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Wang Y, Dooley K, Wang C, Smith K. Biomedical contraceptives and their association with condom use consistency among female sex workers in China: results from a national cross-sectional study. Ann Epidemiol 2022; 74:104-110. [DOI: 10.1016/j.annepidem.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 05/20/2022] [Accepted: 07/30/2022] [Indexed: 12/01/2022]
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Zemlak JL, Bryant AP, Jeffers NK. Systematic Review of Contraceptive Use Among Sex Workers in North America. J Obstet Gynecol Neonatal Nurs 2020; 49:537-548. [PMID: 32931732 DOI: 10.1016/j.jogn.2020.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE To systematically review the literature regarding contraceptive use by sex workers in North America and to understand factors that limit reproductive agency and affect contraceptive use and decision making. DATA SOURCES We searched PubMed, CINAHL, and Embase databases using the search terms "sex work(ers)," "transactional sex," "exchange sex," "prostitution," "contraception," "contraceptive agents," "birth control," "female," and "women." STUDY SELECTION Articles were eligible for inclusion in this review if they (a) reported quantitative or qualitative studies based in North America, (b) were written in English, (c) included sex workers (self-identified sex workers or engaged in sex work behavior) as the primary or secondary population of the study, (d) included a population assigned female sex at birth, (e) reported contraceptive outcomes for sex workers, and (f) were published in peer-reviewed journals. The initial search yielded 2,455 articles, and seven met the inclusion criteria. DATA EXTRACTION Two authors independently reviewed the articles and organized data in a table to capture study design, sample size and study population, study aims, and contraceptive use. We applied Connell's theory of gender and power as an analytic framework to further identify factors that limited reproductive agency. DATA SYNTHESIS Condoms were the most common method of contraceptive used across studies. The use of contraceptives varied by partner type (client vs. nonpaying intimate partners). Access to highly effective contraception was limited by perceived stigma, financial constraints, and substance use. Reproductive and harm reduction services that were co-located where women worked improved contraceptive use. Contraceptive use was affected by factors that limited reproductive agency, including stigma, substance use, intimate partner violence, and condom coercion. CONCLUSION The reliance of sex workers on partner-dependent contraception, such as condoms, combined with factors that limit reproductive agency over contraceptive use and decision making contribute to high potential for contraceptive failure and unintended pregnancy. More research is needed to understand the influence of different sexual partner types, pregnancy intention, and contraceptive decision making on the reproductive agency of sex workers.
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Dulli L, Field S, Masaba R, Ndiritu J. Addressing broader reproductive health needs of female sex workers through integrated family planning/ HIV prevention services: A non-randomized trial of a health-services intervention designed to improve uptake of family planning services in Kenya. PLoS One 2019; 14:e0219813. [PMID: 31339919 PMCID: PMC6655688 DOI: 10.1371/journal.pone.0219813] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 06/25/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite considerable efforts to prevent HIV and other sexually transmitted infections (STI) among female sex workers (FSW), other sexual and reproductive health (SRH) needs, such preventing unintended pregnancies, among FSW have received far less attention. Programs targeting FSW with comprehensive, accessible services are needed to address their broader SRH needs. This study tested the effectiveness of an intervention to increase dual contraceptive method use to prevent STIs, HIV and unintended pregnancy among FSW attending services in drop-in centers (DIC) in two cities in Kenya. The intervention included enhanced peer education, and routine screening for family planning (FP) needs plus expanded non-condom FP method availability in the DIC. METHODS We conducted a two-group, pre-/posttest, quasi-experimental study with 719 FSW (360 intervention group, 359 comparison group). Participants were interviewed at baseline and 6 months later to examine changes in condom and non-condom FP method use. RESULTS The intervention had a significant positive effect on non-condom, FP method use (OR = 1.38, 95%CI (1.04, 1.83)), but no effect on dual method use. Consistent condom use was reported to be high; however, many women also reported negotiating condom use with both paying and non-paying partners as difficult or very difficult. The strongest predictor of consistent condom use was partner type (paying versus non-paying/emotional); FSW reported both paying and non-paying partners also influence non-condom contraceptive use. Substantial numbers of FSW also reported experiencing sexual violence by both paying and non-paying partners. CONCLUSIONS Self-reported difficulties with consistent condom use and the sometimes dangerous conditions under which they work leave FSW vulnerable to unintended pregnancy STIs/HIV. Adding non-barrier FP methods to condoms is crucial to curb unintended pregnancies and their potential adverse health, social and economic consequences. Findings also highlight the need for additional strategies beyond condoms to reduce HIV and STI risk among FSW. TRIAL REGISTRATION Clinicaltrials.gov NCT01957813.
