Widening the harm reduction agenda: From drug use to sex work

Molecular epidemiology of HIV-1 among adult female sex workers at the Guatemala-Mexico border

ABSTRACTSex workers have been demonstrated to have increased vulnerabilities to HIV and a high population prevalence of the disease. Despite their increased risk, sex workers have been underrepresented in molecular epidemiology studies assessing HIV in Mesoamerica. This study aims to describe the sociodemographic characteristics and phylogenetic profile of HIV-1 within a cohort of HIV-positive female sex workers (FSW) situated at the Guatemala-Mexico border. HIV viral sequences were collected from a cohort of FSW ≥18 years of age from San Marcos, Guatemala (n = 6) and compared to viral sequences collected as part of the Mesoamerican Drug Resistance Monitoring Programme to assess HIV viral diversity in Mexico and Guatemala (n = 3956). All of the FSW sampled were determined to have genetically unrelated HIV infections, suggesting multiple introductions of the virus and/or the potential existence of populations not captured by current surveillance efforts. Many reported numerous vulnerabilities that may have heightened their risk of acquiring and transmitting HIV through sex work activities. Our phylogenetic analysis indicated that national surveillance programmes may not fully capture the viral diversity among FSW and their clients within this region. Additional research is needed to fully capture HIV diversity and transmission in Mesoamerica, especially in the Guatemala-Mexico border region.

'People need to know we exist!': an exploratory study of the labour experiences of transmasculine and non-binary sex workers and implications for harm reduction

This article presents findings demonstrating that transmasculine and non-binary people work in sex industries worldwide. Informed by results from a qualitative study with transmasculine and non-binary sex workers, it provides much-needed demographic information about this population, their clients and workers' safety concerns. It explores the importance of using an intersectional framework and inclusive methods to gather demographic data regarding gender and sexuality in studies of sex work. Not only is an intersectional framework necessary for empirical studies of sex work, but it is also vital to developing successful harm reduction strategies. Using an intersectional frame in studies of sex work and harm reduction can provide much-needed insight into the development of inclusive services and programmes that help the most marginal. So long as researchers, social service agencies and health providers treat transmasculine and non-binary providers as non-existent, this reduces their ability to meet the needs of all sex workers.

Antecedents of Job Satisfaction for Migrant Chinese Sex Workers

This study is an empirical response to the scholarly debate regarding sex work and sex worker empowerment. It drew on job satisfaction literature to derive a theoretical model of pathways for job satisfaction in sex work. It tested this model with data from 96 migrant sex workers from China. It used Qualitative Comparative Analysis (QCA) to examine the conjunctive pathways among workers who reported that they were satisfied with their vocation. Of the 96 women interviewed, 12 experienced job satisfaction. QCA identified three antecedent conditions as necessary for producing job satisfaction and two additional conditions, either one of which was also necessary. Job satisfaction required: (1) full awareness of the nature of their work prior to starting, (2) perceived agency, and (3) enjoyment of earnings, beyond meeting survival needs. It also required at least one of two additional antecedents: perceiving workplace autonomy or having a favorable workplace environment. This study demonstrates that, while genuine job satisfaction may be relatively rare for sex workers, there are pathways that make it possible.

Staying safe: how young women who trade sex in Toronto navigate risk and harm reduction

Celling Sex was a community-based participatory research project that used a strengths-based approach to explore the agentic harm reduction practices employed by young women who trade sex and learn about their experience accessing health and social services. Fifteen racially diverse young women participated in interviews. They described how they tried to stay safe and advice for others. Each participant also individually made a brief digital video (cellphilm) to tell their story. Participants were invited to a private screening at which cellphilms were screened and common themes identified. The interviews and cellphilms were subsequently coded according to these themes. Participants identified a number of trading risks including: physical risks (unwanted pregnancy, STIs, and violence), social risks (racism and fetishisation), and mental health risks. To mitigate these concerns, participants detailed the harm reduction strategies they used which included use of technology, screening measures, boundary setting, and actively incorporating sexual health protections. Young women who trade sex are keenly aware of the risks inherent in transactional relationships and proactively negotiate and navigate harm reduction strategies in the context of deep systemic barriers. Further intervention may be necessary for them to actualise these strategies and access important forms of health and social support.

Co-occurring Threats to Agency Among Female Sex Workers in Baltimore, Maryland

Driven largely by the unequal distribution of power, female sex workers (FSW) globally bear a disproportionately high burden of HIV, sexually transmitted infections, and interpersonal violence. Prior literature has identified a number of multi-level factors that may serve to constrain FSWs' agency, or their ability to define and take action to realize goals. Among these are work-based violence and substance use, which are potentiated by the criminalization of sex work and structural vulnerability. Quantitative research related to U.S.-based FSWs' own sense of agency, as well as the barriers that may impede it, is sparse. We sought to identify patterns of various threats to agency and explore to what extent they were associated with perceived agency among a cohort of 381 FSW in Baltimore, Maryland, United States, using latent class analysis. Latent class indictors were past-six-month experience of client-perpetrated sexual violence, client-perpetrated physical violence, homelessness, food insecurity, arrest, daily crack-cocaine use, and daily heroin use. Perceived agency was measured using the short form of the Pearlin Mastery Scale. We identified three typologies of threatened agency among women in our sample: a "threatened by structural factors, drug use, and violence" class, a "threatened by structural factors and drug use" class, and a "less threatened" class. Mean perceived agency score was significantly lower for the class characterized by client-perpetrated violence than for either of the other classes. This suggests violence, in the context of deeper, structural power imbalances embedded in hunger, homelessness, and drug use, may dramatically reduce one's sense of agency and operate as a critical barrier to empowerment. Our study adds important insights to the broader FSW community empowerment literature and supports the need for interventions to bolster both individual and collective agency among U.S.-based FSW, including interventions to prevent sex work-related violence.

