothels along the Myanmar-Chinese border. Participants participated in a self-administered behavioral survey covering demographics, drug use, sex work, and risk behaviors. Bivariate and regression analyses were conducted in SPSS.

RESULTS

Thirty four percent of respondents indicated current drug use. ATS derivatives were the most commonly used drugs (87.5%) with injection drug use being nearly non-existent in the sample. Drug using FSWs were older, had engaged in sex work longer, had more Chinese clients, and were more likely to have a previous boyfriend who had used drugs. They were also 3.5 times more likely to report a STI. Client condom use, HIV testing rates, and familiarity with public health resources did not statistically differ by drug use status.

CONCLUSION

More research is needed to examine how romantic and professional sexual relationships push-and-pull FSW into using drugs. Our results suggest that diverse safer sex strategies, beyond client condom use, should be promoted with drug using FSWs, including strategies that acknowledge the impact of ATS use.

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

Background

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

Methods

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

Results

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

Conclusion

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

Providing comprehensive health services for young key populations: needs, barriers and gaps

INTRODUCTION

Adolescence is a time of physical, emotional and social transitions that have implications for health. In addition to being at high risk for HIV, young key populations (YKP) may experience other health problems attributable to high-risk behaviour or their developmental stage, or a combination of both.

METHODS

We reviewed the needs, barriers and gaps for other non-HIV health services for YKP. We searched PubMed and Google Scholar for articles that provided specific age-related data on sexual and reproductive health; mental health; violence; and substance use problems for adolescent, youth or young sex workers, men who have sex with men, transgender people, and people who inject drugs.

RESULTS

YKP experience more unprotected sex, sexually transmitted infections including HIV, unintended pregnancy, violence, mental health disorders and substance use compared to older members of key populations and youth among the general population. YKP experience significant barriers to accessing care; coverage of services is low, largely because of stigma and discrimination experienced at both the health system and policy levels.

DISCUSSION

YKP require comprehensive, integrated services that respond to their specific developmental needs, including health, educational and social services within the context of a human rights-based approach. The recent WHO Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations are an important first step for a more comprehensive approach to HIV programming for YKP, but there are limited data on the effective delivery of combined interventions for YKP. Significant investments in research and implementation will be required to ensure adequate provision and coverage of services for YKP. In addition, greater commitments to harm reduction and rights-based approaches are needed to address structural barriers to access to care.

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.