HIV/STI risk among venue-based female sex workers across the globe: a look back and the way forward

Typologies of Sex Work Practice and Associations with the HIV Risk Environment and Risk Behaviors in Kazakhstan

Women engaged in sex work (WESW) who use drugs are a key population in Kazakhstan's HIV epidemic. Global research suggests susceptibility to HIV varies by sex work environment. This study aims to identify evidence-based typologies of WESW and examine their associations with HIV risk. We surveyed 400 WESW who use drugs in two Kazakhstani cities, including questions on sociodemographic characteristics, social, physical, and economic risk environments, and sexual risk behaviors. Latent class analysis identified four distinct typologies of sex work practice: occasional sex work (n = 61, 15%), professional sex work for money (n = 187, 47%), sex work in exchange for drugs, goods, or other services (n = 117, 29%), and managed sex work under a boss/pimp/madam (n = 35, 9%). We then used logistic regression to examine associations between typologies and risk behaviors. Compared to professional sex work, occasional sex work was associated with lower odds of multiple sexual partners (aOR:0.46[95%CI:0.24,0.90]), of multiple paid clients (aOR:0.25[0.13,0.49]), and of > 1 instance of unprotected sex with a paying partner (aOR:0.33[0.17,0.63]). Compared to professional sex work, sex work for nonmonetary items was associated with higher odds of multiple sexual partners (aOR:1.85[0.96,3.67]) and of > 1 instance of unprotected sex with a paying partner (aOR:1.71[1.01,2.93]). Results suggest heterogeneity among WESW who use drugs in Kazakhstan, and that typologies of sex work are associated with varying HIV risk environment factors and risk behaviors. Effective HIV prevention efforts must be tailored to address these varying risk environments and the resulting variety of needs.

"You know that we travel a lot": Mobility narratives among female sex workers living with HIV in Tanzania and the Dominican Republic

Female sex workers (FSW) are highly mobile, which may result in reduced access to and use of health services and increased risk for poor health outcomes, particularly for those living with HIV. Mobility includes spatial, temporal, and social elements that are not fully captured by quantitative measures. We conducted two rounds of in-depth interviews with FSW living with HIV in Iringa, Tanzania (n = 20), and Santo Domingo, Dominican Republic (n = 20), to describe mobility experiences and compare mobility narratives across settings. We integrated a thematic analysis of all interviews with a narrative analysis of a subset of 10 information-rich interviews (five in each country) with women who had recently traveled, for sex work or another reason, outside of their hometown. Across narratives, FSW living with HIV traveled locally or to seasonal destinations, for short and long periods. Social factors influencing mobility included economic drivers; risk of arrest, harassment, or violence; anonymity and/or familiarity; social relationships; and clients' mobility. Spatial, temporal, and social factors intersected in unique ways in FSW's mobility experiences, yet distinct mobility typologies were evident across settings and destinations. Together, mobility narratives of FSW living with HIV can inform quantitative research on mobility typologies in Tanzania, the Dominican Republic, and elsewhere. With the potential for economic circumstances, climate change, and other emergencies to increase people's mobility around the world, researchers and practitioners can learn from the lived experiences of FSW to inform whether and how to tailor and improve the accessibility of HIV care and treatment interventions based on spatial, temporal, and social characteristics of mobility.

Understanding the contexts in which female sex workers sell sex in Kampala, Uganda: a qualitative study

BACKGROUND

Structural, interpersonal and individual level factors can present barriers for HIV prevention behaviour among people at high risk of HIV acquisition, including women who sell sex. In this paper we document the contexts in which women selling sex in Kampala meet and provide services to their clients.

METHODS

We collected qualitative data using semi-structured interviews. Women were eligible to participate if they were 18 years or older, self-identified as sex workers or offered sex for money and spoke Luganda or English. Ten women who met clients in venues and outdoor locations were selected randomly from a clinic for women at high risk of HIV acquisition. Ten other women who met clients online were recruited using snowball sampling. Interviews included demographic data, and themes included reasons for joining and leaving sex work, work locations, nature of relationships with clients and peers, interaction with authorities, regulations on sex work, and reported stigma. We conducted interviews over three months. Data were analysed thematically using a framework analysis approach. The coding framework was based on structural factors identified from literature, but also modified inductively with themes arising from the interviews.

RESULTS

Women met clients in physical and virtual spaces. Physical spaces included venues and outdoor locations, and virtual spaces were online platforms like social media applications and websites. Of the 20 women included, 12 used online platforms to meet clients. Generally, women from the clinic sample were less educated and predominantly unmarried, while those from the snowball sample had more education, had professional jobs, or were university students. Women from both samples reported experiences of stigma, violence from clients and authorities, and challenges accessing health care services due to the illegality of sex work. Even though all participants worked in settings where sex work was illegal and consequently endured harsh treatment, those from the snowball sample faced additional threats of cybersecurity attacks, extortion from clients, and high levels of violence from clients.

CONCLUSIONS

To reduce risk of HIV acquisition among women who sell sex, researchers and implementers should consider these differences in contexts, challenges, and risks to design innovative interventions and programs that reach and include all women.

Differential Burden of HIV Among Adolescent Girls and Young Women by Places Associated With Sex Work: An Observational Study in Mombasa, Kenya

BACKGROUND

The design of HIV prevention programs for adolescent girls and young women (AGYW) are informed by data on who is at highest risk and where they can be reached. Places (hotspots) associated with selling sex are an established outreach strategy for sex work (SW) programs but could be used to reach other AGYW at high risk.

SETTING

This study took place in Mombasa, Kenya.

METHODS

We conducted a cross-sectional, bio-behavioural survey among (N = 1193) sexually active AGYW aged 14-24 years recruited at hotspots. We compared HIV prevalence by subgroup (SW; transactional sex, TS; and non-transactional sex), stratified by hotspot type (venues and nonvenues). We examined whether associations between HIV prevalence and hotspot/subgroup remained after adjustment for individual-level risk factors, and estimated HIV prevalence ratio with and without adjustment for these individual-level factors.

RESULTS

Overall HIV prevalence was 5.6%, 5.3% in venues and 7.3% in nonvenues. Overall SW HIV prevalence was 2-fold higher than among participants engaged in nontransactional sex. After adjusting for age and individual-level risk factors, HIV prevalence was 2.72 times higher among venue-based SWs (95% confidence interval: 1.56 to 4.85) and 2.11 times higher among nonvenue AGYW not engaged in SW (95% confidence interval: 0.97 to 4.30) compared with venue-based AGYW not engaged in SW.

CONCLUSION

AGYW who sell sex remain at high risk of HIV across types of hotspots. The residual pattern of elevated HIV burden by AGWY subgroup and hotspot type suggests that unmeasured, network-level factors underscore differential risks. As such, hotspots constitute a "place" to reach AGYW at high risk of HIV.

Biobehavioral survey using time location sampling among female sex workers living in Ghana in 2020

Background

The HIV epidemic in Ghana is characterized as a mix of a low-level generalized epidemic with significant contributions from transmission among female sex workers (FSW) and their clients. This study seeks to identify and describe key characteristics and sexual behaviors of FSW and estimate the prevalence of HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus (HBV) among FSW in Ghana.

Method

A total of 7,000 FSW were recruited for the study using Time Location Sampling (TLS) approach with 5,990 (85.6%) participants completing both biological and the behavioral aspects of the study. A structured questionnaire was administered to respondents to assess several factors, such as background characteristics, sexual risk behaviors, condom usage, HIV/AIDS knowledge, opinions, and attitudes. Trained staff conducted face-to-face interviews using mobile data collection software (REDCap) after provision of specimens for HIV and STI testing. Descriptive statistics such as medians, ranges, charts, and percentages are performed and presented. Also included, are bivariate analyses to establish relationships between FSW type and other relevant characteristics of the study.

Results

Among the 7,000 (100%) FSW sampled from all regions, 6,773 took part in the behavioral and 6,217 the biological. There were 783 (11.2%) respondents who took part only in the behavioral and 227 (3.2%) only in the biological. Most were young, with a median age of 26 years, majority had never been married or were widowed/divorced and a quarter had no education or had only primary education. Majority (74.8%) of FSW first sold sex at age 25 years or less with a median age of 20 years. Most (84.8%) of the FSW indicated that they entered sex work for money, either for self or family and had an average of eleven (11) sexual partners per week. More than half (55.2%) of the FSW were new entrants who had been in sex work for less than 5 years before the study. Consistent condom use with paying clients was generally unsatisfactory (71%), and was however, very low (24%) with their intimate partners or boyfriends. Only about half (54.6%) of FSW have been exposed to HIV prevention services in the last three months preceding the survey, and this varies across regions. Overall, comprehensive knowledge about HIV and AIDS was low. Only 35% of FSW had comprehensive knowledge. HIV prevalence was 4.6% and was higher among seaters (brothel-based) and older FSW who had been sex work for a longer period. The HIV prevalence from the previous bio-behavioral survey (BBS) in 2015 and 2011 were estimated to be 6.9 and 11.1%, respectively.