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Affiliation(s)
- Lisa Dulli
- Family Health International (FHI 360), Durham, NC, United States of America
- * E-mail:
| | - Samuel Field
- Family Health International (FHI 360), Durham, NC, United States of America
| | - Rose Masaba
- Elizabeth Glaser Pediatrics AIDS Foundation, Nairobi, Kenya
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Surie D, Yuhas K, Wilson K, Masese LN, Shafi J, Kinuthia J, Jaoko W, McClelland RS. Association between non-barrier modern contraceptive use and condomless sex among HIV-positive female sex workers in Mombasa, Kenya: A prospective cohort analysis. PLoS One 2017; 12:e0187444. [PMID: 29176849 PMCID: PMC5703462 DOI: 10.1371/journal.pone.0187444] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 10/19/2017] [Indexed: 11/19/2022] Open
Abstract
Background As access to antiretroviral therapy in sub-Saharan Africa continues to expand, more women with HIV can expect to survive through their reproductive years. Modern contraceptives can help women choose the timing and spacing of childbearing. However, concerns remain that women with HIV who use non-barrier forms of modern contraception may engage in more condomless sex because of their decreased risk of unintended pregnancy. We examined whether non-barrier modern contraceptive use by HIV-positive female sex workers was associated with increased frequency of recent condomless sex, measured by detection of prostate-specific antigen (PSA) in vaginal secretions. Methods Women who were HIV-positive and reported transactional sex were included in this analysis. Pregnant and post-menopausal follow-up time was excluded, as were visits at which women reported trying to get pregnant. At enrollment and quarterly follow-up visits, a pelvic speculum examination with collection of vaginal secretions was conducted for detection of PSA. In addition, women completed a structured face-to-face interview about their current contraceptive methods and sexual risk behavior at enrollment and monthly follow-up visits. Log-binomial generalized estimating equations regression was used to test for associations between non-barrier modern contraceptive use and detection of PSA in vaginal secretions and self-reported condomless sex. Data from October 2012 through September 2014 were included in this analysis. Results Overall, 314 women contributed 1,583 quarterly examination visits. There was minimal difference in PSA detection at contraceptive-exposed versus contraceptive-unexposed visits (adjusted relative risk [aRR] 1.28, 95% confidence interval [95% CI] 0.93–1.76). There was a higher rate of self-reported condomless sex at visits where women reported using modern contraceptives, but this difference was not statistically significant after adjustment for potential confounding factors (aRR 1.59, 95% CI 0.98–2.58). Conclusion Non-barrier methods of modern contraception were not associated with increased risk of objective evidence of condomless sex.
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Affiliation(s)
- Diya Surie
- Department of Medicine, University of Washington, Seattle, United States of America
| | - Krista Yuhas
- Department of Global Health, University of Washington, Seattle, United States of America
| | - Kate Wilson
- Department of Global Health, University of Washington, Seattle, United States of America
| | - Linnet N. Masese
- Department of Medicine, University of Washington, Seattle, United States of America
| | - Juma Shafi
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - John Kinuthia
- Departments of Research and Programs, Reproductive Health, Kenyatta National Hospital, Nairobi, Kenya
| | - Walter Jaoko
- Kenya AIDS Vaccine Initiative Institute, University of Nairobi, Nairobi, Kenya
| | - R. Scott McClelland
- Department of Medicine, University of Washington, Seattle, United States of America
- Department of Global Health, University of Washington, Seattle, United States of America
- Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
- Department of Epidemiology, University of Washington, Seattle, United States of America
- * E-mail:
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Ippoliti NB, Nanda G, Wilcher R. Meeting the Reproductive Health Needs of Female Key Populations Affected by HIV in Low- and Middle-Income Countries: A Review of the Evidence. Stud Fam Plann 2017; 48:121-151. [PMID: 28422301 DOI: 10.1111/sifp.12020] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Female sex workers and other women at high risk of acquiring HIV have the right to sexual and reproductive health, including the right to determine the number and timing of pregnancies. We conducted a literature review to examine the data that exist regarding the family planning and reproductive health needs of female key populations, the underlying determinants of these populations' vulnerability to poor reproductive health outcomes, and the obstacles they face in accessing high-quality reproductive health services. Findings indicate that female key populations experience high rates of unmet need for family planning and safer conception services, unintended pregnancies, sexual violence, and abortion, and that they practice inconsistent condom use. Restrictive policy environments, stigma and discrimination in health care settings, gender inequality, and economic marginalization restrict access to services and undermine the ability to safely achieve reproductive intentions. We offer recommendations for structural, health system, community, and individual-level interventions that can mitigate the effects of these barriers and improve reproductive health outcomes.
