Human rights violations against sex workers: burden and effect on HIV

Sexual violence affecting female sex workers in Côte d'Ivoire: prevalence, context, and associated mental health and substance use outcomes

BACKGROUND

Female sex workers are disproportionately affected by sexual violence, which is associated with an increased risk of poor mental health outcomes, substance use, and decreased access to health resources. Understanding the pathways through which sexual violence impacts these outcomes can inform strategies that appropriately and effectively meet the health needs of sex workers.

METHODS

This study investigated the prevalence of sexual violence among female sex workers in Côte d'Ivoire, and the relationship between sexual violence and adverse mental health and substance use outcomes. We examined survey data from female sex workers recruited between November 2019 and May 2020 across five regions of Côte d'Ivoire using respondent driven sampling (RDS), as part of an integrated bio-behavioral survey. The primary exposure of interest was self-reported lifetime experience of sexual violence, and the main outcomes of interest included depression, suicidal ideation, counselling seeking, alcohol consumption, and substance use. Multivariable logistic regression models investigated associations between exposure to sexual violence and the key mental health and substance use outcomes of interest. For each outcome, a directed acyclic graph was developed to identify a minimally sufficient set of covariates for adjustment. Additional sociodemographic characteristics, experiences, and sex work-related behaviors were explored in descriptive analyses using crude and RDS adjusted estimates.

RESULTS

Out of 1,177 participants, 376 (31.9%; RDS weighted: 30.5%; 95% CI: 24.7, 36.3) reported having experienced sexual violence in their lifetime, and of those 31.9% (RDS weighted: 31.2%; 95% CI: 21.3, 41.1) had experienced sexual violence within the previous 12 months. Experience of sexual violence was associated with an increased odds of suicidal ideation (aOR: 1.95; 95% CI: 1.48, 2.55), illicit drug use in the last 12 months (aOR: 2.40; 95% CI: 1.50, 3.86), daily alcohol use (aOR: 1.63; 95% CI: 0.99, 2.67), and having spoken to a counselor or confidant (aOR: 1.90; 95% CI: 1.34, 2.68).

CONCLUSION

Findings confirm a high burden of sexual violence among female sex workers in Côte d'Ivoire, and a need to implement large structural changes that enable female sex workers to seek protection as well as health resources after experiencing sexual violence. This may include reform in the form of targeted social, clinical and mental health resources, along with community development opportunities.

Exploratory analysis of the potential impact of violence on HIV among female sex workers in Mombasa, Kenya: a mathematical modelling study

BACKGROUND

Understanding the frequency of violence experienced by female sex workers (FSWs) and how violence contributes to HIV transmission can help improve HIV programs.

METHODS

Using recent recommendations for modelling structural factors and associated causal pathways, we developed a HIV transmission dynamic model for FSWs and their clients in Mombasa, Kenya, mechanistically representing three types of violence (sexual violence, SV; physical violence, PV; police assault and arrest, PAA). Each type of violence affects HIV transmission through key mediators (condom non-use, HIV testing). We parameterized the model using data from a cross-sectional study of FSWs aged 15-24 recruited from a systematic geographical mapping sampling frame in Mombasa, Kenya (Cheuk E et al., Frontiers in Reproductive Health 2(7), 2020). Using this model, calibrated (and cross-validated) to HIV epidemiological and violence outcomes, we estimated the incidence of violence episodes, the contribution of violence to the HIV epidemic measured by the transmission population-attributable fraction, and the potential impact of possible violence interventions.

RESULTS

The median estimated incidence of PAA in 2023 among FSWs who had not previously experienced that type of violence was 0.20 (95% credible interval: 0.17-0.22) per person-year (ppy), about double the incidence of SV and PV (0.10 (0.09-0.11), 0.11 (0.09-0.12), respectively). The incidence of violence was higher among FSWs who had previously experienced violence: the incidence of recurrent PV was 2.65 (1.82-3.37) ppy, while the incidence of recurrent SV and PAA were 1.26 (0.80-1.67) and 1.37 (0.94-1.74 ppy, respectively. In this setting, we estimated that a median of 35.3% (3.4-55.8%) infections in FSWs and clients combined over the next 10 years may be due to all types of violence (and mediators), mainly through reduced condom use in FSWs who have ever experienced SV (34.6% (2.4-55.5%)). Interventions that prevent future violence without mitigating the effects of past violence may only prevent 8.8% (0.8-14.0%) infections over 10 years.

CONCLUSIONS

FSWs in Mombasa experience violence frequently. In this population, we find that addressing sexual violence, including mitigating the effects of past violence, is potentially important in reducing HIV transmission in this population. However, the wide uncertainty range shows longitudinal studies are needed to strengthen the evidence of the influence of violence on HIV risk behavior. We find that the recommendations for modelling structural factors provide a useful framework for describing the model.

Violence Victimization and Alcohol Use Among Venue-Based Female Sex Workers in Pattaya, Thailand: Unpacking the Temporal Relationship

Female sex workers (FSWs) face prevalent violence victimization and alcohol consumption at work, yet the bidirectional pathways between these factors are not well defined. Using cohort data from 232 venue-based FSWs in Pattaya, associations of violence and alcohol use were examined within a time period and prospectively via structural equation models. Within the time period, violence victimization and alcohol use were consistently associated; by contrast, violence was not prospectively associated with FSW alcohol use. Findings define alcohol as an important risk factor for violence in sex work environments. Alcohol safety interventions should be explored as a vital component of FSW violence prevention.

Association between sex work occupational stigma and inconsistent condom use: findings from a community-based cohort of women sex workers in Vancouver, Canada (2014-2022)

BACKGROUND

Women sex workers face substantial health inequities due to structural barriers including criminalisation and stigma. Stigma has been associated with HIV-related inequities among marginalised populations, however, we know less about the impacts of sex work-specific occupational stigma on HIV/sexually transmitted infection (STI) risk among women sex workers. Given these research gaps and the disproportionate burden of stigma faced by sex workers, we evaluated the association between sex work occupational stigma and recent inconsistent condom use with clients, over an 8-year period (2014-2022).

METHODS

Baseline and semiannual questionnaire data from a prospective, community-based cohort of sex workers in Vancouver, Canada from September 2014 to February 2022 were used. We employed complete-case bivariate and multivariate logistic regression analysis using generalised estimating equations to analyse the relationship between sex work occupational stigma and inconsistent condom use for vaginal/anal sex with clients in the past 6 months.

RESULTS

Among 574 participants, the cumulative prevalence of inconsistent condom use by clients and sex work occupational stigma in the last 6 months was 32.1% (n=184) and 59.9% (n=344), respectively, over the 8-year period. In adjusted multivariable analysis, exposure to sex work occupational stigma was associated with almost twofold increased odds of recent inconsistent condom use with clients (adjusted OR 1.93, 95% CI 1.23 to 3.03) over the 8-year period.

CONCLUSION

Multilevel interventions addressing the role of occupational stigma are needed for HIV and STI prevention efforts, including scale-up of sex worker-led/delivered sexual health services and structural changes to decriminalise and destigmatise sex work.

Optimising the public health benefits of sex work regulation in Senegal: Results from qualitative interviews with policy stakeholders

CONTEXT

There is compelling evidence that eliminating sexually transmitted infections (STIs) among female sex workers (FSWs) is a cost-effective approach to reducing the spread of HIV/AIDS. Although many countries recognise sex work as a public health issue, few have implemented public health policies specifically aimed at controlling the transmission of HIV/AIDS among FSWs. In particular, Senegal stands out as the only African country to regulate sex work through a specific public health policy that requires FSWs to register with a health centre. Despite the potential health and legal benefits associated with registration, a staggering 80% of FSWs in Senegal remain unregistered. This low registration rate hinders the realisation of the policy's full potential for public health benefits. The reluctance of FSWs to register is due to inherent flaws in the policy design, where the disadvantages of registration outweigh the benefits for FSWs.