Conclusion

Compared to the results from the previous studies, the findings give an indication that Ghana is making significant progress in reducing the burden of HIV among FSW in the country. However, risky behaviors such as low consistent condom use, low coverage of HIV services across the regions, and low comprehensive knowledge could reverse the gains made so far. Immediate actions should be taken to expand coverage of HIV services to all locations. Efforts must be made to reach out to the new entrants while also addressing strongly held myths and misconceptions about HIV.

Social and structural determinants associated with the prevalence of sexually transmitted infections among female commercial sex workers in Dhaka City, Bangladesh

Female commercial sex workers (FCSWs) bear higher rates of sexually transmitted infections (STIs) among key populations. The association of structural determinants and STIs among FCSWs was not at the forefront of research earlier in Bangladesh. This study examined how structural factors correlate with the prevalence of STIs at physical/social/economic/policy levels among FCSWs in Dhaka city. 495 FCSWs were screened for HIV, hepatitis B, and syphilis. Structural variables (Individual risks, high-risk sexual behaviors, work environments) were extracted from the previous multi-level study on FCSWs and analyzed in 2020 to determine whether macro/micro-structural factors were associated with STIs. The prevalence of STIs was 43.6% (95% CI: 39.1%-48). Most (n = 207/495) FCSWs were infected with Syphilis or Hepatitis B, only 1.8% had co-infection, and none was positive for HIV. Multiple logistic regression revealed that 'Individual risk' factors like age (≤18 years, adjusted odds ratio = AOR = .28; 18.1-29.9 years, AOR = .57), years in the sex industry (<1 year AOR = .15; 1-5 years, AOR = .39), and condoms as contraceptives (AOR = 2.7) were significantly associated with STIs. Considering 'High-risk behaviors' like monthly coitus with regular clients (AOR = .33), performing no anal sex ever (AOR = .03), and consistent condom use (AOR = .13) were less likely to be associated with STIs (P<0.05), while the association of ever group sex with STIs reported to double (AOR = 2.1). 'Work environment' like sex on roads/parks/shrines/markets (AOR = 2.6) and ever HIV-testing (AOR = 2.5) were significantly linked with STIs. However, micro-level factors like experiencing forced sex in the past year (AOR = 1.79) and condoms collected from hotel boys (AOR = .34) were significantly associated with STIs in the 'Hierarchical- model' with increasing model-power. 'Micro-structural' determinants predominated over 'Macro/policy-level factors' and profoundly influenced STIs. FCSWs need comprehensive and integrated interventions to promote accurate condom use perception, eliminate risky sexual behaviors, and provide quality reproductive health care. Necessary steps at the policy level are urgently needed to decriminalize commercial sex work.

Prevalence and factors associated with pre-exposure prophylaxis awareness among cisgender women of reproductive age in Burkina Faso

BACKGROUND

HIV remains a global public health concern, and women continue to be disproportionately affected. Understanding the factors associated with pre-exposure prophylaxis awareness among women is crucial as an effective HIV prevention strategy.

OBJECTIVES

We investigated the prevalence and associated factors of pre-exposure prophylaxis awareness among women in Burkina Faso.

DESIGN

This was a cross-section study that used population-based data.

METHODS

A total of 17,659 women of reproductive age (15-49 years) from the 2021 Burkina Faso Demographic and Health Survey were analyzed. Percentage and multivariable logistic regression model were used to examine the prevalence and factors associated with pre-exposure prophylaxis awareness.

RESULTS

The prevalence of pre-exposure prophylaxis awareness was 8.2% (95% confidence interval = 7.8%-8.6%). Women's age was positively associated pre-exposure prophylaxis awareness. Women with primary and secondary education had 39% and 48% higher odds of pre-exposure prophylaxis awareness, when compared with women with no formal education. The odds of pre-exposure prophylaxis awareness were 1.40 (95% confidence interval = 1.19-1.66) times higher among Christians when compared with the Muslims. Women who were exposed to mass media including newspaper or magazine, radio, TV, and Internet had higher odds of pre-exposure prophylaxis awareness, when compared with those without exposure to mass media channels. Women who have previously tested for HIV had 37% higher odds of pre-exposure prophylaxis awareness, when compared with those who have not been tested (adjusted odds ratio = 1.37; 95% confidence interval = 1.09-1.72).

CONCLUSION

This study found women's age, geographical region, education, religion, exposure to mass media channels, employment, and HIV testing to be associated with pre-exposure prophylaxis awareness. These findings can inform the development of targeted interventions and public health campaigns to increase awareness and practice to pre-exposure prophylaxis, particularly among key population.

Changes in context, typology and programme outcomes between early and recent periods of sex work among young female sex workers in Mombasa, Kenya: A cross-sectional study

INTRODUCTION

The sex work context and typology change continuously and influence HIV related risk and vulnerability for young female sex workers (YFSW). We sought to describe changes in the context and typology of sex work between the first (early) and past month (recent) of sex work among YFSW to inform HIV prevention programming for sex workers.

METHODS

We used data from a cross-sectional survey (April-November 2015), administered using physical location-based sampling to 408 cis-women, aged 14-24 years, who self-identified as sex workers, in Mombasa, Kenya. We collected self-reported data on the early and recent month of sex work. The analysis focused on changes in a) sex work context and typology (defined by setting where sex workers practice sex work) where YFSW operated, b) primary typology of sex work, and c) HIV programme outcomes among YFSW who changed primary typology, within the early and recent month of sex work. We analysed the data using a) SPSS27.0 and excel; b) bivariate analysis and χ2 test; and c) bivariate logistic regression models.

RESULTS

Overall, the median age of respondents was 20 years and median duration in sex work was 2 years. Higher proportion of respondents in the recent period managed their clients on their own (98.0% vs. 91.2%), had sex with >5 clients per week (39.3% vs.16.5%); were able to meet > 50% of living expenses through sex work income (46.8% vs. 18.8%); and experienced police violence in the past month (16.4% vs. 6.5%). YFSW reported multiple sex work typology in early and recent periods. Overall, 37.2% reported changing their primary typology. A higher proportion among those who used street/ bus stop typology, experienced police violence, or initiated sex work after 19 years of age in the early period reported a change. There was no difference in HIV programme outcomes among YFSW who changed typology vs. those who did not.

CONCLUSIONS

The sex work context changes even in a short duration of two years. Hence, understanding these changes in the early period of sex work can allow for development of tailored strategies that are responsive to the specific needs and vulnerabilities of YFSW.

Using education based on the health belief model to modifications in performance of behaviors related to sexually transmitted infections in vulnerable women

BACKGROUND

Sexually transmitted infections (STIs) have always been considered as a health problem in the world. Also, vulnerable women (addicts, jail breakers, and prostitutes) are at the highest risk. According to the World Health Organization's (WHO) approach, the only effective way to prevent and control this disease is public health education, and high-risk and vulnerable groups should be prioritized in educational programs. The aim of the study was to investigate the effect of health belief model (HBM)-based education on changing the behaviors related to STIs in vulnerable women.

MATERIALS AND METHODS

The present study is an intervention (field trial) study in vulnerable women. Convenience sampling method was used in this study and the sample size was determined to be 84 subjects. Through tossing a coin, the social support center was selected as the intervention group and the drop-in center as the control group. Quantitative data analysis was performed, and descriptive and inferential statistical methods were used.

RESULTS

The mean scores of perceived threat, perceived benefits, perceived barriers, and perceived self-efficacy and changes in performance between the three measurement stages, as well as changes in the scores of perceived threat, perceived benefits, perceived barriers, and perceived self-efficacy over three measurement times were significantly different between the two groups (interaction) (P < 0.001). The mean score of performance 3 months after the intervention was significantly higher than before the intervention (P = 0.001).

CONCLUSIONS

The present study confirmed the effectiveness of the HBM in promoting behavioral modifiers that lead to STIs. Therefore, educational interventions with emphasis on understanding the threats, benefits, barriers, and self-efficacy and, ultimately, performance improvement in relation to STIs are recommended.

Sex Work Venue Disorder and HIV/STI Risk Among Female Sex Workers in Two México-US Border Cities: A Latent Class Analysis

Research increasingly recognizes the importance of social and built environments in shaping health, including risks for and outcomes related to HIV and sexually transmitted infections (STI), but research on sex work venues is limited. We use latent class analysis to identify patterns of sex work venue characteristics and factors associated with class membership in two México-US border cities. Among 603 female sex workers (FSW), three classes of sex work venues were identified: low, medium, and high disorder venues, characterized by level of violence, policing and drug activity. In multivariable analysis, risk exposures and outcomes varied by class, suggesting the need for place-based interventions that are tailored to specific venue profiles and that promote FSW health and safety in the workplace.