Structural, everyday, and symbolic violence and the heightened vulnerability to HIV of women who use drugs in Tanzania

Women who use drugs shoulder a disproportionate burden of the HIV epidemic in Tanzania. The mechanisms through which violence contributes to their excessively high rates of HIV have not been explored. In this paper, we use concepts of everyday, symbolic, and structural violence to critically examine the relationship between violence and heightened HIV vulnerability of women who use drugs in Dar es Salaam, Tanzania. We conducted cross-sectional surveys with 200 women who use drugs and follow-up, in-depth interviews with 30 survey participants who identified as living with HIV between November 2018 and March 2019. We drew from grounded theory methods to analyze qualitative data and complemented qualitative findings with survey results. Structural violence perpetuated constraints on women's economic opportunities and reduced their agency in sexual encounters manifesting in their disproportionately high rates of HIV. Nearly all women in our study engaged in sex work to meet basic needs and to support their drug use. Their involvement in overlapping drug use and sex work scenes exposed them to physical and sexual violence. Despite the pervasiveness of structural and everyday violence, some women reenacted agency by adopting strategies to maintain control and safety, and to exercise harm reduction. A multi-pronged, structural harm reduction strategy is critical to reducing violence experienced by women who use drugs and their ability to protect themselves from HIV.

Police Enforcement of Sex Work Criminalization Laws in an "End Demand" City: The Persistence of Quality-of-Life Policing and Seller Arrests

The purported goals of commercial sex work criminalization policies in the United States have shifted over the past two decades as local jurisdictions have adopted End Demand reforms. These reforms aim to refocus arrest from individuals who sell sexual services to buyers and facilitators, representing a departure from the quality-of-life, nuisance-focused approach of the late twentieth century. This article presents a case study examining enforcement of commercial sex laws in Chicago, a city that has been heralded as a leader in End Demand reforms. Our case study utilized annualized arrest statistics from 1998 to 2017 and individual arrest reports (n = 575) from 2015 to 2017. Commercial sex arrests by the Chicago Police Department have declined substantially over the past two decades, falling 98.4% from its peak. However, our analysis suggests that sellers of sexual services continue to face the heaviest burden of arrest (80.5%) and officers generally continue to approach commercial sex as a quality-of-life issue. We argue that this divergence between the goals and implementation of End Demand are the result of three institutional factors: street-level bureaucracy, logics of spatial governmentality, and participatory security. Our results suggest that the ideals of End Demand may be incompatible with the institutional realties of urban policing.

Labouring in the Sex Industry: A Conversation with Sex Workers on Consent and Exploitation

Sex work in all its forms is an occupation that belongs to the service industry, and like any other work, sexual labour is open to exploitation. However, the reason why sex work is seen to be different from other forms of labour is that it betrays the socially accepted rules of love and intimacy and is exercised within a criminalised environment. As a cultural symbol, sex work remains steadfastly linked to aberration and dangerousness. This article juxtaposes the legal and lay definitions of consent and exploitation based on conversations with fourteen Canadian sex workers. The objective of this exploratory article is to delve within two ill-defined and highly contested notions related to the sex industry—consent and exploitation.

Disagreement, Unenforceability, and Harm Reduction

Talk of harm reduction has expanded horizontally, to apply to an ever-widening range of policy domains, and vertically, becoming part of official legal and political discourse. This expansion calls for philosophical theorization. What is the best way in which to characterize harm reduction? Does it represent a distinctive ethical position? How is it best morally justified, and what are its moral limits? I distinguish two varieties of harm reduction. One of them, technocratic harm reduction, is premised on the fact of non-enforceability of prohibitionist policies. The second, deliberative harm reduction, is premised on the fact of reasonable disagreement, grounded in the fact that reasonable persons disagree about a range of controversial behaviours. I argue that deliberative harm reduction better accounts for some of harm reduction's most attractive features, and provides a plausible way of accounting for harm reductions's justificatory grounds and limits.

"An ethnographic exploration of factors that drive policing of street-based female sex workers in a U.S. setting - identifying opportunities for intervention"

Background

Building on a broader sociological discourse around policing approaches towards vulnerable populations, increasing public health and human rights evidence points to policing practices as a key health determinant, particularly among street-based sex workers. Despite the importance of policing as a structural health determinant, few studies have sought to understand the factors that underlie and shape harmful policing practices towards sex workers. This study therefore aimed to explore the drivers for policing attitudes and practices towards street-based cisgender female sex workers.

Methods

Drawing on ethnographic methods, 280 h of observations with police patrol and 10 stakeholder interviews with senior police leadership in Baltimore City, USA were carried out to better understand the drivers for policing strategies towards cisgender female sex workers. Analysis was data- and theory-driven, drawing on the concepts of police culture and complementary criminological and sociological literature that aided exploration of the influence of the ecological and structural environment on policing practices.

Results

Ecological factors at the structural (e.g., criminalization), organizational (e.g., violent crime control), community and individual level (e.g., stigmatizing attitudes) emerged as key to shaping individual police practices and attitudes towards cisgender female sex workers in this setting. Findings indicate senior police support for increased alignment with public health and human rights goals. However, the study highlights that interventions need to move beyond individual officer training and address the broader structural and organizational setting in which harmful police practices towards sex work operate.

Conclusions

A more in-depth understanding of the circumstances that drive law enforcement approaches to street-based sex work is critical to the collaborative design of interventions with police in different settings. In considering public health-police partnerships to address the rights and health of sex worker populations in the U.S. and elsewhere, this study supports existing calls for decriminalization of sex work, supported by institutional and policy reforms, neighborhood-level dialogues that shift the cultural landscape around sex work within both the police and larger community, and innovative individual-level police trainings.

Women in Sex Work and the Risk Environment: Agency, Risk Perception, and Management in the Sex Work Environments of Two Mexico-U.S. Border Cities

Sex work around the world takes place under conditions of structural violence and vulnerability. The México-U.S. border region is characterized by the presence of factors that increase the risk for health harms among female sex workers (FSW); located in this context, the risk environments of Tijuana and Ciudad Juárez have similar yet distinct characteristics that influence how risk is produced and experienced among FSWs. Exploring the ways in which FSWs enact agency in risk environments can illustrate how environmental characteristics shape perceived risks and the strategies that FSWs develop to manage them. This approach also identifies the limits that are placed by environmental characteristics over the capacity for harm reduction and prevention practices among FSWs. We analyzed the role of agency in the work environments of female sex workers and its relationship with risk perception and management in the cities of Tijuana and Cd. Juárez.