OBJECTIVE

To identify which modifications to the current registration policy have the potential to increase uptake of registration by FSWs and to assess their feasibility in the context of Senegal.

METHOD

We conducted a qualitative policy research study using semi-structured in-depth interviews with 22 national stakeholders in this policy, including representatives from the police, government and non-governmental organisations (NGOs) in Dakar, Senegal, as well as FSWs' leaders. The interview data were thematically coded using the interview topic guide and other recurring themes and analysed using thematic analysis on Nvivo 12.

RESULTS

A total of 20 relevant themes were selected, focusing primarily on assessing the feasibility of potential interventions and identifying potential barriers and associated risks. We found that, without changing current legislation, improving relationships between FSWs and police officers, providing accurate and accessible information about the rules and benefits of the policy, and offering psychosocial support have the potential to improve both the registration rate of FSWs and their wellbeing. Policy features designed to increase registration by improving FSWs' confidentiality, and thus their confidence in the services offered, were also discussed.

CONCLUSIONS

The study highlighted that several national public health policies could be changed to increase the registration rate of FSWs and improve their wellbeing without overturning constitutional law.

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

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

Factors associated with viral load testing and viral suppression among HIV-positive female sex workers in Nigeria

BACKGROUND

Female sex workers (FSWs) are at high risk for HIV infection and face unique barriers to receiving and adhering to testing and treatment. Early viral suppression and consistent viral load testing are critical to optimizing health and reducing transmission in this population. However, the factors associated with testing and successful viral suppression among FSWs are poorly understood, especially in Sub-Saharan Africa. Our study aimed to examine factors, including social, demographic, and clinical characteristics, associated with viral load testing and suppression among female sex workers initiating antiretroviral therapy in Nigeria.

METHODS

In this retrospective study, we analyzed routine programmatic data from FSWs enrolled in the National HIV Key Populations (KP) program in Nigeria. We included FSWs who were newly diagnosed with HIV and registered between January 2016 and January 2022. Primary outcomes of interest were a), receiving a viral load test at any point after treatment initiation and b), viral suppression (<1000 copies/ml) at the test closest to 6 months after treatment initiation. To identify factors associated with the outcomes of interest, we used univariable and multivariable logistic regression, with random intercepts for care facilities, and multiple imputation for missing values.

FINDINGS

Out of 34,976 FSWs, 97.1% (n = 33,945) received at least one viral load test, with 94.5% (n = 32,092) indicating viral suppression. The odds of receiving at least one viral load test were higher for those who entered treatment in more recent years, those with formal education and those with advanced HIV stages at baseline (adjusted odds ratios [aOR]: 1.17 [1.14-1.19] for those who entered treatment in 2020 vs. 2016; 1.02 [1.01-1.03] for post-secondary vs. no education; and 1.05 [1.01-1.10] for WHO clinical stage 3/4 vs. stage 1 respectively). The odds of successful viral suppression were higher for those who entered treatment in more recent years, but lower for those with advanced HIV stages at baseline (aOR: 1.13 [1.09-1.18] for 2022 vs. 2016; and 0.92 [0.87-0.98] for WHO clinical stage 3/4 vs. stage 1 respectively).

CONCLUSIONS

The study underscored the relevance of timely diagnosis and ART initiation for optimal outcomes among HIV-positive FSWs in Nigeria. We also observed significant improvements in the likelihood of early viral load testing and suppression over the study period, reflecting advancements in the KP program. Further research should clarify factors driving these trends to further strengthen the HIV care pipeline for female sex workers.

Esengo ya Bosembo ("Joy of Equity"): Development of an Advocacy Video to Reduce Stigma and to Promote Sexual and Reproductive Health and Rights of Women Sex Professionals in Pointe-Noire, Congo Republic

Sex workers experience elevated risks of sexual and gender-based violence (SGBV) from intimate partners, clients, and community members that harms health and human rights. While SGBV contributes to poorer sexual and reproductive health (SRH) outcomes among sex workers, including elevated human immunodeficiency virus (HIV) vulnerabilities, stigma targeting sex workers reduces SRH service access and uptake. The Congo Republic is an exemplar context to address stigma toward sex workers. Sex workers' HIV prevalence (8.1%) in Congo Republic is double the national prevalence, yet research indicates that nearly one-fifth (17.2%) of sex workers in Congo Republic avoid health care because of stigma and discrimination. This Resources, Frameworks, & Perspectives article describes the process of developing Esengo ya Bosembo ("Joy of Equity"), a culturally tailored advocacy video that aims to reduce health care and community stigma toward women sex professionals (e.g., sex workers) in Pointe-Noire, Congo Republic. This knowledge translation product stems from a participatory mapping intervention with sex professionals in Pointe-Noire that revealed the need for sensitization tools and activities to reduce sex work stigma among health care providers and community members. The video incorporates three overarching key messages: (1) sex professionals are human beings with equal rights to dignity, protection, and health services; (2) elevated risks of SGBV and stigma targeting sex workers reduce SRH service access and uptake; and (3) participatory mapping is a potential way to empower sex professionals to share their experiences and recommendations for change. This article details how health promotion practitioners and sex professionals may use the video to advocate for change.

'Change creates change' - older female sex workers' experiences through the early COVID-19 pandemic

COVID-19 and associated policy responses created unique social, economic and health risks for sex workers. Through semi-structured interviews we explored pre- and early COVID-19 experiences and work practices of ten cisgender female sex workers 50 years of age and older in Queensland, Australia, analysing the findings using a risk environment framework. Throughout early 2020, participants navigated a complex risk environment, managing economic needs, health and safety, occupational stigma and policing. Australia's policy responses altered the risks and opportunities available to participants. Half the participants continued sex work and half stopped sex work with some accessing economic support and withdrawing superannuation savings. Those who continued sex work drew on life and work experience to reassess changing health, stigma, and policing risks, and adapted their work strategies by increasing client screening and modifying services. Participants relied on information from peer networks and organisations to guide work practices but remained wary of contact tracing, police and the media. Decriminalisation of sex work and the strengthening of sex worker organisation and government partnerships are important in embedding equity in responses to ongoing and new public health threats.

Centering PrEP: utilizing ADAPT-ITT to inform group PrEP care for sex workers in Chicago

BACKGROUND

Sex workers, those who trade sex for monetary or nonmonetary items, experience high rates of HIV transmission but have not been adequately included in HIV prevention and Pre-Exposure Prophylaxis (PrEP) adherence program development research. Community-empowered (C.E.) approaches have been the most successful at reducing HIV transmission among sex workers. Centering Healthcare (Centering) is a C.E. model proven to improve health outcomes and reduce health disparities in other populations, such as pregnant women, people with diabetes, and sickle cell disease. However, no research exists to determine if Centering can be adapted to meet the unique HIV prevention needs of sex workers.

OBJECTIVE

We aim to explain the process by which we collaboratively and iteratively adapted Centering to meet the HIV prevention and PrEP retention needs of sex workers.

METHODS

We utilized the Assessment, Decision, Adaptation, Production, Topical Experts, Integration, Training, Testing (ADAPT-ITT) framework, a model for adapting evidence-based interventions. We applied phases one through six of the ADAPT-ITT framework (Assessment, Decision, Adaptation, Production, Topical Experts, Integration) to the design to address the distinct HIV prevention needs of sex workers in Chicago. Study outcomes corresponded to each phase of the ADAPT-ITT framework. Data used for adaptation emerged from collaborative stakeholder meetings, individual interviews (n = 36) and focus groups (n = 8) with current and former sex workers, and individual interviews with care providers (n = 8). In collaboration with our community advisory board, we used a collaborative and iterative analytical process to co-produce a culturally adapted 3-session facilitator's guide for the Centering Pre-exposure Prophylaxis (C-PrEP +) group healthcare model.