HIV- and sex work-related stigmas and quality of life of female sex workers living with HIV in South Africa: a cross-sectional study

BACKGROUND

Environmental quality of life (QoL) assesses individually perceived factors such as physical safety and security, accessibility, quality of healthcare, and physical environment. These factors are particularly relevant in the context of sex work and HIV, where stigma has been identified as an important barrier across several prevention and treatment domains. This study aims to examine the association between different types of HIV- and sex work-related stigmas and environmental QoL among female sex workers (FSW) living with HIV in Durban, South Africa.

METHODS

We conducted cross-sectional analyses using baseline data from the Siyaphambili randomized controlled trial. FSW who reported sex work as their primary source of income and had been diagnosed with HIV for ≥ 6 months were enrolled from June 2018-March 2020, in eThekwini, South Africa. We evaluated the association between environmental QoL, dichotomizing the environmental domain score collected by the WHO Quality of Life HIV Brief (WHOQOL-HIV BREF) questionnaire at the median, and stigma using modified robust Poisson regression models. Five stigma subscales were assessed: sex work-related (anticipated, enacted, or internalized stigma) and HIV-related (anticipated or enacted stigma).

RESULTS

Among 1373 FSW, the median environmental QoL was 10.5 out of 20 [IQR: 9.0-12.5; range 4.0-19.0], while the median overall QoL was 3 out of 5 [IQR: 2-4; range 1-5]. One-third of FSW (n = 456) fell above the median environmental QoL score, while 67% were above the median overall QoL (n = 917). Reporting anticipated sex work stigma was associated with lower environmental QoL (adjusted prevalence ratio [aPR] 0.74 [95% CI 0.61, 0.90]), as was severe internalized sex work stigma (aPR: 0.64, 95% CI 0.48, 0.86). Reporting enacted HIV stigma versus none was similarly associated with lower environmental QoL (aPR: 0.65, 95% CI 0.49, 0.87). Enacted sex work stigma and anticipated HIV stigma were not statistically associated with environmental QoL.

CONCLUSIONS

This study highlights the need to consider the impact of multiple stigmas on FSW's non-HIV related clinical outcomes, including safety and physical well-being. Moreover, these results suggest that addressing underlying structural risks may support the impact of more proximal HIV prevention and treatment interventions. Trial registration NCT03500172 (April 17, 2018).

HIV prevalence and associated factors among female sex workers in Ethiopia, east Africa: A cross-sectional study using a respondent-driven sampling technique

BACKGROUND

HIV acquisition among Female Sex Workers (FSWs) is 30 times higher than the acquisition rate among females in the respective general population. A higher HIV burden in FSWs challenges the prevention and control of the virus in other population groups. However, there is inadequate evidence on the burden of HIV among FSWs in Ethiopia. This study was conducted to assess the extent of HIV and associated factors among FSWs in the country.

METHODS

This was a cross-sectional study that involved a total of 6,085 FSWs. The participants were selected using a respondent-driven sampling technique (RDS). FSWs who lived at the study sites for at least a month before the study time were considered eligible for recruitment. The study was conducted from January 01 to June 30, 2020 in 16 cities across Ethiopia. A mixed-effect logistic regression model was applied to determine factors associated with HIV positivity.

FINDINGS

The pooled HIV prevalence among FSWs in this study was 18·7% (95% CI: 17·8, 19·7) with considerable variation across cities. The highest HIV prevalence was observed in Bahir Dar city, 28·2% (95% CI: 23·9, 33.0) and the lowest was seen in Shashemene city, 14.0% (95% CI: 10·2, 18·9). The odds of HIV positivity in FSWs was associated with being older than 35 years of age (AOR = 8·1; 95% CI: 6·1, 10·3), reactive for Treponema Pallidum (AOR = 2·6; 95% CI: 1·0, 3·4), being widowed (OR = 2·2; 95% CI: 1·6, 2·9), not able to read and write (OR = 2·0; 95% CI: 1·5, 2·4), incidence of condom breakage (OR = 1·5; 95% CI: 1·2, 1·7) and having a history of STIs (OR = 1·3; 95% CI: 1·1, 1·6).

INTERPRETATION

One in five FSWs was HIV positive. HIV prevalence was higher in the older age groups and in those who were positive for Treponema Pallidum (Syphilis). The findings indicated the importance of strengthening HIV prevention and control in FSWs to achieve the national goal to eliminate HIV by 2030.

FUNDING

The study was supported by The Ethiopian Ministry of Health through the Federal HIV/AIDS Prevention and Control Office.

Intentional abortion and its associated factors among female sex workers in Iran: Results from national bio-behavioral surveillance-2020

Purpose

In addition to estimating the prevalence of intentional abortion in Iranian female sex workers (FSWs), this study identified related factors using the data of a national study.

Methods

This cross-sectional study utilizes the third round of integrated bio-behavioral surveillance-III data in Iranian FSWs in December 2019 and August 2020, and 1515 Participants were selected in 8 geographically diverse cities in Iran. Logistic regression was performed using unweighted analysis to identify factors associated with intentional abortion. Stata software (version 14), respondent-driven sampling analyses, and R (version 4.1.2) was used for data analysis.

Results

From 1390 participants with valid responses to the abortion question, 598 (37.3%; 95% CI: 32.43, 42.11%) reported intentional abortion during their life. According to the age groups, the highest prevalence of abortion was in the age group of 31 to 40 years (42.60%). In the multivariate logistic regression model, the marital status (divorced women (AOR = 2.05, 95% CI: 1.29, 3.27), concubines (AOR = 1.78, 95% CI: 1.02, 3.11)), work experience in brothels (AOR = 1.39, 95% CI: 1.04, 1.84), the type of sex (AOR = 2.75, 95% CI: 1.35, 5.58), the history of sexual violence (AOR = 1.54, 95% CI: 1.19, 2.01), and alcohol consumption (AOR = 1.53, 95% CI: 1.18, 2.01) were significantly associated with a history of intentional abortion.

Conclusion

Intentional abortion’s prevalence among Iranian FSWs has been much higher than that of the general female population in Iran, which is an alarming issue in the public health of this group and needs more effective interventions. In addition, alcohol consumption, working in a brothel, and being divorced are essential factors in increasing abortions among sex workers.

Social and structural determinants of health associated with police violence victimization: A latent class analysis of female sex workers who use drugs in Kazakhstan

INTRODUCTION

Punitive legal environments remain a challenge to HIV prevention efforts in Central Asia, and female sex workers who use drugs are vulnerable to police violence. Little is known about the heterogeneity of police violence against female sex workers who use drugs and factors associated with HIV risk in Central Asia, despite the growing HIV epidemic.

METHODS

We recruited a community-based sample of 255 female sex workers who use drugs in Almaty, Kazakhstan between February 2015 and May 2017. We used latent class analysis to differentiate women into distinct classes of police violence victimization, and multinomial logistic regression to identify individual-level health outcomes, HIV risk behaviors, and social and structural factors within the risk environment associated with class membership.

RESULTS

A three-class model emerged: Low Victimization (51%), Discrimination and Extortion (15%), and Poly-Victimization (34%). Relative to Low Victimization, factors associated with Poly-Victimization included being positive for HIV and/or sexually-transmitted infections (STI) (aOR: 1.78 (95% CI: 1.01, 3.14)), prior tuberculosis diagnosis (2.73 (1.15, 6.50)), injection drug use (IDU) (2.00 (1.12, 3.58)), greater number of unsafe IDU behaviors (1.21 (1.08, 1.35)), homelessness (1.92 (1.06, 3.48)), greater drug use (1.22 (1.07, 1.39)) and sex work stigma (1.23 (1.06, 1.43)), greater number of sex work clients (2.40 (1.33, 4.31)), working for a boss/pimp (2.74 (1.16, 6.50)), client violence (2.99 (1.65, 5.42)), economic incentives for condomless sex (2.77 (1.42, 5.41)), accessing needle/syringe exchange programs (3.47 (1.42, 8.50)), recent arrest (2.99 (1.36, 6.55)) and detention (2.93 (1.62, 5.30)), and negative police perceptions (8.28 (4.20, 16.3)). Compared to Low Violence, Discrimination and Extortion was associated with lower odds of experiencing intimate partner violence (aOR= 0.26 (0.12, 0.59)), but no other significant associations with the risk environment upon adjusting for socio-demographic characteristics.

CONCLUSION

Police violence against female sex workers who use drugs is pervasive in Kazakhstan. Patterns of police violence vary, with greater HIV susceptibility associated with a higher probability of experiencing multiple forms of police violence. Police sensitization workshops that integrate policing and harm reduction, and drug policy reforms that decriminalize drug use may help mitigate the HIV epidemic in Kazakhstan.