Drug use in street sex workers (DUSSK) study protocol: a feasibility and acceptability study of a complex intervention to reduce illicit drug use in drug-dependent female street sex workers

INTRODUCTION

Poor health of sex workers continues to be a source of international concern. Sex work is frequently linked with problematic drug use and drug-dependent sex workers typically work on the street, experiencing the greatest risks to health compared with the general population. Street sex workers (SSWs) are much more likely to have experienced incidences of physical and sexual assault, increasing their risk of developing post-traumatic stress disorder (PTSD). We have developed a novel complex intervention designed to reduce illicit drug use in drug-dependent female SSWs which involves: female SSW drug treatment groups (provided by a specialist charity) in a female SSW setting (female sex worker charity premises) provided by female-only staff, PTSD care with eye movement desensitisation and reprocessing (EMDR) therapy provided by female staff from National Health Service (NHS) mental health services.

METHODS AND ANALYSIS

A mixed methods study investigating the feasibility and acceptability of this intervention to inform the design of a future randomised controlled trial. The study aims to recruit up to 30 participants from November 2017 to March 2018 at a single site, with the intervention being delivered until December 2018. It will gather quantitative data using questionnaires and group attendance. Drug treatment group observations and in-depth interviews undertaken with up to 20 service users and 15 service providers to examine experiences and acceptability of the intervention. Study feasibility will be assessed by evaluating the recruitment and retention of participants to the intervention; the feasibility of NHS and third sector organisations working closely to coordinate care for a SSW population; the potential for specialist NHS mental health services to screen and provide EMDR therapy for drug-dependent SSWs and potential costs of implementing the intervention.

ETHICS AND DISSEMINATION

This study was approved by South West-Frenchay Research Ethics Committee (REC reference: 17/SW/0033; IRAS ID: 220631) and the Health Research Authority (HRA). Findings will be disseminated through research conferences and peer-reviewed journals.

“Bitch, You Got What You Deserved!”: Violation and Violence in Sex Buyer Reviews of Legal Brothels

In this article, we use feminist critical discourse analysis to examine online brothel reviews (148 reviews and 2,424 reply posts) of sex buyers in the context of debates surrounding harm minimization. Our findings show that sex buyers actively construct and normalize narratives of sexual violation and violence against women in licensed brothels through their language, referencing objectification, unsafe sex practices, and, in more extreme cases, rape to create a sense of community with other punters. Through this analysis, we challenge existing assumptions about harm minimization in systems of prostitution, which are legalized or fully decriminalized.

Harm reduction principles for healthcare settings

BACKGROUND

Harm reduction refers to interventions aimed at reducing the negative effects of health behaviors without necessarily extinguishing the problematic health behaviors completely. The vast majority of the harm reduction literature focuses on the harms of drug use and on specific harm reduction strategies, such as syringe exchange, rather than on the harm reduction philosophy as a whole. Given that a harm reduction approach can address other risk behaviors that often occur alongside drug use and that harm reduction principles have been applied to harms such as sex work, eating disorders, and tobacco use, a natural evolution of the harm reduction philosophy is to extend it to other health risk behaviors and to a broader healthcare audience.

METHODS

Building on the extant literature, we used data from in-depth qualitative interviews with 23 patients and 17 staff members from an HIV clinic in the USA to describe harm reduction principles for use in healthcare settings.

RESULTS

We defined six principles of harm reduction and generalized them for use in healthcare settings with patients beyond those who use illicit substances. The principles include humanism, pragmatism, individualism, autonomy, incrementalism, and accountability without termination. For each of these principles, we present a definition, a description of how healthcare providers can deliver interventions informed by the principle, and examples of how each principle may be applied in the healthcare setting.

CONCLUSION

This paper is one of the firsts to provide a comprehensive set of principles for universal harm reduction as a conceptual approach for healthcare provision. Applying harm reduction principles in healthcare settings may improve clinical care outcomes given that the quality of the provider-patient relationship is known to impact health outcomes and treatment adherence. Harm reduction can be a universal precaution applied to all individuals regardless of their disclosure of negative health behaviors, given that health behaviors are not binary or linear but operate along a continuum based on a variety of individual and social determinants.

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.

The Impact of Sex Work on Women's Personal Romantic Relationships and the Mental Separation of Their Work and Personal Lives: A Mixed-Methods Study

BACKGROUND

Very limited research has been undertaken on sex workers' personal romantic relationships and the impact the nature of their work has on their relationships. This exploratory study aimed to explore the impact sex work has on women's personal romantic relationships and the use of mental separation as a coping mechanism to balance the two aspects of their lives.

METHODS

Fifty-five women working in the indoor sex industry in Melbourne, Australia, were recruited to complete a self-report questionnaire about various aspects of their work, including the impact of sex work on their personal relationships. Questionnaires were completed anonymously and included both closed and open-ended questions. A further six women were interviewed to 'member check' the accuracy of the questionnaire findings.

RESULTS

Most women (78%) reported that, overall, sex work affected their personal romantic relationships in predominantly negative ways, mainly relating to issues stemming from lying, trust, guilt and jealousy. A small number of women reported positive impacts from sex work including improved sexual self-esteem and confidence. Just under half of women were in a relationship at the time of the study and, of these, 51% reported their partner was aware of the nature of their work. Seventy-seven percent of single women chose to remain single due to the nature of their work. Many women used mental separation as a coping mechanism to manage the tensions between sex work and their personal relationships. Member checking validated the accuracy of the questionnaire data.

CONCLUSION

This exploratory study identified a number of ways in which sex work impacts negatively on women's personal romantic relationships. The findings of this study support the need for further studies to be undertaken to determine if the findings are reflected in a larger, more representative sample of Australian sex workers and should be considered in the context of any future intervention and support programs aimed at addressing the tensions sex workers experience between their work and personal relationships. Greater public awareness and education programs aimed at addressing the negative stigma associated with the sex industry may go some way towards easing the issues faced by women in their personal relationships.

Short-term cessation of sex work and injection drug use: evidence from a recurrent event survival analysis

OBJECTIVE

This study quantitatively examined the prevalence and correlates of short-term sex work cessation among female sex workers who inject drugs (FSW-IDUs) and determined whether injection drug use was independently associated with cessation.

METHODS

We used data from FSW-IDUs (n=467) enrolled into an intervention designed to increase condom use and decrease sharing of injection equipment but was not designed to promote sex work cessation. We applied a survival analysis that accounted for quit-re-entry patterns of sex work over 1-year stratified by city, Tijuana and Ciudad Juarez, Mexico.