RESULTS

The ADAPT-ITT framework offered structure and facilitated this community-empowered innovative adaptation of Centering Healthcare. This process culminated with a facilitator's guide and associated materials ready for pilot testing.

CONCLUSIONS

In direct alignment with community empowerment, we followed the ADAPT-ITT framework, phases 1-6, to iteratively adapt Centering Healthcare to suit the stated HIV Prevention and PrEP care needs of sex workers in Chicago. The study represents the first time the first time Centering has been adapted to suit the HIV prevention and PrEP care needs of sex workers. Addressing a gap in HIV prevention care for sex workers, Centering PrEP harnesses the power of community as it is an iteratively adapted model that can be piloted and replicated regionally, nationally, and internationally.

The preventable burden of mortality from unsafe abortion among female sex workers: a Community Knowledge Approach survey among peer networks in eight countries

Previous studies have found high levels of unintended pregnancy among female sex workers (FSW), but less attention has been paid to their abortion practices and outcomes. This study is the first to investigate abortion-related mortality among FSW across eight countries: Angola, Brazil, Democratic Republic of Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa. The Community Knowledge Approach (CKA) was used to survey a convenience sample of FSW (n = 1280). Participants reported on the deaths of peer FSW in their social networks during group meetings convened by non-governmental organisations (n = 165 groups, conducted across 24 cities in 2019). Details on any peer FSW deaths in the preceding five years were recorded. The circumstances of abortion-related deaths are reported here. Of the 1320 maternal deaths reported, 750 (56.8%) were due to unsafe abortion. The number of abortion-related deaths reported was highest in DRC (304 deaths reported by 270 participants), Kenya (188 deaths reported by 175 participants), and Nigeria (216 deaths reported by 312 participants). Among the abortion-related deaths, mean gestational age was 4.6 months and 75% occurred outside hospital. Unsafe abortion methods varied by country, but consumption of traditional or unknown medicines was most common (37.9% and 29.9%, respectively). The 750 abortion-related deaths led to 1207 children being left motherless. The CKA successfully recorded a stigmatised practice among a marginalised population, identifying very high levels of abortion-related mortality. Urgent action is now needed to deliver comprehensive sexual and reproductive healthcare to this vulnerable population, including contraption, safe abortion, and post-abortion care.

Type of Exchange Sex and Associated Behaviors and Outcomes Among Cisgender Men and Women at Increased Risk for HIV via Heterosexual Transmission in Six U.S. Metropolitan Areas

Exchange sex is associated with sexual risk behaviors and poor outcomes and different types may incur different levels of risk. We assessed risk profiles of different types of exchange sex among non-injecting cisgender men and women who participated in the 2019 National HIV Behavioral Surveillance project at six sites. Six percent of men and 19% of women reported exchange sex in the past year; most engaged in non-commercial exchange sex for drugs/money with smaller percentages reporting formal sex work or non-commercial exchange sex for goods or services other than drugs/money. Exchange sex was associated with sexual risk and prevention behaviors and psychosocial and sexual health outcomes and associations varied by type of exchange sex. Efforts to improve access to STI/HIV testing and PrEP may benefit from tailoring based on type of exchange sex. Findings indicate value in a broader definition of exchange sex with follow-up assessment of exchange sex typology.

Human rights and HIV: rhetoric or determinants?

International donors and UN agencies emphasise the importance of human rights as a key determinant of HIV vulnerability and of access, uptake and retention in HIV prevention and treatment services. Yet, the extent to which HIV researchers are incorporating rights into their research, the specific rights being examined and the frequency of research assessing rights-based approaches, is unknown.

METHODS

We examined all articles published in the five highest impact-factor HIV journals: (1) Lancet HIV; (2) AIDS and Behavior; (3) AIDS; (4) Journal of the International AIDS Society (JIAS); and (5) Journal of Acquired Immune Deficiency Syndromes (JAIDS), between 1 January 2017 and 31 December 2022, for reference to 'human right(s)' or 'right(s)'. We analysed articles to assess: (1) what populations were identified in relation to specific human rights concerns; (2) what specific rights were mentioned; (3) whether researchers cited specific legal frameworks; and (4) if and what types of rights-based interventions were examined.

RESULTS

Overall, 2.8% (n=224) of the 8080 articles reviewed included a mention of 'human right(s)' or 'right(s)'. Forty-two per cent of these (n=94) were original research articles. The most common key population discussed was men who have sex with men (33 articles), followed by sex workers (21 articles) and transgender people (14 articles). Of the 94 articles, 11 mentioned the right to health and nine referenced reproductive rights. Few articles identified a specific authority-whether in national, regional or international law-for the basis of the rights cited. Fourteen articles discussed rights-based interventions.

CONCLUSION

Despite global recognition of the importance of human rights to HIV outcomes, few HIV researchers publishing in the top five cited HIV journals include attention to human rights, or rights-based interventions, in their research. When rights are mentioned, it is often without specificity or recognition of the legal basis for human rights.

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

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

Relationships Between Stigma and Intimate Partner Violence Among Female Sex Workers Living With HIV: Social and Economic Exclusion

Violence against female sex workers (FSWs) perpetrated by their intimate (i.e., non-commercial) partners, particularly against FSWs living with HIV, is understudied. Stigma can deplete the economic resources, social relationships, and mental well-being of stigmatized people, which may increase their intimate partner violence (IPV) risk. We quantitatively assessed relationships between HIV stigma and sex work stigma and IPV victimization among FSWs living with HIV in the Dominican Republic (n = 266). Enacted HIV stigma, in the form of job loss, and anticipated HIV stigma, in the form of fear of exclusion by family, were associated with increased IPV risk. Potential association mechanisms, including increased economic vulnerability and social isolation, and programmatic responses are discussed.

Association of gender-based violence with sexual and drug-related HIV risk among female sex workers who use drugs in Kazakhstan

BACKGROUND

Little is known about the prevalence of intimate partner violence (IPV) or client violence, and associated HIV risk among women who engage in sex work (WESW) and use drugs in Kazakhstan, despite a growing HIV epidemic.

METHODS

Women who reported engaging in sex work and using illicit drugs were recruited from Almaty and Temirtau, Kazakhstan between 2015 and 2017. A cross-sectional analysis was conducted to determine prevalence and correlates of physical and sexual violence perpetrated by intimate partners and clients. Associations between each type of violence with sexual and drug-related HIV risk behaviors were assessed with negative-binomial and logistic regression models, respectively.

RESULTS

Of the 400 women, 45% and 28% reported recent IPV and client violence, respectively. IPV and client violence was associated with a greater number of sex work clients [IPV: adjusted incidence rate ratio (aIRR)physical: 1.86, 1.28-2.71; aIRRsexual: 2.28, 1.56-3.35]; [client violence: aIRRphysical: 2.20, 1.44-3.42; aIRRsexual: 2.54, 1.72-3.83], and client violence was associated with greater frequency of condomless sex with clients [aIRRphysical: 2.33, 1.41-4.03; aIRRsexual: 2.16, 1.35-3.56]. Violence was not associated with injection drug use, despite exchanging sex for drugs being associated with higher odds of violence.

CONCLUSION

HIV prevention programs for WESW in Kazakhstan should consider multi-sectoral approaches that address economic hardship and relationship-based components, in addition to violence reduction.

