Clients of street-based female sex workers and potential bridging of HIV/STI in Russia: results of a pilot study

Exploring the why: risk factors for HIV and barriers to sexual and reproductive health service access among adolescents in Nigeria

BACKGROUND

Early sexual debut, low educational attainment, history of rape and transactional and intergenerational sex have been associated with HIV infection among Nigerian adolescents, especially females. We sought to understand the "why", and how to mitigate against these determinants and barriers to addressing adolescent sexual and reproductive health (SRH) and HIV prevention needs.

METHODS

This qualitative study generated data from 49 focus group discussions with male and female adolescents living with and without HIV, healthcare workers, members of civil society organizations working with young people, and parents of adolescents living with HIV. Participants were recruited from all six geopolitical zones in Nigeria. Data was analysed with ATLAS.ti software. Hermeneutic units were created, and codes developed from focus group transcripts. Network View Manager was used to create maps of codes, memos and quotations, and relevant quotes were retrieved from transcripts.

RESULTS

Four major themes were identified, relating to individual, parental, community and government roles in reducing the risk of HIV and unplanned pregnancy among adolescents in Nigeria. Individual factors influencing sexual risk behaviours of adolescents include peer pressure, poor risk perception for HIV, and misconceptions about the efficacy of contraceptives and condoms. Respondents entrusted State responsibilities such as facilitation of HIV-affected adolescents' access to education, rather, to individuals, parents and the community; and placed the blame for rape on rape survivors. Findings also highlighted the inadequacy of health systems to address adolescents' needs for treatment of sexually transmitted infections and to provide appropriate education on secondary HIV prevention for those living with HIV.

CONCLUSION

Rigorous studies are needed to understand dynamics between adolescents' risk behavior, HIV risk perception, parental roles in mitigating HIV risk in adolescents, and the role of communities and government in HIV prevention and treatment for adolescents in Nigeria.

Sexually Transmitted Infections and Associated Risk Factors Among Male Clients of Sex Workers: A Cross-Sectional Pilot Project in Antwerp, Belgium

INTRODUCTION

Prevalence of sexually transmitted infections (STIs) is increasing in Belgium in recent years. Clients of sex workers form a key population for acquisition of STIs, due to their sexual relations, with or without a condom, with sex workers. STI testing uptake is low among clients of sex workers, and prevalence of STIs remains to be investigated in Belgium. Therefore, we offered STI-testing to clients of sex workers during outreach sessions in Antwerp.

METHODS

Time location sampling (TLS) was used to improve representativeness of the sample during ten test sessions in the red light district, Antwerp in May and September 2019 by using a passive approach. Individuals that were interested to get tested for STIs could enter the study. Participants completed an online survey and samples for STI testing were collected. Testing included HIV, syphilis, Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (Ng). Test results were communicated via a cell phone message (for negative test results) or by phone (for positive test results).

RESULTS

In total, 154 male clients of sex workers with a median age of 38 participated. A total of eight Ct and one Ng infections were detected. TLS analysis revealed a Ct/Ng prevalence of 8.2%. No new HIV nor syphilis infections were detected. Using univariate analysis, testing positive for STI was associated with younger age and anorectal sex with a sex worker. Using multivariate analysis, an STI-positive test result was associated with being younger, having non-Belgian nationality, and being in a relationship.

CONCLUSION

Our study found a substantial prevalence of Ct/Ng which highlights the need for sensitization and facilitation of STI testing among clients of sex workers. It is difficult to compare results due to the lack of reference material. Moreover, our relatively small convenience sample limits generalizability of results. However, phone counseling (for positive test results) was accepted, linkage to care was provided, and partner notification was facilitated.

Systematic Review of Interventions to Reduce HIV Risk Among Men Who Purchase Sex in Low- and Middle-Income Countries: Outcomes, Lessons Learned, and Opportunities for Future Interventions

Along with other partners of key population groups, men who purchase sex (MWPS) contributed to around 18% of new reported HIV cases in 2018 among people aged 15-49 years worldwide. A systematic review was performed to evaluate interventions conducted to reduce HIV risk among MWPS in low- and middle-income countries (LMICs). A comprehensive search of studies published in Embase, Medline, Global Health, Scopus, and Cinahl was performed. Among 32,115 studies found, 21 studies met the review's inclusion criteria. Only four studies recruited MWPS, while the rest recruited groups often used as proxy populations for MWPS. The interventions were made primarily to increase HIV-related knowledge or perceptions through education and to improve condom usage rates through promotion and distribution. Few studies evaluated the impact of interventions on HIV testing rates and none looked at HIV treatment. Given the important role of testing as a prevention gate, together with UNAIDS' 90-90-90 testing and treatment coverage goals for people infected with HIV, more studies which evaluate the impact of HIV testing and treatment provision among this group are needed.