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Yi S, Tuot S, Chhoun P, Pal K, Ngin C, Chhim K, Brody C. Sex with sweethearts: Exploring factors associated with inconsistent condom use among unmarried female entertainment workers in Cambodia. BMC Infect Dis 2017; 17:20. [PMID: 28056842 PMCID: PMC5217300 DOI: 10.1186/s12879-016-2101-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 12/08/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the success in promoting condom use in commercial relationships, condom use with regular, noncommercial partners remains low among key populations in Cambodia. This study explores factors associated inconsistent condom use with sweethearts among unmarried sexually active female entertainment workers (FEWs). METHODS In 2014, the probability proportional to size sampling method was used to randomly select 204 FEWs from entertainment venues in Phnom Penh and Siem Reap for face-to-face interviews. Multivariate logistic regression analysis was conducted to examine independent determinants of inconsistent condom use. RESULTS Of total, 31.4% of the respondents reported consistent condom use with sweethearts in the past three months. After adjustment, respondents who reported inconsistent condom use with sweethearts remained significantly less likely to report having received any form of sexual and reproductive health education (AOR = 0.49, 95% CI = 0.22-0.99), but more likely to report having been tested for HIV in the past six months (AOR = 2.19, 95% CI = 1.03-4.65). They were significantly more likely to report having used higher amount of alcohol in the past three months (AOR = 1.29, 95% CI = 1.01-1.99) and currently using a contraceptive method other than condoms such as pills (AOR = 4.46, 95% CI = 1.34-10.52) or other methods (AOR = 9.75, 95% CI = 2.07-9.86). CONCLUSIONS The rate of consistent condom use in romantic relationships among unmarried FEWs in this study is considerably low. The importance of consistent condom use with regular, non-commercial partners should be emphasized in the education sessions and materials, particularly for FEWs who use non-barrier contraceptive methods.
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Affiliation(s)
- Siyan Yi
- KHANA Center for Population Health Research, No. 33, Street 71, Tonle Bassac, Chamkar Mon, Phnom Penh, Cambodia. .,Center for Global Health Research, Public Health Program, Touro University California, Vallejo, USA.
| | - Sovannary Tuot
- KHANA Center for Population Health Research, No. 33, Street 71, Tonle Bassac, Chamkar Mon, Phnom Penh, Cambodia
| | - Pheak Chhoun
- KHANA Center for Population Health Research, No. 33, Street 71, Tonle Bassac, Chamkar Mon, Phnom Penh, Cambodia
| | - Khuondyla Pal
- KHANA Center for Population Health Research, No. 33, Street 71, Tonle Bassac, Chamkar Mon, Phnom Penh, Cambodia
| | - Chanrith Ngin
- KHANA Center for Population Health Research, No. 33, Street 71, Tonle Bassac, Chamkar Mon, Phnom Penh, Cambodia
| | - Kolab Chhim
- HIV/AIDS Flagship Project, KHANA, Phnom Penh, Cambodia
| | - Carinne Brody
- Center for Global Health Research, Public Health Program, Touro University California, Vallejo, USA
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Reed E, Erausquin JT, Biradavolu M, Servin AE, Blankenship KM. Non-barrier contraceptive use and relation to condom use behaviour by partner type among female sex workers in Andhra Pradesh, India. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2017; 43:60-66. [PMID: 26699872 PMCID: PMC5284462 DOI: 10.1136/jfprhc-2014-100918] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 10/30/2015] [Accepted: 11/08/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The study assessed non-barrier contraceptive use among female sex workers (FSW) in Andhra Pradesh, India and relation to inconsistent condom use among commercial and non-commercial male sexual partners. METHODS FSW at least 18 years of age (n=2338) were recruited through respondent-driven sampling for an HIV risk survey. Analysis was restricted to women of childbearing age (n=2197). Crude and adjusted logistic regression models were used to assess non-barrier contraceptive use and relation to inconsistent condom use with husbands or regular male partners (i.e. non-clients), regular clients and occasional clients. RESULTS Non-barrier methods of contraception included contraceptive pills (3.8%) and sterilisation (68.4%). In logistic regression models adjusted for relevant demographics, FSW using contraceptive pills were more likely to report inconsistent condom use with a regular client (past week) [adjusted odds ratio (AOR) 2.2, 95% confidence interval (CI) 1.2-4.0] and with an occasional client (past week) (AOR 2.6, 95% CI 1.6-5.3), as well as accepting more money for sex without a condom (past 30 days) (AOR 2.5, 95% CI 1.5-4.3). No significant associations were found between pill use and inconsistent condom use among women's non-client partners, potentially related to small sample sizes within these subgroups. Reporting sterilisation, which was more common among FSW who were older in age, was not associated with inconsistent condom use with client or non-client sexual partners. CONCLUSIONS Findings document potential unmet need for modern, spacing contraceptives (i.e. pill, intrauterine device), but also indicate the importance for family planning services, particularly those promoting modern contraceptive methods to be provided alongside HIV prevention among FSW in Andhra Pradesh, India.