Reforming the registration policy of female sex workers in Senegal? Evidence from a discrete choice experiment

Evidence suggests that treating sexually transmitted infections (STIs) amongst female sex workers (FSWs) is a cost-effective strategy to reduce the spread of HIV/AIDS. Senegal is the only African country where sex work is regulated by a public health policy which aims to monitor and routinely treat STIs. The law requires FSWs to be at least 21 years old, register with a health centre and the police, carry an up-to-date registration booklet, attend monthly health check-ups, and test negative for STIs. Despite health and legal benefits of registration, 80% of FSWs in Senegal are not registered. Hence, the potential health benefits of the policy have not materialised. To understand why FSWs do not want to register and to define policy changes that would increase the registration rate of FSWs in Senegal, we designed and implemented a discrete choice experiment (DCE) completed by 241 registered and 273 non-registered FSWs. Participants made choices between a series of hypothetical but realistic registration policy changes. Conditional logit models were used to analyse the DCE data. The results highlighted that confidentiality at the health facility was an important element, registered and non-registered FWs were respectively 26.0 percentage points (pp) and 22.1 pp more likely to prefer a policy that guaranteed confidentiality at the health centre. Similarly, both groups preferred a policy where their health record was only held at the health centre and not with the police. Several interventions to increase FSW registration rate and improve their wellbeing may be implemented without modifying the law. For example, the introduction of psychosocial support in the registration policy package, replacing the registration booklet by a QR code, the use of electronic medical files and the integration of FSWs routine visits with maternal health appointments to increase confidentiality have the potential to encourage registration of FSWs.

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.

HIV care continuum among cisgender and transgender women sex workers in Greater Kuala Lumpur, Malaysia

An estimated 37,000 cisgender and transgender women work as sex workers in Malaysia, a population that has been disproportionately affected by the HIV epidemic. Although Malaysia provides no-cost antiretroviral therapy (ART) to people with HIV, little is known about sex workers' engagement in the HIV care continuum. We analyzed data from 57 HIV-infected cisgender women (n = 33) and transgender women (n = 24) sex workers from a respondent-driven sampling study on HIV prevalence among sex workers in Kuala Lumpur, Malaysia. We examined the proportion of women who were newly diagnosed with HIV, had a baseline CD-4 count test, were initiated and retained on antiretroviral treatment (ART). Overall, only 26.3% had ever been HIV tested and almost 60% were newly diagnosed. Only a small proportion of cisgender (15.2%) and transgender (12.5%) women were currently taking ART. Interventions to enhance sex workers' engagement in the HIV care continuum are urgently needed. Deployment of evidence-based strategies to improve linkage and retention in HIV care should be adapted to address the unique needs of this important key population.

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

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

Housing Instability and Evictions Linked to Elevated Intimate Partner and Workplace Violence Among Women Sex Workers in Vancouver, Canada: Findings of a Prospective, Community-Based Cohort, 2010-2019

Objectives. To model the relationship of unstable housing and evictions with physical and sexual violence perpetrated against women sex workers in intimate and workplace settings. Methods. We used bivariate and multivariable logistic regression with generalized estimating equations to model the association of unstable housing exposure and evictions with intimate partner violence (IPV) and workplace violence among a community-based longitudinal cohort of cisgender and transgender women sex workers in Vancouver, Canada, from 2010 through 2019. Results. Of 946 women, 85.9% experienced unstable housing, 11.1% eviction, 26.2% IPV, and 31.8% workplace violence. In multivariable generalized estimating equation models, recent exposure to unstable housing (adjusted odds ratio [AOR] = 2.04; 95% confidence interval [CI] = 1.45, 2.87) and evictions (AOR = 2.45; 95% CI = 0.99, 6.07) were associated with IPV, and exposure to unstable housing was associated with workplace violence (AOR = 1.46; 95% CI = 1.06, 2.00). Conclusions. Women sex workers face a high burden of unstable housing and evictions, which are linked to increased odds of intimate partner and workplace violence. Increased access to safe, women-centered, and nondiscriminatory housing is urgently needed. (Am J Public Health. 2023;113(4):442-452. https://doi.org/10.2105/AJPH.2022.307207).

Client-Perpetrated Violence Experience Among Female Sex Worker in Guangdong, South China: Results from a Cross-Sectional Study

Client-perpetrated violence (CPV) can lead to worse health consequences. However, little attention is paid to the CPV experience among Chinese female sex workers. Our study aimed to assess the association between CPV experience and health risk behaviors among FSWs in China. Data used in this study was from the baseline interviewer-administered questionnaire of a cluster randomized controlled trial conducted in June-October 2020. The collected information included sociodemographic characteristics, HIV/STI symptoms, number of clients, quality of the workplace, and past CPV experience. The association between violence experience and potential HIV/STI risk factors was explored using multivariable regression. Among 480 FSWs who participated in this study, 13.5% experienced CPV in the past. Compared to those who had never experienced CPV, FSWs who experienced CPV were more likely to report previous STI-related symptoms (aOR 4.29, 95% CI 1.73-10.64), more than 15 clients in the past month (aOR 2.56, 95% CI 1.18-5.52), a history of HIV testing (aOR 2.99, 95% CI 1.64-5.46), and work at low-tier workplaces (aOR 2.09, 95% CI 1.18-3.70). Overall, CPV prevalence is not low among Chinese FSWs, and there are some associations with HIV/STI risk factors; a future intervention targeting CPV in HIV/STI prevention programs is needed.

Poverty, Psychological Distress, and Suicidality Among Gay Men and Transgender Women Sex Workers During the Covid-19 Pandemic in Phuket, Thailand

Introduction

Thai gay men and transgender women (GM&TGW) sex workers are more likely to suffer from economic harm since the sex tourism industry in Thailand has been hit hard by the Covid-19 pandemic. They also are more likely to experience poverty and mental health issues subsequent to the pandemic as minority groups in conservative Thai society. While their highly problematic social and economic situation would predict a wide range of psychological issues, little is known about their mental health. Hence, this study examined the prevalence and symptom severity of psychological distress among the group as well as the associations between suicidal ideation, poverty, and psychological distress.

Methods

Two hundred seventy questionnaire responses were collected online via Google forms in Phuket in 2021. Data analysis was conducted using SPSS and Smart-PLS.

Results

Based on the results, most respondents had experienced mild to extremely severe symptoms of psychological distress. However, transgender women sex workers scored higher on depression and anxiety compared to gay men sex workers. This study confirmed the prominent associations between the study variables and the mediation effect of psychological distress.

Conclusions

Poverty resulting from the pandemic imposes a substantial human cost for this vulnerable minority beyond the virus itself as it amplifies mental health problems.

Policy Implications

The findings further extend our awareness of the discriminatory treatment of Thai GM&TGW sex workers and address a gap in Thai law and policy for prohibiting discrimination against them. It is of urgent necessity for Thai public health and tourism policymakers to establish sound support interventions.

Mental health and HIV risk differs by co-occurring structural vulnerabilities among women who sell sex

Female sex workers (FSW) experience many structural vulnerabilities (SV; e.g., violence, economic insecurity) which contribute to increased risk of HIV and mental distress. However, little research has examined how SV co-occur to shape HIV risk, and none have studied mental distress. Among FSW (n = 385) in Baltimore, Maryland, latent class analysis of five binary indicators (housing insecurity; financial dependence on others; client-perpetrated physical or sexual violence; food insecurity) determined classes of SV and differential HIV risk behavior and mental health outcomes. A 3-class model fit the data best: minimal SV (i.e., low probabilities of all indicators); material needs (i.e., housing, food insecurity); and high SV (i.e., high probability of all indicators). Compared to minimal SV, high SV and material needs had significantly greater adjusted probability of drug injection and poorer adjusted depression, post-traumatic stress disorder, and mental distress scores. The high SV class had significantly higher probability of reporting condomless sex with clients compared to material needs and minimal SV. Results show the deleterious effect of co-occurring SV on HIV risk behaviors among FSW with particular emphasis on co-occurring food and housing insecurities. This is the first study of co-occurring SV on mental health outcomes in this key population.