The role of education and income as protective factors against intimate partner violence and HIV exposure among Kenyan women

Introduction

Intimate partner violence (IPV) is a public health problem that impacts approximately one in three women worldwide in their life-time. The purpose of the study was to explore the lived experiences of women teachers and violence in Kenya. It also explores the intersection between intimate partner violence, HIV risk, and gender inequality.

Method

Data were collected through two focus groups of a total of 15 women teachers. We recruited women ages 21-44 from two geographically diverse urban and rural schools. The data were analyzed using a thematic analysis method to identify text themes and meaning patterns.

Results

Three contextual experiences emerged: socio-cultural influences of gender norms, masculinity and patriarchy; uneven power dynamics; and institutionalized gender inequality.

Discussion

Findings suggest that education alone is not sufficient to end GBV. Comprehensive and gender transformative governmental policy approaches are needed to mitigate GBV in Kenya.

Sex work within emerging Latino immigrant communities: a typology

Little is known about the organisation and types of sex work emerging urban Latino immigrant communities. To develop a typology of the local sex work industry, we conducted 39 in-depth interviews with foreign-born and US-born Latina female sex workers, Latino immigrant clients, and key informants such as bartenders and brothel managers in Baltimore, Maryland, USA. Interview transcripts were coded through an iterative process, and descriptions of sex work were grouped into types. Three types of direct sex work (the street, houses that operate as brothels, and weekend brothels operating out of hotels), three types of indirect sex work (bar workers, opportunistic, and as-needed), and one type that could be either direct or indirect (individual arrangements) were identified. Understanding the local sex industry and its variability has implications for developing and implementing programmes and interventions tailored to the context of sex work type in order to reduce HIV transmission.

Patterns of Sex Work Client Solicitation Settings and Associations with HIV/STI Risk Among a Cohort of Female Sex Workers in Baltimore, Maryland

Female sex workers' (FSWs) risk for HIV/STIs is influenced by their work environments. While previous research has characterized vulnerability in a single workplace, many FSWs solicit clients from multiple settings. Using latent class analysis (LCA), we examined client solicitation patterns and associated HIV/STI-related behaviors (consistent condom use with clients, asking clients about HIV/STIs, and past 6-month HIV/STI testing) among 385 FSWs in Baltimore, Maryland. The LCA yielded a three-class solution: predominantly street (61.2%), mixed street/venue (23.7%), and multisource (street, venue, and online) (15.1%). Consistent condom use differed significantly (p < 0.01) by class, with the mixed street/venue having the lowest (40.6%) rate and the multisource having the highest (70.6%). Classes differed on HIV/STI testing (p < 0.01), with the predominantly street class having the lowest testing rate (56.2%) and multisource with the highest (85.7%). These findings underscore the importance of considering how solicitation patterns are linked to HIV/STI susceptibility of FSWs and adapting interventions accordingly.

Daily activity spaces and drug use among female sex workers living with HIV in the Dominican Republic

The purpose of this study was to explore the daily activity spaces of female sex workers living with HIV in the Dominican Republic and assess the relationship between activity path and location-based risk exposure measures and daily drug use. The study employed a micro-longitudinal observational study design using an innovative 7-day travel diary to capture daily activity routes and a 7-day mobile health (mHealth) daily diary to collect daily substance use behaviors among 51 female sex workers. To estimate between-subject variability, a series of crude and adjusted modified log-Poisson repeated measures regression models with generalized estimating equations, clustering by individual with a compound symmetry working correlation structure were fit to estimate the relative risks and 95% confidence intervals. Controlling for individual level factors, findings showed that female sex workers exposed to a higher number of risk outlets (e.g., liquor stores, bars, hotels, nightclubs, brothels, etc.) within 200 and 100-meters of sex work locations were at an increased risk of daily drug use (RRadj: 1.03, 95%CI: 1.01, 1.05, RRadj: 1.05, 95%CI: 1.01, 1.09). No association was detected between activity path exposure and daily drug use. These findings illustrate the importance of moving beyond static residential neighborhood boundaries for measuring risk exposures and highlight the significant role that daily work environments have on drug harms among a highly stigmatized and vulnerable population.

Human papillomavirus genotype distribution and factors associated among female sex workers in West Africa

OBJECTIVES

This study aimed to: (1) Estimate HPV prevalence and genotype distribution among female sex workers (FSWs) in Mali and Benin as well as the prevalence of multiple HPV type infections in this group, and (2) Identify potential risk factors associated with high-risk (HR) HPV infections.

METHODS

We analyzed baseline data of 665 FSWs aged ≥ 18 years recruited during a prospective cohort of cervical cancer screening in Cotonou (Benin) and Bamako (Mali) from 2017 to 2018. The Linear Array HPV genotyping test was used to identify HPV genotypes. Descriptive statistics and multivariate log-binomial regression were used. Adjusted prevalence ratios (APR) with 95% confidence intervals (95%CI) were estimated to identify risk factors associated with HR-HPV infections.

RESULTS

HPV data were available for 659 FSWs (Benin: 309; Mali: 350). The mean age was 35.0 years (± 10.7) in Benin and 26.8 years (± 7.6) in Mali. The overall HPV prevalence rates were 95.5% in Benin and 81.4% in Mali. About 87.7% and 63.4% of FSWs harbored ≥ 2 HPV types in Benin and Mali, respectively. The top three prevalent HR-HPV among FSWs in Benin were: HPV58 (37.5%), HPV16 (36.6%) and HPV52 (28.8%). Corresponding patterns in Mali were HPV16 (15.7%), HPV51 (14.3%) and HPV52 (12.9%). In Benin, the main factors associated with HR-HPV were vaginal douching (APR = 1.17; 95%CI:1.02-1.34) and gonococcal infection (APR = 1.16; 95%CI:1.04-1.28), while in Mali they were sex work duration ≤ 1 year (APR = 1.35; 95%CI:1.10-1.65) and HIV infection (APR = 1.26; 95%CI: 1.06-1.51).

CONCLUSION

Our study found a very high prevalence of HPV infection as well as high frequency of multiple HPV type infections in FSWs in two countries in West Africa. These findings suggest the necessity to emphasize cervical cancer prevention in this high-risk group.

A Mixed Methods Analysis of the Venue-Related Social and Structural Context of Drug Use During Sex Among Male Clients of Female Sex Workers in Tijuana, Mexico

Drug use during sex increases risks for HIV acquisition. Male clients of female sex workers (FSW) represent both a key population at risk for HIV as well as a transmission bridge population. In Tijuana, Mexico, drug use is prevalent and there is a need to understand male clients' drug use during sex with FSW. Characteristics of sex work venues may confer higher risks for drug use, risky sex, and HIV/STI. It is essential to understand the venue-related social and structural factors associated with drug use during sex in order to inform HIV prevention interventions with male clients in this region. We used a Mixed-Methods Sequential Explanatory Design to conduct an enriched examination of drug use during sex among male clients of FSW in Tijuana. Findings from logistic regression analysis showed that drug use during sex was significantly correlated with police harassment (AOR = 4.06, p < .001) and methamphetamine use (AOR = 33.77, p < .001). In-depth interview data provided rich meaning behind and context around the quantitative associations. Social and structural interventions to reduce police harassment, methamphetamine use, and promote condom availability are needed to reduce risks for HIV among male clients of FSW in Tijuana.

Prevalence of syphilis in female sex workers in three countryside cities of the state of Pará, Brazilian Amazon

Background

Syphilis is a sexually transmitted infection (STI) transmitted from person to person mainly by sexual intercourse or through vertical transmission during pregnancy. Female sex workers (FSWs) are exposed especially to syphilis infection, and besides all the efforts to control the spread of STIs, syphilis prevalence is still rising, mainly occurring in low-income countries. This study aimed to investigate the syphilis prevalence, demographic characteristics and sexual habits among FSWs in the Amazon region of Brazil.

Methods

A cross-sectional study was carried out including 184 FSWs from 3 countryside cities of the state of Pará, Amazon region of Brazil. A venereal disease research laboratory test and an indirect immunoenzyme assay to test antibodies against Treponema pallidum were used for screening syphilis infection, while sexual habits and demographic data information were collected through a semi-structured questionnaire. Data was analyzed comparing groups with/without syphilis. Poisson regression models were used to estimate the reasons of prevalence (RP).

Results

The overall prevalence of syphilis was 14.1% (95% CI = 9.8–17.8). FSWs had between 15 and 56 years of age, most were unmarried (65.7%), had attended less than 8 years of formal education (64.1%), had between 10 and 20 partners per week (64.1%), and reported no previous history of STIs (76.1%) and regular use of condom (52.7%). Low level of education attending up to the primary school (RP adjusted = 3.8; 95% CI = 1.4–9.2) and high frequency of anal sex during the past year (RP adjusted = 9.3; 95% CI = 3.5–28.7) were associated with a higher prevalence of syphilis.