RESULTS

Overall, 55% of participants stopped sex work at least once during follow-up. Controlling for other characteristics and intervention assignment, injection drug use was inversely associated with short-term sex work cessation in both cities. In Ciudad Juarez, women receiving drug treatment during follow-up had a 2-fold increase in the hazard of stopping sex work. In both cities, income from sources other than sex work, police interactions and healthcare access were independently and significantly associated with shorter-term cessation.

CONCLUSIONS

Short-term sex work cessation was significantly affected by injection drug use. Expanded drug treatment and counseling coupled with supportive services such as relapse prevention, job training, and provision of alternate employment opportunities may promote longer-term cessation among women motivated to leave the sex industry.

Streets, strolls and spots: sex work, drug use and social space in Detroit

BACKGROUND

In this paper, we explore social spaces related to street sex work and illicit drug use in Detroit. We consider these spaces as assemblages (Duff, 2011, 2013; Latour, 2005) that reflect the larger moral geography (Hubbard, 2012) of the city and fulfill specific functions in the daily lives of drug using sex workers.

METHODS

We draw on thirty-one in-depth qualitative interviews with former street sex workers who were recruited through a court-based treatment and recovery program, as well as ethnographic field notes from drug treatment and law enforcement settings.

RESULTS

Our interview findings reveal highly organized and routine activities that exist in a relatively stable, symbiotic relationship with law enforcement practices, employment and commuter patterns, and built environments. While the daily life of street sex work involves a good deal of individual agency in terms of moving between spaces and negotiating terms of exchange, daily trajectories were also circumscribed by economics, illicit substance use, and the objective risks of the street and the police.

CONCLUSION

We consider the implications of these results for future policy directed at harm reduction in the street setting.

Early sex work initiation independently elevates odds of HIV infection and police arrest among adult sex workers in a Canadian setting

OBJECTIVES

To explore factors associated with early sex work initiation and model the independent effect of early initiation on HIV infection and prostitution arrests among adult sex workers (SWs).

DESIGN

Baseline data (2010-2011) were drawn from a cohort of SWs who exchanged sex for money within the last month and were recruited through time location sampling in Vancouver, Canada. Analyses were restricted to adults ≥18 years old.

METHODS

SWs completed a questionnaire and HIV/sexually transmitted infection testing. Using multivariate logistic regression, we identified associations with early sex work initiation (<18 years old) and constructed confounder models examining the independent effect of early initiation on HIV and prostitution arrests among adult SWs.

RESULTS

Of 508 SWs, 193 (38.0%) reported early sex work initiation, with 78.53% primarily street-involved SWs and 21.46% off-street SWs. HIV prevalence was 11.22%, which was 19.69% among early initiates. Early initiates were more likely to be Canadian born [adjusted odds ratio (AOR): 6.8, 95% confidence interval (CI): 2.42 to 19.02], inject drugs (AOR: 1.6, 95% CI: 1.0 to 2.5), and to have worked for a manager (AOR: 2.22, 95% CI: 1.3 to 3.6) or been coerced into sex work (AOR: 2.3, 95% CI: 1.14 to 4.44). Early initiation retained an independent effect on increased risk of HIV infection (AOR: 2.5, 95% CI: 1.3 to 3.2) and prostitution arrests (AOR: 2.0, 95% CI: 1.3 to 3.2).

CONCLUSIONS

Adolescent sex work initiation is concentrated among marginalized, drug, and street-involved SWs. Early initiation holds an independent increased effect on HIV infection and criminalization of adult SWs. Findings suggest the need for evidence-based approaches to reduce harm among adult and youth SWs.

Gender influences on initiation of injecting drug use

BACKGROUND AND OBJECTIVES

Gender differences in illicit drug use patterns and related harms (e.g. HIV infection) are becoming increasingly recognized. However, little research has examined gender differences in risk factors for initiation into injecting drug use. We undertook this study to examine the relationship between gender and risk of injection initiation among street-involved youth and to determine whether risk factors for initiation differed between genders.

METHODS

From September 2005 to November 2011, youth were enrolled into the At-Risk Youth Study, a cohort of street-involved youth aged 14-26 in Vancouver, Canada. Cox regression analyses were used to assess variables associated with injection initiation and stratified analyses considered risk factors for injection initiation among male and female participants separately.

RESULTS

Among 422 street-involved youth, 133 (32.5%) were female, and 77 individuals initiated injection over study follow-up. Although rates of injection initiation were similar between male and female youth (p = 0.531), stratified analyses demonstrated that, among male youth, risk factors for injection initiation included sex work (Adjusted Hazard Ratio [AHR] = 4.74, 95% Confidence Intervals [CI]: 1.45-15.5) and residence within the city's drug use epicenter (AHR = 1.95, 95% CI: 1.12-3.41), whereas among female youth, non-injection crystal methamphetamine use (AHR = 4.63, 95% CI: 1.89-11.35) was positively associated with subsequent injection initiation.

CONCLUSION

Although rates of initiation into injecting drug use were similar for male and female street youth, the risk factors for initiation were distinct. These findings suggest a possible benefit of uniquely tailoring prevention efforts to high-risk males and females.

Transgender women and the sex work industry: roots in systemic, institutional, and interpersonal discrimination

Because transgender people face discrimination on systemic, institutional, and interpersonal levels, the previous literature has supported that many transgender women view the sex work industry as their only viable career option. The current article reviews the literature on discrimination against transgender people, explores how discrimination influences their participation in sex work, and discusses how institutional discrimination against transgender women manifests within the criminal justice system. Furthermore, recommendations are provided for advocating for the rights of transgender people while promoting healthy behaviors and higher quality of life. Throughout the article, quotes from previous qualitative research are used to illustrate the experiences of transgender women through their own voices and perspectives.

Individual, interpersonal, and social-structural correlates of involuntary sex exchange among female sex workers in two Mexico-U.S. border cities

BACKGROUND

To investigate individual, interpersonal, and social-structural factors associated with involuntary sex exchange among female sex workers (FSWs) along the Mexico-U.S. border.

METHODS

In 2010 to 2011, 214 FSWs from Tijuana (n = 106) and Ciudad Juarez (n = 108) aged ≥ 18 years who reported lifetime use of heroin, cocaine, crack, or methamphetamine, having a stable partner, and having sold/traded sex in the past month completed quantitative surveys and HIV/sexually transmitted infection testing. Logistic regression was used to identify correlates of involuntary sex exchange among FSWs.