Assessing risk factors and health impacts across different forms of exchange sex among young women in informal settlements in South Africa: A cross-sectional study

For women in South Africa, engaging in exchange sex, including transactional sex (TS), or sex work (SW), is associated with several shared poor health outcomes; yet the practices themselves differ in meaningful ways. SW is a form of commodity exchange, while TS is grounded in gendered relationship expectations of male provision and aspects of emotional intimacy. Additionally, exchange sex types could be imagined on a "continuum of instrumentality" from relationships that do not include material support; to those characterized, but not driven by support; to those primarily motivated by material support. We use cross-sectional data from 644 women ages 18-30 enrolled in a trial addressing intimate partner violence in urban KwaZulu-Natal, South Africa to assess whether these conceptualizations may also map onto different types or levels of risk. Using self-reports, we developed four exchange sex relationship categories corresponding to a continuum of instrumentality: no exchange-based relationship; TS with a main partner only; TS with a casual partner; and SW. Using tests of association and adjusted logistic regression models, we compared socio-economic and behavioural risk factors, and health outcomes across reported forms of exchange sex. We find little difference between women who report no exchange sex and those who report TS only with a main partner. By contrast, as compared to women not in exchange sex, women in casual TS and SW were poorer, and significantly more likely to report problematic alcohol use, past drug use, prior non-partner sexual violence, and PTSD; with aOR higher for women in SW for many outcomes. When comparing casual TS to SW, we find women in SW held more gender equitable attitudes and were more likely to report modern contraceptive use. We discuss the implications for distinguishing between TS and SW, and use of the continuum of instrumentality conceptualization for research and programming.

Substance Use and Violence Victimization Among Women: A Review of Relevant Literature

A review of the recent scientific literature on the relationship between substance use and violence victimization among women in the United States is presented. Systematic review methodology adhered to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. In total, 15 studies were identified that met inclusion criteria. There is substantial evidence suggesting substance use (e.g., severity of use, types of substances used) is associated with women's violent victimization histories. Evidence suggests that women are uniquely situated in illicit drug markets and other illicit economies in a manner that increases their risk for violent victimization. The strengths and shortcomings of current theoretical explanations of substance use and violence victimization are discussed, as well as considerations for future research and interventions.

Criminalization and coercion: sexual encounters with police among a longitudinal cohort of women who exchange sex in Baltimore, Maryland

BACKGROUND

The criminalization of sex work and drug use creates unequal power dynamics easily exploited by police. Women who exchange sex (WES) in settings around the globe have reported coerced sex and sexual assault by police, and some have reported police as paying clients. Little research has examined nuances underlying WES's sexual interactions with police.

METHODS

A cohort of cisgender WES (N = 308) was recruited through targeted sampling in Baltimore, Maryland and completed a structured survey every 6 months for 18 months. Follow-up surveys included detailed questions about recent sexual encounters with police. In bivariate and multivariate models using generalized estimating equations to account for intra-person correlation, we examined correlates of reporting recent sex with police over time.

RESULTS

One-third reported recent sex with police at any study visit. At each time point, about 90% of women who reported sex with police reported any uniformed or non-uniformed police had paid for sex. Between 72 and 85% had been solicited for paid sex by uniformed police. Between 41 and 50% of women who reported recent sex with police indicated they had done so because they feared arrest otherwise; one-third were directly pressured for sex by police to avoid arrest or trouble. In the final adjusted model, severe food insecurity [adjusted odds ratio (aOR) = 2.05; 95% confidence interval (CI) 1.13-3.71], Black race (vs. white, non-Hispanic; aOR = 1.90; 95% CI 1.13-3.17), recent arrest (aOR = 1.51; 95% CI 1.01-2.27), nonfatal overdose (aOR = 1.94; 95% CI 1.24-3.01), and client- or non-paying intimate partner-perpetrated violence (aOR = 2.46; 95% CI 1.63-3.71) were significantly independently associated with recent sex with police.

CONCLUSIONS

Sexual encounters between WES and police in Baltimore are common and often coerced to avoid arrest in a setting where both drug use and sex work are criminalized. Recent sex with police was more prevalent among WES who were racially marginalized, highly structurally vulnerable, and/or at high risk for drug overdose-and therefore subject to the dual-criminalization of sex work and drug use. This indicates deep power imbalances and their exploitation by police as the root of such sexual encounters and adds to the evidence regarding the need for decriminalization to support the health and wellbeing of WES.

An Evaluation of Indoor Sex Workers' Sexual Health Access in Metro Vancouver: Applying an Occupational Health & Safety Lens in the Context of Criminalization

The criminalization of sex work has been consistently shown to undermine workers' Occupational Health and Safety (OHS), including sexual health. Drawing on the 'Guide to OHS in the New Zealand Sex Industry' (the Guide), we assessed barriers to sexual health best practices among indoor sex workers in Metro Vancouver, Canada, in the context of ongoing criminalization. Part of a longstanding community-based study, this analysis drew on 47 qualitative interviews (2017-2018) with indoor sex workers and third parties. Participants' narratives were analyzed drawing on a social determinants of health framework and on the Guide with specific focus on sexual health. Our findings suggest that sex workers and third parties utilize many sexual health strategies, including use of Personal Protective Equipment (PPE) and peer-driven sexual health education. However, participant narratives demonstrate how structural factors such as criminalization, immigration, and stigma limit the accessibility of additional OHS best practices outlined in the Guide and beyond, including access to non-stigmatizing sexual health assessments, and distribution of diverse PPE by third parties. Our current study supports the need for full decriminalization of sex work, including im/migrant sex work, to allow for the uptake of OHS guidelines that support the wellbeing and autonomy of all sex workers.

Mapping the number of female sex workers in countries across sub-Saharan Africa

Female sex workers (FSW) are affected by individual, network, and structural risks, making them vulnerable to poor health and well-being. HIV prevention strategies and local community-based programs can rely on estimates of the number of FSW to plan and implement differentiated HIV prevention and treatment services. However, there are limited systematic assessments of the number of FSW in countries across sub-Saharan Africa to facilitate the identification of prevention and treatment gaps. Here we provide estimated population sizes of FSW and the corresponding uncertainties for almost all sub-national areas in sub-Saharan Africa. We first performed a literature review of FSW size estimates and then developed a Bayesian hierarchical model to synthesize these size estimates, resolving competing size estimates in the same area and producing estimates in areas without any data. We estimated that there are 2.5 million (95% uncertainty interval 1.9 to 3.1) FSW aged 15 to 49 in sub-Saharan Africa. This represents a proportion as percent of all women of childbearing age of 1.1% (95% uncertainty interval 0.8 to 1.3%). The analyses further revealed substantial differences between the proportions of FSW among adult females at the sub-national level and studied the relationship between these heterogeneities and many predictors. Ultimately, achieving the vision of no new HIV infections by 2030 necessitates dramatic improvements in our delivery of evidence-based services for sex workers across sub-Saharan Africa.

Factors Associated with Exchange Sex Among Cisgender Persons Who Inject Drugs: Women and MSM-23 U.S. Cities, 2018

Persons who inject drugs (PWID) and exchange sex face disproportionate HIV rates. We assessed prevalence of exchange sex (receiving money/drugs for sex from ≥ 1 male partner(s) during the past year) among cisgender PWID, separately for women and men with a history of sex with men (MSM). We examined factors associated with exchange sex, including sociodemographic characteristics, sexual and drug use behaviors, and healthcare access/utilization. Over one-third of the 4657 participants reported exchange sex (women: 36.2%; MSM: 34.8%). Women who exchanged sex (WES) were significantly more likely to test HIV-positive than other women. Men who exchanged sex with men (MESM) showed a similar trend. WES and MESM shared many characteristics, including being uninsured, experiencing recent homelessness, condomless sex, polydrug use, and receptive/distributive needle sharing. These findings highlight a need to strengthen prevention interventions and address structural determinants of HIV for WES and MESM, particularly PWID who exchange sex.