Conclusions

A high prevalence of syphilis among FSWs in the Brazilian Amazon region was identified, showing that syphilis is more likely to be transmitted in FSW working in low-income areas, which is attributed to the low level of education. Anal intercourse was found as a risk factor associated with syphilis. Health programs focused on risk populations appear as a rational way to control syphilis spread, which is a rising problem in Brazil and in other several countries.

Implementing Respondent-Driven Sampling to Recruit Women Who Exchange Sex in New York City: Factors Associated with Recruitment and Lessons Learned

Respondent-driven sampling (RDS) relies on productive peer recruitment to capture hidden populations. Domestic studies have identified characteristics of productive recruitment among RDS samples of men who have sex with men and persons who use drugs, but not of women who exchange sex, a group vulnerable to HIV infection. We examined sociodemographic-, behavioral-, exchange-sex-, and protocol-related factors associated with recruitment among seeds (n = 25) and peers (n = 297) in the 2016 New York City National HIV Behavioral Surveillance Study cycle focused on women who exchange sex. Recruiter productivity was significantly associated with not having been recently incarcerated, lower rate of HIV testing, and larger exchange sex networks among seeds, and with HIV-prevention services usage among peers. We describe challenges and lessons learned from implementing RDS in this population. Our study identifies seed characteristics and protocol improvements researchers can utilize when implementing future RDS studies among women who exchange sex.

Use of long-acting reversible contraception in a cluster-random sample of female sex workers in Kenya

OBJECTIVE

To assess correlates of long-acting reversible contraceptive (LARC) use, and explore patterns of LARC use among female sex workers (FSWs) in Kenya.

METHODS

Baseline cross-sectional data were collected between September 2016 and May 2017 in a cluster-randomized controlled trial in Mombasa. Eligibility criteria included current sex work, age 16-34 years, not pregnant, and not planning pregnancy. Peer educators recruited FSWs from randomly selected sex-work venues. Multiple logistic regression identified correlates of LARC use. Prevalence estimates were weighted to adjust for variation in FSW numbers recruited across venues.

RESULTS

Among 879 participants, the prevalence of contraceptive use was 22.6% for implants and 1.6% for intra-uterine devices (IUDs). LARC use was independently associated with previous pregnancy (adjusted odds ratio for one pregnancy, 11.4; 95% confidence interval, 4.25-30.8), positive attitude to and better knowledge of family planning, younger age, and lower education. High rates of adverse effects were reported for all methods.

CONCLUSION

The findings suggest that implant use has increased among FSWs in Kenya. Unintended pregnancy risks remain high and IUD use is negligible. Although LARC rates are encouraging, further intervention is required to improve both uptake (particularly of IUDs) and greater access to family planning services.

Hepatitis B, C and Delta Viruses’ Infections and Correlate Factors Among Female Sex Workers in Burkina Faso, West-Africa

Background:

Female Sex Workers (FSW) have increased vulnerability to viral hepatitis B, C and D transmission. Our study aimed to assess the seroprevalence of hepatitis B, C and D viruses and their associated factors among FSW in Ouagadougou, Burkina Faso.

Methods:

This is a cross-sectional study among FSW at least 18 years old in Ouagadougou, Burkina Faso. Data were collected from February 2013 to May 2013 using Respondent-Driven Sampling (RDS). Hepatitis B, C, and D tests were performed on FSW storage serums using fourth generation ELISA kits. Survey-weighted bivariate and multivariate logistic regression analyses were performed using Stata version 14 to identify factors associated with viral hepatitis infections.

Results:

Population-weighted prevalence of viral hepatitis infections in FSW was respectively 18.2% (95%CI: 14.4-22.9) for Hepatitis B Virus (HBV), 10.6% (95%CI: 07.5-14.8) for Hepatitis C Virus (HCV) and 1.5% (95Cl: 0.2-10.3) for Hepatitis D Virus (HDV). Factors independently associated with HCV include positive HIV status, inconsistent condom use during the last 12 months, condom reuse with clients, sex with clients in the street, bars or public gardens. No sociodemographic or behavioral factors were independently associated with HBV infection.

Conclusion:

The prevalence of HBV and HCV was high among FSW and the prevalence of HDV was relatively low in this group in Burkina Faso. These findings suggest urgent and comprehensive prevention of these viruses through education for safer sex and behaviors, and immunization against HBV for FSW.

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.

Behaviour change techniques in brief interventions to prevent HIV, STI and unintended pregnancies: A systematic review

BACKGROUND

Behaviour-change interventions have been consistently considered an essential part of comprehensive HIV, STI and unintended pregnancy prevention. In 2015, the World Health Organization reviewed and assessed existing evidence on brief behavioural interventions, leading to the publication of Brief sexuality-related communication: recommendations for a public health approach. This guideline recommends the use of brief behaviour intervention and communication programmes to promote sexual health and to prevent HIV, STIs, and unintended pregnancies in primary health services, particularly sexual and reproductive health services.

OBJECTIVE

With the purpose of informing the development of a brief behaviour intervention in sexual and reproductive health, we conducted a systematic review of brief intervention to prevent HIV, STI and unintended pregnancies, to identify behaviour change techniques (BCTs) used in health care settings.

METHODS

Participants from all ages and genders were included. Brief interventions delivered in ≤ 60 minutes were included. Data was extracted, and interventions were coded following the Behaviour Change Techniques Taxonomy (BCTTv1) guidelines.

RESULTS

Of the 6.687 articles identified, 355 were reviewed and 37 studies were included. In effective interventions, we identified 48 behaviour change techniques (BCTs). A core set of 8 frequently used behaviour change techniques was identified: "Problem solving", "Feedback on behaviour", "Social support (unspecified)", "Instructions on how to perform the behaviour", "Information about health consequences", "Information about social and environmental consequences", "Demonstration of the behaviour" and "Credible source".

CONCLUSIONS

The technical content of brief behaviour interventions was identified in a reliable and standardized way providing preliminary indications on potentially effective techniques to achieve behaviour change.

Health Issues Associated with Commercial Sexual Exploitation and Sex Trafficking of Children in the United States: A Systematic Review

This article reviews studies examining health issues associated with commercial sexual exploitation and sex trafficking (CSE/ST) of children in the United States. We searched five health and social sciences databases for peer-reviewed articles published in English between January 1990 and April 2017. After independent screening of the records, we identified 27 studies that met the inclusion criteria. Descriptions of the included studies and their definitions of CSE/ST are provided. Most of the studies sampled children and youth in urban, metropolitan areas and employed cross-sectional surveys or reviewed case files and medical records of convenience samples. Studies differed widely in their operationalization of CSE/ST, which limit systematic comparison across studies and the generalizability of findings. Qualitative analysis of the included studies shows that among commercially sexually exploited/trafficked children, there are elevated burdens of substance use and abuse, mental health disorders such as depression, PTSD, suicidal behaviors, and sexual and reproductive health issues including STIs, HIV, and pregnancy. This review underscores the need for more empirical studies, to guide an evidence-based understanding of and response to the range and complexity of the health issues in this population. Of particular utility are studies that address some of the methodological limitations of prior research in this field (e.g., cross-sectional, convenience samples) and those that assess overlooked health issues (e.g., malnutrition, eating disorders, post-trauma growth, and long-term health consequences).

Factors associated with HIV infection among female sex workers in Brazil

BACKGROUND

Female sex workers (FSWs) are one of the most-at-risk population groups for human immunodeficiency virus (HIV) infection. This paper aims at identifying the main predictors of HIV infection among FSW recruited in the 2nd Biological and Behavioral Surveillance Survey in 12 Brazilian cities in 2016.

METHOD

Data were collected on 4245 FSW recruited by respondent driven sampling (RDS). Weights were inversely proportional to participants' network sizes. To establish the correlates of HIV infection, we used logistic regression models taking into account the dependence of observations resultant from the recruitment chains. The analysis included socio-demographic sex work characteristics, sexual behavior, history of violence, alcohol and drug use, utilization of health services, and occurrence of other sexually transmitted infections (STIs).

RESULTS

HIV prevalence was estimated as 5.3% (4.4%-6.2%). The odds ratio (OR) of an HIV-positive recruiter choosing an HIV-positive participant was 3.9 times higher than that of an HIV-negative recruiter (P < .001). Regarding socio-demographic and sex work characteristics, low educational level, street as the main work venue, low price per sexual encounter, and longer exposure time as a sex worker were found to be associated with HIV infection, even after controlling for the homophily effect. The OR of being HIV infected among FSW who had been exposed to sexual violence at least once in a lifetime (OR = 1.5, P = .028) and the use of illicit drugs at least once a week were highly significant as well, particularly for frequent crack use (OR = 3.6, P < .001). Among the sexual behavior indicators, not using condoms in some circumstances were significantly associated with HIV infection (OR = 1.8, P = .016). Regarding the occurrence of other STI, the odds of being HIV infected was significantly higher among FSW with a reactive treponemal test for syphilis (OR = 4.6, P < .001).