RESULTS

Of 214 FSWs, 31 (14.5%) reported involuntary sex exchange These women were younger at sex industry entry [adjusted odds ratio (AOR): 0.84/1-year increase, 95% confidence interval (CI): 0.72 to 0.97] and were significantly more likely to service clients whom they perceived to be HIV/sexually transmitted infection-infected (AOR: 12.41, 95% CI: 3.15 to 48.91). In addition, they were more likely to have clients who used drugs (AOR: 7.88, 95% CI: 1.52 to 41.00), report poor working conditions (AOR: 3.27, 95% CI: 1.03 to 10.31), and report a history of rape (AOR: 4.46, 95% CI: 1.43 to 13.91).

CONCLUSIONS

Involuntary sex exchange is disproportionate among FSWs who begin to exchange sex at a younger age, and these women experience elevated risk of violence and HIV/STIs related to their clients' behaviors and their working conditions. These data suggest the critical need for evidence-based approaches to preventing sexual exploitation of women and girls and to reducing harm among current sex workers. Multilevel interventions for all females who exchange sex and their clients that target interpersonal and social-structural risks (eg, measures to improve safety and reduce exploitation within the workplace) are needed.

The influence of having children on HIV-related risk behaviors of female sex workers and their intimate male partners in two Mexico-US border cities

Among female sex workers who use drugs, the experience of having children and its effect on HIV risk behaviors remains underexplored. We draw from a study of 214 female sex workers and their intimate non-commercial partners in Tijuana and Ciudad Juárez, México (n = 428), approximately 30% of whom have children living with them. During qualitative interviews with 41 of these couples, having children emerged as an important topic. Children influenced partners' lives and HIV-related risk behaviors in positive and negative ways. Couples perceived that children strengthened their relationships. Concern for children's well-being motivated couples to contemplate healthier lifestyle changes. However, childrearing costs motivated sex work and structural constraints prevented couples from enacting lifestyle changes. Case studies illustrate these themes and highlight implications for couple- and family-based harm reduction interventions. Specifically, our results suggest a need for economic alternatives to sex work while working with families to develop risk reduction skills.

Can't buy my love: a typology of female sex workers' commercial relationships in the Mexico-U.S. Border Region

Female sex workers (FSWs) experience elevated risk for HIV and sexually transmitted infections (STIs) through unprotected sex with male clients, yet the complexity of these commercial relationships remains understudied. From 2010 to 2011, we explored FSWs' conceptualizations of various client types and related risk behavior patterns using semistructured interviews with 46 FSWs in Tijuana and Ciudad Juarez, Mexico, where FSWs' HIV/STI prevalence is increasing. Our grounded theory analysis identified four types of commercial relationships: nonregular clients, regular clients and friends, clients who "fell in love" with FSWs, and long-term financial providers who often originated from the United States. As commercial relationships developed, clients' social and emotional connections to FSWs increased, rendering condom negotiation and maintaining professional boundaries more difficult. Drug abuse and poverty also influenced behaviors, particularly in Ciudad Juárez, where lucrative U.S. clients were increasingly scarce. While struggling to cultivate dependable relationships in a setting marked by historical sex tourism from a wealthier country, some FSWs ceased negotiating condom use. We discuss the need for HIV/STI research and prevention interventions to recognize the complexity within FSWs' commercial relationships and how behaviors (e.g., condom use) evolve as relationships develop through processes that are influenced by local sociopolitical contexts and binational income inequality.

Acceptability of vaginal microbicides among female sex workers and their intimate male partners in two Mexico-US border cities: a mixed methods analysis

Female sex workers (FSWs) may benefit from pre-exposure prophylaxis (PrEP) including microbicides for HIV prevention. Since adherence is a key factor in PrEP efficacy, we explored microbicide acceptability and potential barriers to use within FSWs' intimate relationships in Tijuana and Ciudad Juárez, Mexico, where HIV prevalence is increasing. FSWs and their verified intimate (non-commercial) male partners completed quantitative and qualitative interviews from 2010 to 2012. Our complementary mixed methods design followed an iterative process to assess microbicide acceptability, explore related relationship dynamics and identify factors associated with concern about male partners' anger regarding microbicide use. Among 185 couples (n=370 individuals), interest in microbicides was high. In qualitative interviews with 28 couples, most participants were enthusiastic about microbicides for sex work contexts but some explained that microbicides could imply mistrust/infidelity within their intimate relationships. In the overall sample, nearly one in six participants (16%) worried that male partners would become angry about microbicides, which was associated with higher self-esteem among FSWs and lower self-esteem and past year conflicts causing injury within relationships among men. HIV prevention interventions should consider intimate relationship dynamics posing potential barriers to PrEP acceptability and adherence, involve male partners and promote risk communication skills.

Reducing harm from HIV/AIDS misconceptions among female sex workers in Tijuana and Ciudad Juarez, Mexico: A cross sectional analysis

Background

HIV prevalence is increasing among female sex workers (FSWs) in Mexico’s Northern border region, who experience multiple occupational risks. Improving vulnerable populations’ education, empowerment, and access to preventive services are important components of harm reduction strategies. Given the increasing interest in adapting harm reduction principles from drug use to sex work and other public health responses to the HIV epidemic, we used a sex work harm reduction framework to guide our investigation of FSWs’ HIV knowledge.

Methods

From 2004–2006, FSWs aged ≥18 years in Tijuana and Ciudad Juarez participated in a behavioral intervention study and completed structured interviews. Measures included HIV knowledge assessment and factors within each domain of our theoretical framework for sex work harms: (1) socio-demographic factors that may lead to sex work, (2) sex work characteristics and behaviors that may lead to harm, and (3) mutually reinforcing harms that lead to sex work and result from it (e.g., drug abuse). Negative binomial regression identified factors independently associated with suboptimal HIV knowledge (i.e., incorrect responses during the HIV knowledge assessment).

Results

Among 924 FSWs, the median proportion of incorrect responses was nearly one third (28% incorrect). Examination of item responses revealed misconceptions regarding specific transmission and prevention mechanisms, including prevention of mother to child transmission. Suboptimal HIV knowledge was independently associated with older age, lower education, living in Tijuana (vs. Ciudad Juarez), inconsistent condom use for vaginal sex with male clients, and lacking prior HIV testing.