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.

Validation of a Brief Internalized Sex-work Stigma Scale among Female Sex Workers in Kenya

Female sex workers (FSW) often face severe stigma and discrimination and are extremely vulnerable to HIV and other sexually transmitted infections. In the fields of HIV and mental health, internalized stigma is associated with poor health care engagement. Due to the lack of valid, standardized measures for internalized sex work-related stigma, its dimensions and role are not well-understood. This study aimed to validate the six-item Internalized AIDS-Related Stigma Scale adapted to capture internalized sex work-related stigma by examining the scale's psychometric properties and performance among a cross-sectional, snowball sample of FSW (N = 497) in Kenya. While the original pre-hypothesized six-item model yielded acceptable CFI and SRMR values (CFI = 0.978 and SRMR = 0.038), the RMSEA was higher than desirable (RMSEA = 0.145). Our final four-item model demonstrated improved goodness of fit indices (RMSEA = 0.053; CFI = 0.999; and SRMR = 0.005). Both the pre-hypothesized six-item and reduced final four-item model demonstrated good internal consistency (Cronbach's alphas of 0.8162 and 0.8754, respectively). Higher levels of internalized stigma were associated with depression, riskier sexual behavior, and reduced condom use. This very brief measure will allow for reliable assessment of internalized stigma among FSW. Further investigation of internalized stigma among male sex workers, particularly the intersection of sex work-related and same-sex behavior-related stigmas, is needed.

Violence against sex workers: Correlates and Changes under 'End-Demand' legislation in Canada: A five city study

Canada is among several countries to have implemented 'end-demand' criminalization frameworks for sex work. Drawing on interviews with sex workers (n = 200) in five cities, we employed multivariate logistic regression to identify associations with workplace violence. We also analysed descriptive data on trafficking and on workplace violence under end-demand legislation. In the past 12 months, being unable to call 911 in a safety emergency at work for fear of police detection (Adjusted Odd Ratio AOR: 4.307, 95% Confidence Interval CI: 1.697 -10.927), being unable to screen clients due to fear of police detection (AOR: 2.175, 95% CI: 1.074 -4.405), having experienced anti-sex work housing policy/eviction (AOR: 2.031, 95% CI: 0.897-4.598), and being Indigenous (Adjusted Odd Ratio (AOR): 2.167, 95% Confidence Interval (CI): 1.060-4.428) were all independently associated with workplace violence in the past 12 months. Of those who worked prior to the law change (n = 167), a majority of respondents (80.24% (134)) reported that violence in the workplace had increased or stayed the same compared to the previous criminalization model and 87.43% (n = 146) reported it was harder or the same to get help in an emergency.

A retreat from human rights? A reflection on sex work's place in contemporary HIV prevention

In 2012, the World Health Organization guidelines for HIV prevention recommended the decriminalisation of sex work as their number one good practice. Although human rights language played a key role in the international scientific and activist endorsement of the WHO policies, since then there have been few initiatives in terms of advancing the kinds of structural and political changes endorsed. In this Commentary, we reflect on sex work's place in the broader field of the biomedicalization of responses to HIV. The analysis is based on literature reviews and our research trajectories, including preliminary results from a qualitative study on the implementation of PrEP in Rio de Janeiro, Brazil. We argue that sex workers occupy an ambiguous and less visible role in current AIDS policies, and that such policies are increasingly characterised by their prioritisation of biomedical approaches over structural factors. These shifts should be understood as part of a broader, global hegemony of clinical responses to HIV prevention and the continuation of a neoliberal discourse around human rights, without adequate investment in the material conditions necessary to guarantee these rights.

Intersectional Experienced Stigma and Psychosocial Syndemic Conditions in a Sample of Black Men Who Have Sex with Men Engaged in Sex Work (BMSM-SW) from Six US Cities

Black men who have sex with men (BMSM) in the United States experience a disproportionate burden of violence, substance use, physical and mental health conditions relative to other racial groups. BMSM who engage in sex work (BMSM-SW) experience a high burden of psychosocial conditions, sexually transmitted infections, including HIV, and intersectional stigma. This analysis characterizes remuneration and client typologies for BMSM-SW, documents intersectional stigma experienced by BMSM-SW relative to other BMSM, and explores the impact of experienced intersectional stigma on the relationship between sex work engagement and psychosocial syndemic conditions (violence, polydrug use, and depression symptoms). Results show that a majority of BMSM-SW in the sample had female clients and that sex workers were more likely than other BMSM to hire another sex worker. BMSM-SW were more likely than other BMSM to report stigma attributed to race; sexuality; HIV status; socioeconomic status; and "other" attributes, and were more likely to report experiencing stigma across all settings assessed (schools; healthcare; employment; housing; police/courts; and in public/community). Intersectional stigma mediated the relationship between sex work engagement and psychosocial syndemic conditions, accounting for 49% (95% CI: 47.6-50.0%) of the relationship. Interventions for BMSM-SW should include resilience-building components to counteract the effects of intersectional stigma.

Understanding the longitudinal relationship between substance use and violent victimization among street-based women who exchange sex in Baltimore, Maryland

BACKGROUND

Women who exchange sex (WES) experience extensive interpersonal violence from multiple perpetrators. Violence towards WES contributes to poor mental and behavioral health outcomes, including high rates of drug use. However, it is difficult to disentangle the temporal relationship between drug use and violence among WES.

METHODS

We used data from 251 WES, who completed baseline and 6-month follow up surveys. WES reported baseline sociodemographic characteristics, including homelessness and hunger. Participants reported their drug use by type and violent experiences by perpetrator at each time point. We conducted a path analysis examining the associations between drug use and violent victimization over time.

RESULTS

Participants were on average 37.8 years old, non-Hispanic White (57.4%) and experiencing high levels of structural vulnerability (59.4% homelessness; 58.6% weekly hunger). Drug use and violence were significantly correlated within each time point. Prospectively, baseline violent victimization was significantly associated with drug use (ß (SE) = 0.13 (0.06)) and violence (ß (SE) = 0.47 (0.05)) at follow up. Baseline drug use was associated with drug use at follow up (ß (SE) = 0.45 (0.05)) but was not significantly associated with violence at follow up (ß (SE) = 0.10 (0.06)).

CONCLUSIONS

Violence and drug use are closely linked in this population; and violence appears to facilitate sustained drug use. Interventions to address the dual epidemics of violence and substance use in this population should address underlying trauma as well as socio-structural drivers of violence as well as tailored harm reduction services for this population.

Sexual Violence and Low Rates of HIV Post-exposure Prophylaxis Access Among Female Sex Workers in Brazil

Female sex workers (FSW) are disproportionately affected by sexual violence (SV) and HIV. Social and structural barriers limit their access to post-exposure prophylaxis (PEP). Respondent-driven sampling survey in 12 Brazilian cities among 4188 FSW aimed to estimate the rates of SV and factors associated with access to PEP use among FSW who experienced SV. The prevalence of SV was 26.3% (1199). Of the 1199, 7.5% sought out healthcare and used PEP, 19% sought out healthcare, but did not use PEP, and 73.5% did not seek out healthcare after SV. Factors associated with PEP use included PEP awareness, participation in HIV/STI prevention workshops, and disclosure of FSW status in healthcare services. Although Brazil has a PEP program free of charge, it is not readily accessible, even for FSW who seek out healthcare. The development of effective strategies to link FSW to HIV preventive services is urgently needed.