CONCLUSIONS

The main factors associated with HIV infection identified in our study characterize a specific type of street-based sex work in Brazil and provided valuable information for developing interventions. However, there is a further need of addressing social and contextual factors, including illicit drug use, violence, exploitation, as well as stigma and discrimination, which can influence sexual behavior.

Efficacy of Human Immunodeficiency Virus/Sexually Transmitted Infection Trial on Condom Use Among Heterosexual Men Patronizing Entertainment Establishments Who Engaged in Casual or Paid Sex in Singapore

BACKGROUND

We assessed the efficacy of a multi-component sexual health promotion program on condom use and human immunodeficiency virus (HIV)/sexually transmitted infection (STI) testing among heterosexual men (HSM) patronizing entertainment establishments who engaged in casual or paid sex in Singapore.

METHODS

This was a quasi-experimental trial with a comparison group using cross-sectional surveys at baseline and 6 months postintervention. A locality patronized by local HSM was assigned the intervention, a comparable and distant area served as the comparison site. Using time location sampling, cross-sectional samples of these men were assessed on sexual behaviors using an anonymous questionnaire at baseline (n = 604) and 6 months postintervention (n = 360) in both groups. The coprimary outcomes were condom use at last vaginal and oral sex with casual partner respectively. Mixed effects Poisson regression model accounting for clustering by establishment was used to compute the adjusted prevalence ratio (aPR) of the outcomes postintervention.

RESULTS

At postintervention, the intervention group was more likely than the comparison group to report condom use at last vaginal (aPR, 1.41; 95% confidence interval [CI], 1.05-1.89) and oral (aPR, 1.70; 95% CI. 1.11-2.61) sex, respectively, with casual partner. Similar findings were found for consistent condom use in the last 6 months for vaginal (aPR, 1.67; 95% CI, 1.13-2.48) and oral (aPR, 1.97; 95% CI, 1.16-3.32) sex, respectively, with casual partner. The HIV/STI testing was not significantly higher in the intervention than the comparison group (aPR, 1.43; 95% CI, 0.98-2.09).

CONCLUSIONS

This trial was effective in promoting condom use with casual partners but not HIV/STI testing among HSM in Singapore.

Using qualitative and community-based engagement approaches to gain access and to develop a culturally appropriate STI prevention intervention for foreign female entertainment workers in Singapore

Background

There is an increasing global movement of foreign female entertainment workers (FEWs), a hard-to-reach population vulnerable to HIV/STIs. This paper described the needs assessment phase before intervention implementation where the socio-organisation, sexual risk behaviours and access to health services of foreign FEWs in Singapore were explored. We also highlighted how qualitative inquiry, census enumeration technique and community-based engagement approaches were used to gain access and to develop a culturally appropriate STI prevention intervention.

Methods

In-depth interviews, observations, informal conversational interviews, mystery client and critical incident technique were used. We estimated the size of FEW population using the census enumeration technique. The findings were used to inform intervention development and implementation.

Results

We estimated 376 Vietnamese and 330 Thai FEWs in 2 geographical sites where they operated in Singapore. Their reasons for non-condom use included misconceptions on the transmission and consequences of STI/HIV, low risk perception of contracting HIV/STI from paid/casual partner, lack of skills to negotiate or to persuade partner to use condom, unavailability of condoms in entertainment establishments and fear of the police using condom as circumstantial evidence. They faced difficulties in accessing health services due to fear of identity exposure, stigmatisation, cost and language differences. To develop the intervention, we involved FEWs and peer educators, and ensured that the intervention was non-stigmatising and met their needs. To foster their participation, we used culturally-responsive recruitment strategies, and ensured that the trial was anonymous and acceptable to the FEWs. These strategies were effective as we achieved a participation rate of 90.3%, a follow-up rate of 70.5% for the comparison and 66.8% for the intervention group. The interventions group reported a significant increase in consistent condom use with a reduction in STI incidence compared to no significant change in the comparison group.

Conclusions

The qualitative inquiry approaches to gain access, to foster participation and to develop a culturally appropriate intervention, along with the census enumeration technique application to estimate the FEW population sizes has led to successful intervention implementation as well as safer sexual behaviour and STI incidence reduction.

Trial registration

ClinicalTrials.gov, NCT02780986. Registered 23 May 2016 (retrospectively registered).

Electronic supplementary material

The online version of this article (10.1186/s12992-018-0358-5) contains supplementary material, which is available to authorized users.

A typology of female sex work in the Metropolitan Region of Santiago, Chile

In Chile, sex work takes place covertly in a variety of venues and locations. Formative research using time-location sampling methods is important in order to understand the nature of this diversity. This study used qualitative methods to develop a typology of female sex work in the Metropolitan Region of Santiago, Chile, using semi-structured interviews, focus groups and ethnographic fieldwork during visits to sex work venues. The study identified seven types of venue, which reflect the context and regulatory framework of the country and the structural vulnerabilities that affect female sex workers in Chile. These venues and locations include: cafés con piernas (coffee with legs); nightclubs, topless bars and cabarets; brothels; hotels; street and highway soliciting; massage parlours; and private residences. Formative research methods were helpful in identifying and characterising the venues and locations in which sex work occurred. Barriers to accessing and mapping specific locations were also identified. Recommendations for addressing these barriers include working with non-governmental organisations to map venues and initiate contact with the populations of interest. A comprehensive typology of sex work in the Metropolitan Region of Santiago, Chile, is an essential element for future time-location sampling and bio-behavioural research in the context of second-generation surveillance for HIV and sexually transmitted infections in Chile.

Structural factors associated with methamphetamine smoking among female sex workers in Tijuana, Mexico

INTRODUCTION AND AIMS

Smoking methamphetamine is associated with increased risk of HIV among female sex workers (FSW). The structural context of substance use is an important shaper of individual behaviour; however, structural determinants of methamphetamine use among FSWs are largely unknown. We identified individual, structural and neighbourhood factors associated with smoking methamphetamine among FSWs in the border city of Tijuana, Baja California, Mexico.

DESIGN AND METHODS

A prospective cohort of 301 FSWs sampled from indoor and outdoor sex work venues throughout Tijuana participated in quantitative surveys on behaviours and mapping of home and work neighbourhoods across three visits. Multinomial logistic regression using generalised estimating equations identified individual, structural and neighbourhood variables associated with smoking methamphetamine.

RESULTS

Methamphetamine use, particularly smoking, was highly prevalent among FSWs. Over half (61%) of FSWs had ever used methamphetamine in their lifetime and at baseline, 38% currently smoked methamphetamine. Smoking methamphetamine daily was associated with living in the red light district [adjusted odds ratio (AOR) = 2.72, 95% confidence interval (CI) = 1.23-6.02] and with perceived homelessness, but only among women in a good financial situation (AOR = 4.08, 95% CI = 1.58-10.50). Smoking methamphetamine less than daily was associated with older age (AOR = 1.06, 95% CI = 1.02-1.10).

DISCUSSION AND CONCLUSIONS

Our findings point to the important dynamic between the residential environment and more severe methamphetamine use. FSWs may prioritise the purchase of methamphetamine over stable housing if they have the financial means. Given the high prevalence of smoking methamphetamine among FSWs in Tijuana, drug treatment options, especially for women living in the red light district, are needed.

Community Engagement and Venue-Based Sampling in Adolescent Male Sexually Transmitted Infection Prevention Research

OBJECTIVES

Middle adolescent males are a difficult group to recruit for community sexually transmitted infection (STI) prevention research. We describe a process of community engagement, and venue-based sampling of 14-17-year-old adolescent males, and compare rates of STIs and STI risk behaviors by venue.

METHODS

Community engagement consisted of (1) informational meetings with organizations; (2) participation in community meetings and events; (3) hiring community members as study personnel; and (4) an adolescent advisory board recruited from the community. Venues were identified and assessed at different times of the day and days of the week using a structured tool. At selected venues, males ages 14-17 years were invited to participate in a brief survey and provide a urine sample and an optional anal swab for DNA-based STI testing.

RESULTS

Venues were assessed (n = 249), and 31 were selected for recruitment, including parks, apartment complexes, community events, entertainment venues, a community school, and community programs for LGBT (gay, lesbian, bisexual, transgender) and adjudicated youth. We enrolled 667 participants, average age 15.7 years. Participants reported high rates of sexual and STI risk behaviors, but had low rates of STIs. These rates differed by venue, with more structured venues recruiting youth reporting fewer STI risk behaviors and less structured venues within the highest STI prevalence zip code recruiting youth reporting more STI risk behaviors.