Conclusions

Our application of a sex work harm reduction framework to the study of FSWs’ HIV knowledge is an important first step in enhancing HIV prevention efforts in Northern Mexican border cities. Our findings imply that interventions should identify and discredit local HIV misconceptions to improve knowledge of specific HIV transmission routes and self-protective strategies (e.g., condom negotiation). Interventions will require materials appropriate for women from diverse socio-economic backgrounds and may benefit from innovative harm reduction approaches such as peer education and outreach.

Sex, price and preferences: accounting for unsafe sexual practices in prostitution markets

Unsafe sexual practices are persistent in prostitution interactions: one in four contacts can be called unsafe. The determinants of this are still matter for debate. We account for the roles played by clients' preferences and the hypothetical price premium of unsafe sexual practices with the help of a large dataset of clients' self-reported commercial sexual transactions in Belgium and The Netherlands. Almost 25,000 reports were collected, representing the whole gamut of prostitution market segments. The first set of explanations consists of an analysis of the price-fixing elements of paid sex. With the help of the so-called hedonic pricing method we test for the existence of a price incentive for unsafe sex. In accordance with the results from studies in some prostitution markets in the developing world, the study replicates a significant wage penalty for condom use of an estimated 7.2 per cent, confirmed in both multilevel and fixed-effects regressions. The second part of the analysis reconstructs the demand side basis of this wage penalty: the consistent preference of clients of prostitution for unsafe sex. This study is the first to document empirically clients' preference for intercourse without a condom, with the help of a multilevel ordinal regression.

Study protocol for the recruitment of female sex workers and their non-commercial partners into couple-based HIV research

Background

Researchers are increasingly recognizing the importance of addressing sexual and drug-related HIV risk within the context of intimate relationships rather than solely focusing on individual behaviors. Practical and effective methods are needed to recruit, screen, and enroll the high risk and hard-to-reach couples who would most benefit from HIV interventions, such as drug-using female sex workers (FSWs) and their intimate, non-commercial partners. This paper outlines a bi-national, multidisciplinary effort to develop and implement a study protocol for research on the social context and epidemiology of HIV, sexually transmitted infections (STI), and high risk behaviors among FSWs and their non-commercial male partners in Tijuana and Ciudad Juarez, Mexico. We provide an overview of our study and specifically focus on the sampling, recruitment, screening, and successful enrollment of high risk couples into a public health study in this context.

Methods/Design

We used targeted and snowball sampling to recruit couples through the female partner first and administered a primary screener to check her initial eligibility. Willing and eligible females then invited their primary male partners for couple-based screening using a couple verification screening (CVS) instrument adapted from previous studies. The CVS rechecked eligibility and separately asked each partner the same questions about their relationship to "test" if the couple was legitimate. We adapted the original protocol to consider issues of gender and power within the local cultural and socioeconomic context and expanded the question pool to create multiple versions of the CVS that were randomly administered to potential couples to determine eligibility and facilitate study enrollment.

Discussion

The protocol successfully enrolled 214 high risk couples into a multi-site public health study. This work suggests the importance of collaborating to construct a study protocol, understanding the local population and context, and drawing on multiple sources of input to determine eligibility and verify the legitimacy of relationships. We provide a practical set of tools that other researchers should find helpful in the study of high risk couples in international settings, with particular relevance to studies of FSWs and their intimate partners.

The street cost of drugs and drug use patterns: relationships with sex work income in an urban Canadian setting

BACKGROUND

This study investigated the relationship between drug use and sex work patterns and sex work income earned among street-based female sex workers (FSWs) in Vancouver, Canada.

METHODS

We used data from a sample of 129 FSWs who used drugs in a prospective cohort (2007-2008), for a total of 210 observations. Bivariate and multivariable linear regression using generalized estimating equations was used to model the relationship between explanatory factors and sex work income. Sex work income was log-transformed to account for skewed data.

RESULTS

The median age of the sample at first visit was 37 years (interquartile range[IQR]: 30-43), with 46.5% identifying as Caucasian, 48.1% as Aboriginal and 5.4% as another visible minority. The median weekly sex work income and amount spent on drugs was $300 (IQR=$100-$560) and $400 (IQR=$150-$780), respectively. In multivariable analysis, for a 10% increase in money spent on drugs, sex work income increased by 1.9% (coeff: 0.20, 95% CIs: 0.04-0.36). FSWs who injected heroin, FSWs with higher numbers of clients and youth compared to older women (<25 versus 25+ years) also had significantly higher sex work income.

CONCLUSIONS

This study highlights the important role that drug use plays in contributing to increased dependency on sex work for income among street-based FSWs in an urban Canadian setting, including a positive dose-response relationship between money spent on drugs and sex work income. These findings indicate a crucial need to scale up access and availability of evidence-based harm reduction and treatment approaches, including policy reforms, improved social support and economic choice for vulnerable women.

Amphetamine-type stimulant use and HIV/STI risk behaviour among young female sex workers in Phnom Penh, Cambodia

BACKGROUND

Use of amphetamine-type substances (ATS) has been linked to increased risk of HIV and other sexually transmitted infections (STI) worldwide. In Cambodia, recent ATS use is independently associated with incident STI infection among young female sex workers (FSWs).

METHODS

We conducted 33 in-depth interviews with women (15-29 years old) engaged in sex work to explore ATS use and vulnerability to HIV/STI.

RESULTS

Participants reported that ATS, primarily methamphetamine in pill and crystalline forms (yama), were cheap, widely available and commonly used. Yama was described as a "power drug" (thnam kamlang) which enabled women to work long hours and serve more customers. Use of ATS by clients was also common, with some providing drugs for women and/or encouraging their use, often resulting in prolonged sexual activity. Requests for unprotected sex were also more common among alternatives intoxicated clients and strategies typically employed to negotiate condom use were less effective.

CONCLUSION

ATS use was highly functional for young women engaged in sex work, facilitating a sense of power and agency and highlighting the occupational significance and normalization of ATS in this setting. This highly gendered dynamic supports the limited but emerging literature on women's use of ATS, which to date has been heavily focused on men. Results indicate an urgent need to increase awareness of the risks associated with ATS use, to provide women with sustainable alternatives for income generation, to better regulate the conditions of sex work, and to work with FSWs and their clients to develop and promote culturally appropriate harm reduction interventions.