A Human Rights Case Study on Access to Pre-exposure Prophylaxis for Female Sex Workers in South Africa

This paper examines the extent to which access to HIV preventive medicines such as pre-exposure prophylaxis (PrEP) are ensured under the International Covenant on Economic, Social and Cultural Rights. There is a lack of human rights-focused research on access to HIV preventive medicines for vulnerable populations such as female sex workers in HIV-endemic countries. To help fill this gap, I utilized a case study approach to critically examine the rollout of PrEP for female sex workers in South Africa, drawing on the country's Bill of Rights, health care policies, and PrEP implementation. My analysis found that (1) PrEP rollout was largely physically and economically inaccessible for female sex workers outside of urban centers; (2) the dissemination of PrEP information specific to female sex workers was limited both virtually and in clinics, reducing the medicine's acceptability; and (3) South Africa's overburdened public health care system and continued criminalization of sex work limited the accessibility and quality of HIV prevention services, contributing to weak uptake of PrEP among female sex workers. To remedy these issues, state leaders should prioritize PrEP counseling and socially acceptable information dissemination; expand comprehensive, coherent, and coordinated sexual health services for female sex workers; increase the financial resources available for programs specific to female sex workers; and decriminalize sex work.

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.

Seeing pre-screened, regular clients associated with lower odds of workplace sexual violence and condom refusal amidst sex work criminalization: findings of a community-based cohort of sex workers in Metro Vancouver, Canada (2010-2019)

Background

Research that accurately represents how characteristics of sex work clients relate to sex workers’ labour conditions is crucial for informing evidence-based legislation which upholds sex workers’ human rights. As little quantitative research has examined how seeing regulars (repeat clients) impacts sex workers’ occupational safety, particularly under ‘end-demand’ criminalization in Canada, our study aimed to explore how seeing mostly regulars shapes workplace sexual violence and client condom refusal.

Methods

We drew on longitudinal data from a community-based open cohort of 900+ sex workers in Vancouver, recruited via time-location sampling during day and late-night outreach to indoor, outdoor, and online solicitation spaces. We used logistic regression analyses and multivariable GEE confounder models to 1) describe correlates of seeing mostly pre-screened, regular clients, 2) identify associations between seeing mostly regulars and odds of experiencing occupational outcomes of workplace sexual violence and client condom refusal, and 3) examine the interaction between seeing mostly regulars and work environment on workplace sexual violence and client condom refusal.

Results

Participants’ median age was 35, and 55.6% had completed high school. Over the 9-year study (n=925), 20.9% (193) experienced 282 events of workplace sexual violence and 40.2% (372) faced 702 events of client condom refusal. In multivariable GEE confounder models, seeing mostly regulars was associated with reduced odds of sexual violence (AOR 0.73, 95%CI 0.53-1.02, p=0.067) and client condom refusal (AOR 0.70, 95%CI 0.57-0.86). In multivariable GEE confounder models examining the additive interaction between seeing mostly regulars and work environment, participants who saw mostly regulars and primarily worked in outdoor or informal indoor venues faced significantly lower odds of experiencing workplace sexual violence (AOR 0.69, 95%CI 0.49-0.95) and client condom refusal (AOR 0.64, 95%CI 0.52 -0.80) relative to those who worked in the same venues and did not see mostly regulars.

Conclusion

Our findings highlight protective effects of seeing pre-screened regulars within a criminalized setting. Removal of ‘end-demand’ client criminalization is needed to enable sex workers to effectively screen clients, support HIV/STI prevention, and advance sex workers’ human rights.

Intertwined epidemics: progress, gaps, and opportunities to address intimate partner violence and HIV among key populations of women

The intersection of intimate partner violence and HIV is a public health problem, particularly among key populations of women, including female sex workers, women who use drugs, and transgender women, and adolescent girls and young women (aged 15-24 years). Intimate partner violence results in greater risk of HIV acquisition and creates barriers to HIV prevention, testing, treatment, and care for key populations of women. Socioecological models can be used to explain the unique multilevel mechanisms linking intimate partner violence and HIV. Few interventions, modelling studies, and economic evaluations that concurrently address both intimate partner violence and HIV exist, with no interventions tailored for transgender populations. Most combination interventions target individual-level risk factors, and rarely consider community or structural factors, or evaluate cost-efficacy. Addressing intimate partner violence is crucial to ending the HIV epidemic; this Review highlights the gaps and opportunities for future research to address the intertwined epidemics of intimate partner violence and HIV among key populations of women.

Prevalence and Correlates of Sexual Violence Experienced by Female Sex Workers in Iran: Results from a National HIV Bio-Behavioral Surveillance Survey

Sexual violence increases the risk of adverse health outcomes among female sex workers (FSWs). Using data from the 2015 national bio-behavioral survey, we explored the experience of sexual violence and its associated factors among Iranian FSWs. Lifetime and recent sexual violence were reported by 40.1% and 16.9%, respectively. History of substance use, ever engaging in anal sex, engaging in group sex within the last year, a high number of clients, recent unstable housing, and incarceration increased the likelihood of experiencing recent sexual violence. These findings underscore the need for community-empowerment and policy-level interventions to address violence among FSWs in Iran.

Sex work community participation in criminalized environments: a community-based cohort study of occupational health impacts in Vancouver, Canada: 2010-2019

Background

Sex work criminalization and occupational stigma pose barriers to sex workers’ access to support services, including community participation — engagement with sex work specific community organizing at both formalized and grassroots capacities. In light of gaps in evidence regarding impacts of community participation on sex workers’ occupational health in higher-income settings, we evaluated engagement in community participation and associations with occupational sexual health outcomes among sex workers in Vancouver, Canada.

Methods

Prospective data from a community-based cohort of 943 women sex workers in Vancouver, British Columbia (2010–2019). We used logistic regression with generalised estimating equations (GEE) to model correlates of community participation, and a confounder modeling approach to examine the association of community participation on sexually transmitted infection (STI) seropositivity.

Results

Among participants, 38.1% were Indigenous, 31.4% identified as women of colour (e.g., East Asian, Southeast Asian, Black) and 29.3% were im/migrants to Canada. Over a quarter (28.3%, n = 267) serviced in informal indoor spaces, while 38.0% (n = 358) serviced clients in outdoor/public and 31.4% (n = 296) in formal in-call spaces. 8.9% of participants reported sex work community participation at least once over the 9-year study. In multivariable GEE analysis, Indigenous (adjusted odds ratio(aOR) 1.71, 95% confidence interval (CI) 0.88–3.32) and trans women (aOR 4.69, 95%CI 2.43–9.06) had higher odds of community participation; women of colour had lower odds (aOR 0.18, 95%CI 0.06–0.57). In a multivariable GEE confounder model, community participation was independently associated with lower odds of STI seropositivity (aOR 0.66, 95% CI0.45–0.96).

Conclusion

Sex workers who engaged in sex work community participation faced reduced odds of STI seropositivity. Building off reserach evaluating community interventions in low and middle income contexts, our study provides some of the first quantitative evidence on community participation among sex workers in Canada, and is the first to examine this in relation to sexual health outcomes. This research demonstrates the need to scale up community participation access for sex workers, via linguistically diverse community spaces, anti-stigma initiatives, and decriminalization to reduce barriers faced by racialized sex workers and support occupational health and rights for all sex workers.

The role of local business employees and community members in the HIV risk environment of female sex workers in an urban setting: associations between negative interactions and inconsistent condom use

Background

The role of business employees and community members in the HIV risk environment of female sex workers (FSW) is underexplored, despite sex work often located in commercial and residential urban areas. We explored the effect of negative interactions between business employees and community members on inconsistent condom use with clients of female sex workers.