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Affiliation(s)
- Elizabeth Reed
- Assistant Professor, Division of Global Public Health, School of Medicine, University of California, San Diego, La Jolla, CA,USA
| | - Jennifer Toller Erausquin
- Assistant Professor, Department of Public Health Education, University of North Carolina at Greensboro, Greensboro, NC, USA
| | - Monica Biradavolu
- Scholar in Residence, Department of Sociology, American University, Washington, DC, USA
| | - Argentina E Servin
- Postdoctoral Fellow, Division of Global Public Health, School of Medicine, University of California, San Diego, La Jolla, CA,USA
| | - Kim M Blankenship
- Professor and Chair, Department of Sociology, American University, Washington, DC, USA
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Luchters S, Bosire W, Feng A, Richter ML, King’ola N, Ampt F, Temmerman M, Chersich MF. "A Baby Was an Added Burden": Predictors and Consequences of Unintended Pregnancies for Female Sex Workers in Mombasa, Kenya: A Mixed-Methods Study. PLoS One 2016; 11:e0162871. [PMID: 27689699 PMCID: PMC5045288 DOI: 10.1371/journal.pone.0162871] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 08/30/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Female sex workers (FSW) have high rates of unintended pregnancy, sexually transmitted infections including HIV, and other adverse sexual and reproductive health outcomes. Few services for FSWs include contraception. This mixed-methods study aimed to determine the rate, predictors and consequences of unintended pregnancy among FSWs in Mombasa, Kenya. METHODS A prospective cohort study of non-pregnant FSWs was conducted. Quantitative data were collected quarterly, including a structured questionnaire and testing for pregnancy and HIV. Predictors of unintended pregnancy were investigated using multivariate logistic regression. Qualitative data were gathered through focus group discussions and in-depth interviews with FSWs who became pregnant during the study, and interviews with five key informants. These data were transcribed, translated and analysed thematically. RESULTS Four hundred women were enrolled, with 92% remaining in the cohort after one year. Fifty-seven percent reported using a modern contraceptive method (including condoms when used consistently). Over one-third (36%) of women were using condoms inconsistently without another method. Twenty-four percent had an unintended pregnancy during the study. Younger age, having an emotional partner and using traditional or no contraception, or condoms only, were independent predictors of unintended pregnancy. Women attributed pregnancy to forgetting to use contraception and being pressured not to by clients and emotional partners, as well as "bad luck". They described numerous negative consequences of unintended pregnancy. CONCLUSION Modern contraceptive uptake is surprisingly low in this at-risk population, which in turn has a high rate of unintended pregnancy. The latter may result in financial hardship, social stigma, risk of abandonment, or dangerous abortion practices. FSWs face considerable barriers to the adoption of dual method contraceptive use, including low levels of control in their emotional and commercial relationships. Reproductive health services need to be incorporated into programs for sexually transmitted infections and HIV, which address the socially-determined barriers to contraceptive use.