CONCLUSION

Venue-based sampling is a feasible mechanism to target recruitment and enrollment adolescent males with high STI risk behaviors in community settings, with risk profiles varying by setting.

Experiences of structural vulnerability among exotic dancers in Baltimore, Maryland: Co-occurring social and economic antecedents of HIV/STI risk

BACKGROUND

Women who grow up in economic scarcity often face limited opportunities for upward mobility, as a result of challenges securing stable housing, quality education, and steady employment. Chronic instability may limit the capacity of women to protect themselves against HIV/STI-related harm when engaging in sexual activity or drug use. Characterizing the structural contexts that facilitate HIV/STI risk among women are critical to effective design and implementation of drug and sexual harm reduction interventions.

METHODS

Semi-structured in-depth interviews were completed with 25 female exotic dancers working in Baltimore City and County exotic dance clubs July 2014-May 2015. Using thematic analysis, interviews were examined to understand the nature of structural vulnerability experienced by dancers during their early lives through the initial months of exotic dancing, including an examination of the roles of drug use and social relationships in engagement of sexual risk behavior.

RESULTS

Dancers depicted early experiences of social and economic disadvantage, which accumulated through early adulthood. Substance use emerged as an important subject for the majority of women, operating cyclically as both precursor to and product of accumulating social and economic hardship. Dancers revealed social strategies that buffered the effects of structural vulnerability and minimized exposure to workplace-related drug and sexual harms.

CONCLUSION

This study provides insight on an understudied group of at-risk women with a unique demographic profile. Findings illustrate how the effects of structural vulnerability, substance abuse, social strategies, and opportunities for economic gain through sexual services in the workplace converge to produce varying levels of HIV/STI risk among exotic dancers.

The Peer and Non-peer: the potential of risk management for HIV prevention in contexts of prostitution

Sex workers have been the protagonists and focus of HIV prevention campaigns and research since the late 1980s in Brazil. Through a review of national and international literature, combined with a history of sex workers' involvement in the construction of the Brazilian response, this article explores the overlaps and disconnects between research and practice in contexts of prostitution over the past three decades. We review the scientific literature on the epidemiology of HIV among sex workers and prevention methodologies. We conclude that although research focus and designs often reinforce the idea that sex workers' vulnerability is due to their sexual relationships with clients, their greatest vulnerability has been found to be with their nonpaying intimate partners. Few studies explore their work contexts and structural factors that influence safe sex practices with both types of partners. The negative effects of criminalization, stigma, and exclusively biomedical and peer education-based approaches are well documented in the scientific literature and experiences of sex worker activists, as is the importance of prevention programs that combine empowerment and human rights-based approach to reduce HIV infection rates. We conclude that there is a need for actions, policies, and research that encompass the environment and context of sex workers' lives and reincorporate the human rights and citizenship frame that dominated the Brazilian response until the end of the 2000s. As part of HIV prevention efforts, female sex workers need to be considered above all as women, equal to all others.

Correlates of HIV and Inconsistent Condom Use Among Female Sex Workers in Ukraine

While female sex workers (FSWs) carry one of the highest risks of HIV transmission, little is known about predictors of HIV and risky behavior of FSWs in Ukraine. In this study of 4806 Ukrainian FSWs, the prevalence of HIV was 5.6 %. FSWs had higher odds to be HIV infected if they had lower income, were older, injected drugs, experienced violence, and solicited clients on highways. Inconsistent condom use with clients was reported by 34.5 % of FSWs. FSWs who solicited clients at railway stations, via media, through previous clients and other FSWs, and on highways reported lower consistency of condom use. Furthermore, inconsistent condom use was related to younger age, alcohol use, having fewer clients, not being covered with HIV prevention, and experiences of violence. The present study expands on the rather limited knowledge of correlates of the HIV and inconsistent condom use among FSWs in Ukraine.

Efficacy of Human Immunodeficiency Virus/Sexually Transmitted Infection Prevention Interventions Targeting Female Entertainment Workers: A Systematic Review and Meta-analysis

Female entertainment workers (FEWs) working in karaoke lounges, bars, pubs, nightclubs, discotheques, dance halls, massage parlours, restaurants (as hostesses or singers) and beer gardens are at high risk for human immunodeficiency virus (HIV)/sexually transmitted infection (STI). The aim of the systematic review and meta-analysis is to evaluate the efficacy of HIV/STI intervention programmes targeting FEWs. Among the 14 included studies, majority were in Asia and targeted native FEWs. Most studies were quasi-experimental and the overall quality was relatively low. While most studies employed only behavioural strategies, structural interventions were the least common. In studies with structural interventions, there was a preference for behavioural and biomedical-based outcome measurements rather than structural-related indicators. FEWs in the intervention group were significantly more likely to report condom use with paying (odds ratio OR 1.7; 95% CI 1.0-2.9, p 0.04), but not with regular (OR 1.0; 95% CI 0.8-1.3, p 0.84) partner than the control/comparison group post-intervention.

The Role of Sex Work Pay in Moderating the Effect of Mobile Phone Solicitation on Condom Practices: An Analysis of Female Sex Workers in India

Mobile phones remain a largely untapped resource in the ongoing challenge to address Female Sex Worker (FSW) health, including HIV prevention services, in India. An important step towards designing effective mobile phone-based initiatives for FSWs is clarifying the contextual influences of mobile phone solicitation on sexual risk behavior. In this paper, we extend previously identified associations between mobile phone solicitation and condom practices by examining whether this association is moderated by sex work pay and offer key considerations for future research and implementation. Specifically, we conducted an analysis among 589 Indian FSWs, where FSWs who did not use mobile phones to solicit clients had the lowest mean sex work pay (INR 394/ USD 6.54) compared to FSWs who used both mobile and traditional strategies (INR 563/ USD 9.34). Our analysis indicate low paid FSWs who used mobile phones concurrently with traditional strategies had 2.46 times higher odds of inconsistent condom use compared to low paid FSWs who did not use mobile phones for client solicitation. No such effect was identified among high paid FSWs. These findings also identified group level differences among FSWs reporting different mobile phone solicitation strategies, including violence, client condom use and HIV status. Our results indicate that low pay does moderate the association between mobile phone solicitation and condom practices, but only among a sub-set of low paid FSWs. These findings also demonstrate the utility of classification by different mobile phone solicitation strategies for accurate assessment of sexual risk among mobile phone soliciting FSWs. In turn, this paves the way for novel approaches to utilize mobile phones for FSW HIV prevention. We discuss one such example, a mobile phone-based rapid screening tool for acute HIV infection targeting Indian FSWs.

Induced abortion among Brazilian female sex workers: a qualitative study

Prostitutes are vulnerable to unplanned pregnancies and abortions. In Brazil, abortion is a crime and there is no data about unsafe abortions for this population. The study describes how prostitutes perform illegal abortions and the health consequences thereof. Semi-structured interviews with 39 prostitutes from three cities in Brazil with previous induced abortion experience were conducted. Sixty-six abortions, with between one and eight occurrences per woman, were recorded. The majority of the cases resulted from sexual activity with clients. The inconsistent use of condoms with regular clients and the consumption of alcohol during work were indicated as the main causes of unplanned pregnancies. The main method to perform abortion was the intravaginal and oral use of misoprostol, acquired in pharmacies or on the black market. Invasive measures were less frequently reported, however with more serious health complications. The fear of complaint to the police meant that most women do not inform the health team regarding induced abortion. The majority of prostitutes aborted with the use of illegally-acquired misoprostol, ending abortion in a public hospital with infection and hemorrhagic complications. The data indicate the need for a public policy focusing on the reproductive health of prostitutes.

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

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

What role does transactional sex play in the HIV/STI and reproductive health risk behaviour among high-tier entertainment centre workers in China?

China's rapid economic growth over the last three decades has led to increased population wealth and the proliferation of entertainment centres where people can conduct business, relax and meet new people. Little is known about the sexual risk behaviours of employees at high-tier entertainment centres. This paper addresses this gap in knowledge by comparing HIV risk perception and sexual and reproductive health behaviours among female and male employees at three high-tier entertainment centres in two cities in China, comparing those who report a history of transactional sex to those who do not. In both cities, participants who reported a history of transactional sex were more likely than those without a history of transactional sex to report multiple sexual partnerships, more lifetime sexual partners, a history of sexually transmitted infections (STIs), having anal sex and/or recent abortions, and were more likely to perceive themselves to be at risk for STIs/HIV. However, risk behaviour was also high among those with no history of transactional sex. These findings highlight the need for targeted sexual and reproductive health initiatives for employees in these work settings.