Methods

This study uses baseline data from the EMERALD study, a community empowerment intervention with FSW. We recruited a sample of 361 FSW in Baltimore, Maryland using targeted sampling techniques in ten zones characterized by high rates of sex work, located throughout the city. Participants were recruited between September 2017 and January 2019 and completed a survey, HIV rapid testing, and self-administered gonorrhea and chlamydia testing. The outcome, inconsistent condom use, was defined as not reporting “always” using condoms with paying clients. Poisson regressions with robust variance were used to model the effect of business employee and/or community member interactions on inconsistent condom use.

Results

Over half (54%) the sample was between 18 and 40 years old, 44% Black or another race, and experienced a range of structural vulnerabilities such as housing instability and food insecurity. Forty-four percent of the sample reported inconsistent condom use with clients. FSW reported being reported to the police weekly or daily for selling drugs (14% by employees, 17% by community), for selling sex (19% by employees, 21% by community), and experiencing weekly or daily verbal or physical threats (18% by employees, 24% by community). In multivariable models, being reported to the police for selling sex weekly or daily by community members (vs. never, aRR = 1.42, 95% CI = 1.08, 1.86) and business owners (vs. never, aRR = 1.36, 95% CI = 1.05, 1.76) increased risk of inconsistent condom use, as did monthly verbal or physical threats by community members (vs. never, aRR = 1.43, 95% CI = 1.08, 1.91).

Conclusions

Results show that both actors play important roles in FSWs’ HIV risk environment. Businesses and community members are important targets for holistic HIV prevention interventions among FSW in communities where they coexist in close proximity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12293-4.

Trafficking, Client and Police Violence, Sexual Risk and Mental Health Among Women in the Sex Industry at the Thai-Myanmar Border

This study describes sex trafficking and associations with violence and health among female migrants in the sex industry in Mae Sot, Thailand. The mixed-methods study included a qualitative interview phase (n = 10), followed by a cross-sectional survey phase (n = 128). Entry via trafficking (force, fraud, or coercion [FFC], or as minors) was prevalent (76.6%), primarily FFC (73.4%). FFC was associated with inconsistent condom use, inability to refuse clients, poor health, and anxiety. Past-year violence was normative including client sexual violence (66.4%), client coercion for condom nonuse (> 95%), and police extortion (56%). Working conditions enabled violence irrespective of mode of entry. Profound unmet needs exist for safety and access to justice irrespective of trafficking history.

Social service responses to human trafficking: the making of a public health problem

Human trafficking has received considerable attention from policymakers, researchers and service providers globally, with resulting interventions often positioning trafficking as something that simply exists. Drawing on Bacchi's 'What's the Problem Represented to be?' approach, this article proposes that trafficking is continually made through efforts designed to eradicate it. We conducted 22 interviews with representatives from social service organisations funded by the government of Ontario, Canada, for anti-trafficking programming. These interviews provide insight into how trafficking is being represented and with what effects. Our findings suggest that organisational initiatives often rely on individualised health-related interventions, such as trauma-informed counselling and other mental health support, to address trafficking. In the process, various sex work activities are deemed 'symptoms' of trafficking, and perceived pathways to engaging in sex work (such as drug use/dependence, a history of trauma and low self-esteem) are produced as 'causes' or 'risk factors'. We contend that by pathologising sex work and sex workers, organisations are employing a contradictory neoliberal paternalism to advance a public health representation of human trafficking that simultaneously responsibilises and disenfranchises purported victims.

Cumulative Violence and PTSD Symptom Severity Among Urban Street-Based Female Sex Workers

Female sex workers (FSW) are a marginalized and vulnerable population at high risk of gender-based violence within and outside of their occupation. However, FSW remain underrepresented in the trauma and mental health literature. The aims of this study were to (a) characterize exposure to violence among street-based FSW, including violence type, patterns over the life course, and key perpetrator groups, and (b) examine the multivariate associations between posttraumatic stress disorder (PTSD) symptom severity and two constructs (revictimization across life stages and cumulative violence). Data were drawn from the Sex Workers and Police Promoting Health in Risky Environments (SAPPHIRE) study, an observational community-based cohort of street-based FSW recruited through targeted sampling across Baltimore, Maryland (USA) in 2016 to 2017. PTSD symptom severity was measured using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5). At baseline, 61% of FSW screened positive for PTSD symptoms. The mean PCL-5 score was 38.6. We documented extensive histories of sexual and physical violence (lifetime: 81.8%; childhood and adult revictimization: 15.0% for sexual and 37.7% for physical). The vast majority of perpetrators were male and included paying clients, police officers, family members, and intimate partners. Exposure to childhood and adult sexual violence were independently associated with higher PTSD severity (p < .05), with marginal associations observed for physical violence. Data supported a cumulative violence model of PTSD severity (p < .05). Binge drinking also appeared to be a contributing factor (p < .05). The levels of PTSD observed among our sample were comparable with that reported among treatment-seeking war veterans. Our findings underscore the urgent need for tailored trauma-informed interventions and policies to address violence among urban street-based FSW, a population experiencing extremely high levels of violence, PTSD, and substance use.

Integrating HIV services and other health services: A systematic review and meta-analysis

BACKGROUND

Integration of HIV services with other health services has been proposed as an important strategy to boost the sustainability of the global HIV response. We conducted a systematic and comprehensive synthesis of the existing scientific evidence on the impact of service integration on the HIV care cascade, health outcomes, and cost-effectiveness.

METHODS AND FINDINGS

We reviewed the global quantitative empirical evidence on integration published between 1 January 2010 and 10 September 2021. We included experimental and observational studies that featured both an integration intervention and a comparator in our review. Of the 7,118 unique peer-reviewed English-language studies that our search algorithm identified, 114 met all of our selection criteria for data extraction. Most of the studies (90) were conducted in sub-Saharan Africa, primarily in East Africa (55) and Southern Africa (24). The most common forms of integration were (i) HIV testing and counselling added to non-HIV services and (ii) non-HIV services added to antiretroviral therapy (ART). The most commonly integrated non-HIV services were maternal and child healthcare, tuberculosis testing and treatment, primary healthcare, family planning, and sexual and reproductive health services. Values for HIV care cascade outcomes tended to be better in integrated services: uptake of HIV testing and counselling (pooled risk ratio [RR] across 37 studies: 1.67 [95% CI 1.41-1.99], p < 0.001), ART initiation coverage (pooled RR across 19 studies: 1.42 [95% CI 1.16-1.75], p = 0.002), time until ART initiation (pooled RR across 5 studies: 0.45 [95% CI 0.20-1.00], p = 0.050), retention in HIV care (pooled RR across 19 studies: 1.68 [95% CI 1.05-2.69], p = 0.031), and viral suppression (pooled RR across 9 studies: 1.19 [95% CI 1.03-1.37], p = 0.025). Also, treatment success for non-HIV-related diseases and conditions and the uptake of non-HIV services were commonly higher in integrated services. We did not find any significant differences for the following outcomes in our meta-analyses: HIV testing yield, ART adherence, HIV-free survival among infants, and HIV and non-HIV mortality. We could not conduct meta-analyses for several outcomes (HIV infections averted, costs, and cost-effectiveness), because our systematic review did not identify sufficient poolable studies. Study limitations included possible publication bias of studies with significant or favourable findings and comparatively weak evidence from some world regions and on integration of services for key populations in the HIV response.

CONCLUSIONS

Integration of HIV services and other health services tends to improve health and health systems outcomes. Despite some scientific limitations, the global evidence shows that service integration can be a valuable strategy to boost the sustainability of the HIV response and contribute to the goal of 'ending AIDS by 2030', while simultaneously supporting progress towards universal health coverage.