Stigma and sex work from the perspective of female sex workers in Hong Kong

While the stigma surrounding sex work is both well documented and easily recognised, few studies examine stigma in this context from the perspective of the sex workers themselves. In this article we report on a study using a modified grounded theory approach to analyse a series of semi-structured interviews with 49 female sex workers in Hong Kong, in order to examine the ways in which this group experiences and negotiates the stigma which arises from their employment in the sex industry. Sex workers in Hong Kong were subject to various stigmatising forces in their daily lives in their interactions with the public, the police and their families. These processes could have a negative impact on the sex workers' health, both through obvious manifestations such as physical or verbal abuse and through more subtle processes such as those which generated or perpetuated vulnerability and those which compelled the sex workers to conceal their identities and withdraw themselves from social networks. These findings are situated in the context of broader research surrounding sex work, drawing attention to the consequences of stigma on health and their interaction with health-service providers, before briefly discussing possible means of overcoming stigma-related barriers to providing adequate healthcare for this marginalised group.

A peer-led mobile outreach program and increased utilization of detoxification and residential drug treatment among female sex workers who use drugs in a Canadian setting

BACKGROUND

The objectives of this study were to examine the determinants of using a peer-led mobile outreach program (the Mobile Access Project [MAP]) among a sample of street-based female sex workers (FSWs) who use drugs in an urban Canadian setting and evaluate the relationship between program exposure and utilizing addiction treatment services.

METHODS

A detailed questionnaire was administered at baseline and bi-annual follow-up visits over 18 months (2006-2008) to 242 FSWs in Vancouver, Canada. We used bivariate and multivariate logistic regression with generalized estimating equations for both objectives, reporting unadjusted and adjusted odds ratios (AOR) with 95% confidence intervals (CIs).

RESULTS

Over 18 months, 42.2% (202) reports of peer-led mobile outreach program use were made. High-risk women, including those servicing a higher weekly client volume (10+ compared to <10; AOR: 1.7, 95%CIs: 1.1-2.6) and those soliciting clients in deserted, isolated settings (AOR: 1.7, 95%CIs: 1.1-2.7) were more likely to use the program. In total, 9.4% (45) reports of using inpatient addiction treatment services were made (7.5% detoxification; 4.0% residential drug treatment), and 33.6% (161) using outpatient treatment (28.8% methadone; 9.6% alcohol/drug counsellor). Women who used the peer-led mobile outreach were more likely to use inpatient addiction treatment (AOR: 4.2, 95%CIs: 2.1-8.1), even after adjusting for drug use, environmental-structural factors, and outpatient drug treatment.

DISCUSSION

Our findings demonstrate that FSWs at higher risk for sexually transmitted infections and violence are more likely to access this peer-led mobile outreach program and suggest that the program plays a critical role in facilitating utilization of detoxification and residential drug treatment.

'They bring AIDS to us and say we give it to them': Socio-structural context of female sex workers' vulnerability to HIV infection in Ibadan, Nigeria

The aim of the study was to examine and describe the individual and structural-environmental factors that shape the vulnerability of brothel-based female sex workers (FSWs) in Ibadan, southwest Nigeria to HIV infection. A descriptive qualitative research design was utilised to elicit data, using in-depth interviews and focus group discussions, from 60 randomly selected participants in four brothels. A thematic analysis of data was undertaken following transcription and validation of interviews. Five themes emerged from the data: (i) flawed knowledge and fatalistic attitudes; (ii) the psychosocial and economic context of sex work; (iii) religious beliefs, stigma and risk taking; (iv) barriers to HIV testing; and (v) legal and policy constraints to sex work. We describe the complex interaction between these themes and how they combine to increase the risk of HIV infection among FSWs. The impact of previous interventions to reduce the risk of HIV infection among FSWs has been limited by personal and structural factors; hence we recommend that new strategies that recognise the practical constraints to HIV prevention among FSWs are urgently needed to make the environment of commercial work safer for FSWs, their clients, and by extension the general population.

The Role of Youth Problem Behaviors in the Path From Child Abuse and Neglect to Prostitution: A Prospective Examination

Behaviors beginning in childhood or adolescence may mediate the relationship between childhood maltreatment and involvement in prostitution. This paper examines five potential mediators: early sexual initiation, running away, juvenile crime, school problems, and early drug use. Using a prospective cohort design, abused and neglected children (ages 0-11) with cases processed during 1967-1971 were matched with non-abused, non-neglected children and followed into young adulthood. Data are from in-person interviews at approximate age 29 and arrest records through 1994. Structural Equation Modeling tested path models. Results indicated that victims of child abuse and neglect were at increased risk for all problem behaviors, except drug use. In the full model, only early sexual initiation remained significant as a mediator in the pathway from child abuse and neglect to prostitution. Findings were generally consistent for physical and sexual abuse and neglect. These findings suggest that interventions to reduce problem behaviors among maltreated children may also reduce their risk for prostitution later in life.

Rapid assessment of HIV risk behavior in drug using sex workers in three cities in South Africa

A rapid assessment was undertaken with drug using commercial sex workers (CSWs) to investigate practices putting them at risk for contracting HIV. It included key informant (KI) (N = 67) and focus group (N = 10) interviews in locations with a high prevalence of drug use in Cape Town, Durban and Pretoria, South Africa. HIV testing of KIs was conducted. Cocaine, Ecstasy, heroin and methaqualone are used by CSWs prior to, during and after sex. Drugs enhance the sexual experience and prolong sex sessions. Interviews revealed inconsistent condom use among CSWs together with other risky sexual practices such as needle sharing. Among CSWs who agreed to HIV testing, 34% tested positive. Barriers to accessing drug treatment and HIV treatment and preventive services were identified. Interventions recognizing the role of drug abuse in HIV transmission should be prioritized, and issues of access to services, stigma and power relations must be considered.

Injection drug use among street-involved youth in a Canadian setting

Background

Street-involved youth contend with an array of health and social challenges, including elevated rates of blood-borne infections and mortality. In addition, there has been growing concern regarding high-risk drug use among street-involved youth, in particular injection drug use. We undertook this study to examine the prevalence of injection drug use and associated risks among street-involved youth in Vancouver, Canada.