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Affiliation(s)
- Stanley Luchters
- Burnet Institute, Melbourne, Australia
- International Centre for Reproductive Health (ICRH), Department of Obstetrics and Gynaecology, Ghent University, Ghent, Belgium
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- * E-mail:
| | - Wilkister Bosire
- International Centre for Reproductive Health (ICRH), Mombasa, Kenya
| | - Amy Feng
- Department of Obstetrics and Gynaecology, The Royal Women’s Hospital, Melbourne, Australia
| | - Marlise L. Richter
- Department of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- African Centre for Migration & Society, University of the Witwatersrand, Johannesburg, South Africa
| | - Nzioki King’ola
- International Centre for Reproductive Health (ICRH), Mombasa, Kenya
| | - Frances Ampt
- Burnet Institute, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Marleen Temmerman
- International Centre for Reproductive Health (ICRH), Department of Obstetrics and Gynaecology, Ghent University, Ghent, Belgium
- Department of Reproductive Health Research, World Health Organization, Geneva, Switzerland
| | - Matthew F. Chersich
- International Centre for Reproductive Health (ICRH), Department of Obstetrics and Gynaecology, Ghent University, Ghent, Belgium
- Centre for Health Policy, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Yam EA, Okal J, Musyoki H, Muraguri N, Tun W, Sheehy M, Geibel S. Kenyan female sex workers' use of female-controlled nonbarrier modern contraception: do they use condoms less consistently? Contraception 2015; 93:222-5. [PMID: 26656841 DOI: 10.1016/j.contraception.2015.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 11/02/2015] [Accepted: 11/10/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To examine whether nonbarrier modern contraceptive use is associated with less consistent condom use among Kenyan female sex workers (FSWs). STUDY DESIGN Researchers recruited 579 FSWs using respondent-driven sampling. We conducted multivariate logistic regression to examine the association between consistent condom use and female-controlled nonbarrier modern contraceptive use. RESULTS A total of 98.8% reported using male condoms in the past month, and 64.6% reported using female-controlled nonbarrier modern contraception. In multivariate analysis, female-controlled nonbarrier modern contraceptive use was not associated with decreased condom use with clients or nonpaying partners. CONCLUSION Consistency of condom use is not compromised when FSWs use available female-controlled nonbarrier modern contraception. IMPLICATIONS FSWs should be encouraged to use condoms consistently, whether or not other methods are used simultaneously.
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Affiliation(s)
- Eileen A Yam
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington, DC 20008, USA.
| | - Jerry Okal
- Population Council, General Accident House, Ralph Bunche Road, Nairobi, Kenya
| | - Helgar Musyoki
- National AIDS and Sexually Transmitted Infection Control Programme, Ministry of Health, PO Box 19361-00202, Nairobi, Kenya
| | - Nicholas Muraguri
- National AIDS and Sexually Transmitted Infection Control Programme, Ministry of Health, PO Box 19361-00202, Nairobi, Kenya
| | - Waimar Tun
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington, DC 20008, USA
| | - Meredith Sheehy
- Population Council, One Dag Hammarskjold Plaza, New York, NY 10017, USA
| | - Scott Geibel
- Population Council, 4301 Connecticut Avenue NW, Suite 280, Washington, DC 20008, USA
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López Entrambasaguas OM, Granero-Molina J, Hernández-Padilla J, Fernández-Sola C. Understanding Sociocultural Factors Contributing to HIV Risk Among Ayoreo Bolivian Sex Workers. J Assoc Nurses AIDS Care 2015; 26:781-93. [PMID: 26329475 DOI: 10.1016/j.jana.2015.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 08/10/2015] [Indexed: 11/25/2022]
Abstract
The Bolivian indigenous Ayoreo ethnic people are vulnerable to sexually transmitted infections and HIV. Ayoreo women who also work in sex trades belong to an extremely high-risk group, and prevention programs are not delivering effective outcomes for them. The aim of our study was to explore, describe, and understand behavioral and cultural patterns related to sexual and reproductive health in Ayoreo sex workers. A qualitative-ethnographic study was designed; data were collected through participant observation and in-depth interviews with sex workers and key informants. Two fundamental themes contributing to HIV risk for female Ayoreo sex workers in Bolivia emerged: reproductive/sexual freedom and sociocultural risk determinants. We concluded that the in-depth examination of the sexual-reproductive culture amongst the Ayoreo has provided useful information, which might contribute to the cultural adaptation and design of future policies and prevention programs for sexually transmitted infections and HIV in this group.
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