Quantitative, Qualitative and Geospatial Methods to Characterize HIV Risk Environments

Increasingly, ‘place’, including physical and geographical characteristics as well as social meanings, is recognized as an important factor driving individual and community health risks. This is especially true among marginalized populations in low and middle income countries (LMIC), whose environments may also be more difficult to study using traditional methods. In the NIH-funded longitudinal study Mapa de Salud, we employed a novel approach to exploring the risk environment of female sex workers (FSWs) in two Mexico/U.S. border cities, Tijuana and Ciudad Juárez. In this paper we describe the development, implementation, and feasibility of a mix of quantitative and qualitative tools used to capture the HIV risk environments of FSWs in an LMIC setting. The methods were: 1) Participatory mapping; 2) Quantitative interviews; 3) Sex work venue field observation; 4) Time-location-activity diaries; 5) In-depth interviews about daily activity spaces. We found that the mixed-methodology outlined was both feasible to implement and acceptable to participants. These methods can generate geospatial data to assess the role of the environment on drug and sexual risk behaviors among high risk populations. Additionally, the adaptation of existing methods for marginalized populations in resource constrained contexts provides new opportunities for informing public health interventions.

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.

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

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

Systematic review of interventions to reduce illicit drug use in female drug-dependent street sex workers

OBJECTIVES

Most female street-based sex workers (SSWs) are drug users and this group experience particularly poor outcomes in achieving and maintaining abstinence. In 2010 the UK adopted a recovery-orientated Drug Strategy. This strategy did not specifically highlight the complex drug treatment needs of SSWs. Therefore we sought to synthesise and critically appraise existing evidence of interventions to reduce illicit drug use in this group, in order to guide service change toward better provision for the drug treatment needs of SSWs.

METHODS

A systematic review of evidence on the effectiveness of interventions to reduce illicit drug use in female SSWs. Following the PRISMA guidelines, a structured search strategy was used. Searches included databases, organisational and government websites to identify published and grey literature, as well as contacting experts in the field, and hand-searching reference lists and journals.

RESULTS

Six studies, one experimental and five observational, were identified which met review inclusion criteria. Intervention approaches evaluated included substitute prescribing, educational sessions and motivational interviewing. All studies reported a positive intervention effect but the five observational studies were all subject to a relatively high risk of bias. By contrast, the experimental study provided little or no evidence of positive effect (OR for reduction of illicit drug in intervention compared to controls 1.17 95%CI 0.84-1.66 at 3 months and 1.14 (95% CI 0.8 to 1.61) at 6 months follow-up). All six studies described challenges and solutions to study recruitment, retention and follow-up, which were influenced by issues affecting SSWs' health and social stability.

CONCLUSIONS

There is currently no strong evidence for effectiveness of interventions to reduce illicit drug use in female SSWs with problematic drug use. Thus, the development and robust evaluation of effective interventions should be a priority if recovery-orientated goals are to become more achievable for this group.

Prevalence and Correlates of Hazardous Drinking among Female Sex Workers in 13 Mexican Cities

AIMS

To describe the prevalence and correlates of hazardous drinking among female sex workers (FSWs) at 13 sites throughout Mexico.

METHODS

FSWs (N = 1089) who were enrolled in a brief sexual risk reduction intervention (Mujer Segura) were queried about their sexual risk and substance use practices and their work contexts. Participants were classified as hazardous or non-hazardous drinkers based on the Alcohol Use Disorders test (AUDIT-C). Logistic regression models were used to examine individual, contextual, and community-level factors as correlates of hazardous drinking.

RESULTS

Ninety-two percent of participants reported alcohol consumption in the past month. Among drinkers (N = 1001), 83% met AUDIT-C criteria for hazardous drinking. Factors that were independently associated with hazardous drinking included: drug use in the past month (adjusted odds ratio (AOR) = 3.31; 95% CI 1.29-8.45), being a cigarette smoker (AOR = 1.71; 95% CI 1.13-2.58), being a barmaid or dance hostess (AOR = 3.40; 95% CI 1.95-5.91), alcohol use before or during sex with clients (AOR = 7.78; 95% CI 4.84-12.52), and working in a city with a higher marginalization index (AOR = 1.07; 95% CI 1.04-1.11).

CONCLUSIONS

Findings support the high prioritization by public health authorities of alcohol prevention and treatment programs for FSWs.

Contextual influence on condom use in commercial sex venues: A multi-level analysis among female sex workers and gatekeepers in Guangxi, China

This study aims to assess the influence of commercial sex venues on consistent condom use among female sex workers (FSWs) and to examine associations between individual and venue level factors and consistent condom use with clients. Analysis was based on a sample of 637 FSWs and 123 gatekeepers from 51 venues in Guangxi, China. Multi-level logistic regression using Bayesian simulation via Markov Chain Monte Carlo was applied to investigate whether FSWs' individual propensity to use condom with clients was statistically dependent on the venue of working. Multi-level modeling revealed considerable variability across venues in the likelihood of consistent condom use with clients among FSWs. Characteristics at both individual and venue levels helped to explain the observed variation. Certain venue-level factors exerted their influence on condom use over and above the effect of individual-level characteristics. The contextual influence exerted on condom use behaviors among FSWs may imply a potential to harness the path to individual behaviors from a higher and more dominant level, and shed light on the design of more effective sexual risk reduction intervention among venue-based FSWs.

Structural vulnerabilities to HIV/STI risk among female exotic dancers in Baltimore, Maryland

Female exotic dancers (FEDs) are an important, yet understudied group of women who may engage in drug- and sex-related HIV/STI risk behaviors through their work. The study objective was to identify co-occurring indicators of vulnerability (e.g., housing, income, incarceration) associated with HIV/STI risk behavior among FEDs in Baltimore, Maryland. Surveys administered during July 2008-February 2009 captured socio-demographic characteristics, drug use, and sexual practices among dancers (N = 101) aged ≥18 years. Multivariate logistic regression was used to assess the relationship between vulnerability and risk behavior. Dancers with a high vulnerability score (i.e., 2 or more indicators) were more likely to report sex exchange (AOR: 10.7, 95% CIs: 2.9, 39.9) and multiple sex partnerships (AOR: 6.4, 95% CIs: 2.3, 18.3), controlling for demographics and drug use, compared to their less vulnerable counterparts. Findings point to primacy of macro-level factors that need to be addressed in HIV/STI prevention efforts targeting this and other high-risk populations.

Mobile phones and sex work in South India: the emerging role of mobile phones in condom use by female sex workers in two Indian states

The aim of this study was to examine female sex workers' solicitation of clients using mobile phones and the association between this and condom use with clients. Cross-sectional data were utilised to address the study's aim, drawing on data collected from female sex workers in Calicut, Kerala, and Chirala, Andhra Pradesh. Use of mobile phone solicitation was reported by 46.3% (n = 255) of Kerala participants and 78.7% (n = 464) of those in Andhra Pradesh. Kerala participants reporting exclusive solicitation using mobile phones demonstrated 1.67 times higher odds (95% CI: 1.01-2.79) of inconsistent condom use than those reporting non-use of mobile phones for solicitation. However, those reporting exclusive solicitation through mobile phones in Andhra Pradesh reported lower odds of inconsistent condom use (OR: 0.03; 95% CI: 0.01-0.26) than those not using mobile phones for solicitation. Findings indicate that solicitation of clients using mobile phones facilitates or hampers consistency in condom use with clients depending on the context, and how mobile phones are incorporated into solicitation practices. Variations in sex work environments, including economic dependence on sex work or lack thereof may partially account for the different effects found.

Hombre Seguro (Safe Men): a sexual risk reduction intervention for male clients of female sex workers

BACKGROUND

Male clients of female sex workers (FSWs) are at risk of HIV and other sexually transmitted infections (STIs). We conducted a two-arm randomized controlled trial to test the efficacy of a sexual risk reduction intervention for male clients of FSWs in Tijuana, Mexico.

METHODS/DESIGN

Male clients of FSWs who were at least 18, were HIV-negative at baseline, and reported recent unprotected sex with FSWs were randomized to the Hombre Seguro sexual risk reduction intervention, or a time-attention didactic control condition. Each condition lasted approximately one hour. Participants underwent interviewer-administered surveys and testing for HIV and other STIs at baseline, and at 4, 8, and 12 month follow-ups. Combined HIV/STI incidence and unprotected vaginal and anal sex acts with FSWs were the primary outcomes.

DISCUSSION

A total of 400 participants were randomized to one of the two conditions. Analyses indicated that randomization was successful; there were no significant differences between the participants in the two conditions at baseline. Average follow-up was 84% across both conditions. This is the first study to test the efficacy of a sexual risk reduction intervention for male clients of FSWs using the rigor of a randomized controlled trial.

TRIAL REGISTRATION

NCT01280838, Date of registration: January 19, 2011.