Methods

From September 2005 to November 2007, baseline data were collected for the At-Risk Youth Study (ARYS), a prospective cohort of street-recruited youth aged 14 to 26 in Vancouver, Canada. Using multiple logistic regression, we compared youth with and without a history of injection.

Results

The sample included 560 youth among whom the median age was 21.9 years, 179 (32%) were female, and 230 (41.1%) reported prior injection drug use. Factors associated with injection drug use in multivariate analyses included age ≥ 22 years (adjusted odds ratio [AOR] = 1.18, 95% CI: 1.10–1.28); sex work involvement (AOR = 2.17, 95% CI: 1.35–3.50); non-fatal overdose (AOR = 2.10, 95% CI: 1.38–3.20); and hepatitis C (HCV) infection (AOR = 22.61, 95% CI: 7.78–65.70).

Conclusion

These findings highlight an alarmingly high prevalence of injection drug use among street-involved youth and demonstrate its association with an array of risks and harms, including sex work involvement, overdose, and HCV infection. These findings point to the need for a broad set of policies and interventions to prevent the initiation of injection drug use and address the risks faced by street-involved youth who are actively injecting.

Structural and environmental barriers to condom use negotiation with clients among female sex workers: implications for HIV-prevention strategies and policy

OBJECTIVES

We investigated the relationship between environmental-structural factors and condom-use negotiation with clients among female sex workers.

METHODS

We used baseline data from a 2006 Vancouver, British Columbia, community-based cohort of female sex workers, to map the clustering of "hot spots" for being pressured into unprotected sexual intercourse by a client and assess sexual HIV risk. We used multivariate logistic modeling to estimate the relationship between environmental-structural factors and being pressured by a client into unprotected sexual intercourse.

RESULTS

In multivariate analyses, being pressured into having unprotected sexual intercourse was independently associated with having an individual zoning restriction (odds ratio [OR] = 3.39; 95% confidence interval [CI] = 1.00, 9.36), working away from main streets because of policing (OR = 3.01; 95% CI = 1.39, 7.44), borrowing a used crack pipe (OR = 2.51; 95% CI = 1.06, 2.49), client-perpetrated violence (OR = 2.08; 95% CI = 1.06, 4.49), and servicing clients in cars or in public spaces (OR = 2.00; 95% CI = 1.65, 5.73).

CONCLUSIONS

Given growing global concern surrounding the failings of prohibitive sex-work legislation on sex workers' health and safety, there is urgent need for environmental-structural HIV-prevention efforts that facilitate sex workers' ability to negotiate condom use in safer sex-work environments and criminalize abuse by clients and third parties.

Violence, dignity and HIV vulnerability: street sex work in Serbia

Sex work can be contextualized by violence, social and material inequality, and HIV vulnerability. We undertook a qualitative study to explore female and transvestite sex workers' accounts (n = 31) of HIV risk environment in Belgrade and Pancevo, Serbia. Violence emerged as a key theme. Accounts emphasise the ubiquity of multiple forms of everyday violence - physical, emotional, social - in street sex work scenes, linked to police as much as clients. We highlight the salience of emotions in sex work risk management, in which the preservation of dignity is of prime importance. Accounts draw upon narratives of hygiene and responsibility which, we argue, seek to resist portrayals, normative to this setting, of sex workers as contaminated and irresponsible. Findings highlight how the ubiquity of the risk of violence in street sex work scenes reflects institutionalised social inequalities and injustices. Sex workers are inevitably participant in the cycle of symbolic violence they seek to resist. The challenges for HIV prevention are therefore considerable, and require interventions which not only seek to foster safer micro-environments of sex work but structural changes in the welfare, criminal justice and other social institutions which reproduce the cycle of violence faced by sex workers day to day.

Intimate partner violence is as important as client violence in increasing street-based female sex workers' vulnerability to HIV in India

OBJECTIVES

There are no studies that examine street-based female sex workers' vulnerability to HIV from both clients and intimate partners. This study documents street-based female sex workers' experiences of client and intimate partners, examines the intersections of violence, alcohol use in condom use, and highlights survival strategies used to avert harm.

METHODS

Ethnographic data were collected from 49 female sex workers through focus group discussions and in-depth interviews.

RESULTS

Female sex workers experienced multifarious forms of severe client and intimate partner violence. Sexual coercion and forced group sex in the context of alcohol use posed formidable barriers for condom use negotiation. Further, traditional gender norms dictated women's inabilities to negotiate condom-use with intimate partners. However, there was evidence of adoption of successful survival strategies in the face of danger and women's positive evaluations of the benefits of sex work and their contributions to family well-being.

CONCLUSIONS

Harm reduction efforts with female sex workers need to account for their vulnerability to HIV from intimate partners in addition to clients. HIV prevention programmes need to include male clients in order to reduce harm among street-based female sex workers. There is an urgent need to build on sex workers' strengths and involve them in designing individual level, community, and structural interventions that could help in reducing women's vulnerability to intimate partner violence and HIV in India.

HIV, injecting drug use and harm reduction: a public health response

Injecting drug use is driving HIV epidemics in many countries around the world. There is evidence that such epidemics can be averted, halted and reversed if comprehensive HIV programmes targeting drug users are put into place. The term 'harm reduction' is used widely to describe the goals, policies and interventions of such programmes. However, despite its rapidly expanding use, the term has no universally accepted definition. This paper aims to describe the evolution and branding of the term 'harm reduction' and the adoption of the concept across a wide range of countries. It highlights a range of issues that remain controversial in the harm reduction discourse related to HIV and injecting drug use, including: the definition of 'harm reduction' and related terms; the scope of harm reduction; the promotion of a public health versus drug control dichotomy; the feasibility and appropriateness of harm reduction in low- and middle-income countries; and the strength of evidence on harm reduction interventions. The paper argues that harm reduction should be a core element of a public health response to HIV/AIDS where injecting drug use exists. The effectiveness of policies and programmes targeting drug users should be measured against public health outcomes. This requires the alignment of drug control measures with public health goals. A 'model package' for harm reduction is proposed, which provides guidance to countries on the selection of evidence-based policies and interventions, including: interventions for reducing HIV transmission; treatment of HIV/AIDS and associated comorbidities; appropriate models of service delivery; creation of supportive policy, legal and social environments; and strengthening of strategic information systems to better guide responses.