The burden of HIV infection among men who purchase sex in low- and middle-income countries - a systematic review and meta-analysis

Background

Since the start of the HIV epidemic, transactional sexual relationships have been considered to present a high risk of HIV transmission to both the client and the person offering the sexual service. However, prevention research and programs have focused predominantly on sex workers rather than on their clients, who are generally men. To support effective and targeted interventions, we undertook a systematic review and meta-analysis of the evidence of the prevalence of HIV infection among men who purchase sex (MWPS) in low- and middle-income countries (LMICs), and the association between HIV infection and purchase of sex.

Methods

We included articles that reported from LMICs on the prevalence of HIV in MWPS and those that reported on HIV prevalence among both MWPS and non-MWPS in the same study, or any information which allowed calculation of the prevalence. We defined MWPS as heterosexual males (not men who purchase sex or individuals of other sexual orientation) who purchased sex mostly from women (and not men), or who have had sexual contact with female sex workers (FSWs). We searched Medline, Global Health, Scopus, Embase and Cinahl for articles published up until 1 March 2020. Meta-analysis was conducted using a random effects model to estimate the pooled HIV prevalence and the relative risk (RR) of HIV infection associated with purchasing sex.

Results

Of 34862 studies screened, we included 44 studies (59515 men, 47753 MWPS) from 21 countries. The pooled HIV prevalence among MWPS was 5% (95%CI: 4%-6%; I² = 95.9%, p < 0.001). The pooled HIV prevalence calculated from studies that reported data collected pre-2001 was highest, i.e. 10% (95% CI: 6%-14%; I² = 91.2%, p < 0.001), compared to studies whose data was collected between 2001–2010, i.e. 4% (95%CI: 2%-6%; I² = 96.6%, p < 0.001), and from 2011 and beyond, i.e. 3% (95% CI: 2%-5%; I² = 94.3%, p < 0.001). For studies which included comparisons of HIV infection among MWPS and non-MWPS, the relative risk of HIV infection was consistently higher among MWPS than among non-MWPS within the same study, with the overall pooled relative risk of 1.95 (95%CI: 1.56–2.44; I² = 84.3%, p < 0.001), and 2.85 (95%CI: 1.04–7.76; I² = 86.5%, p < 0.001) for more recent studies.

Conclusions

This review represents the first comprehensive assessment of the burden of HIV among MWPS in LMICs. We found that HIV prevalence was elevated compared to the population as a whole, and that there was a strong association between purchasing sex and HIV prevalence. Despite a reduction over time in prevalence, these data highlight that MWPS need better access to HIV preventive interventions.

Left behind?: male clients of female sex workers in Zambia

Male clients of female sex workers (CFSWs) are a key-affected group within the HIV epidemic. However, few studies have quantified HIV/STI burdens among CFSWs. This study used nationally representative data from the 2013-14 Zambia Demographic and Health Survey to estimate proxies for HIV and STI prevalence among sexually active men aged 15-59 paying for sex recently (past 12 months) [5%, n = 679] or in their lifetime [15%, n = 1,887]. Chi-square tests were calculated to assess differences in prevalence estimates between CFSWs and non-clients. Multivariable logistic regression models were generated to identify sociodemographic factors associated with prevention characteristics. CFSWs had higher odds of reporting HIV infection (recent: aOR 1.413, p < 0.05; lifetime: aOR 1.604, p < 0.001) and past-year STI symptomology (recent: aOR 3.342, p < 0.001; lifetime: aOR 2.266, p < 0.001) than non-clients, irrespective of transactional sex recency. Compared to non-clients, CFSWs were more likely to be <25yo (42% vs. 29%, p < 0.001), have a cohabitating partner (43% vs. 35%, p < 0.001), use condoms at last sex (31% vs. 27%, p < 0.001), and never test for HIV (36% vs. 29%, p < 0.001). When comparing CFSWs to non-clients, marital status was an effect modifier of HIV testing, medical circumcision, and condom use at last sex. Findings suggest high HIV/STI burdens and highlight the urgent need for differentiated HIV prevention programming for CFSWs in Zambia including the provision of PrEP.

Sexual Exploitation as a Minor, Violence, and HIV/STI Risk among Women Trading Sex in St. Petersburg and Orenburg, Russia

Child sexual exploitation (CSE) is a major risk factor for acquiring human immunodeficiency virus/sexually transmitted infections (HIV/STI), violence and other health concerns, yet few studies have examined these associations in Russia until now. This study examines the prevalence of CSE (those entering the sex trade as a minor) among women in the sex trade in Russia and how exposures and behaviors related to violence and HIV/STI structural risks differ from those who entered the sex trade as an adult. Women in the sex trade (N = 896) in St. Petersburg and Orenburg, Russia were recruited via time-location sampling and completed structured surveys. Adjusted logistic regression analyses assessed associations between CSE victimization and HIV risk-related exposures. Of the 654 participants who provided their age at first sexual exploitation, 11% reported CSE prior to age 18. Those who reported CSE were more likely to be organized by others and to be prohibited from leaving a room or house and from using condoms; three-quarters experienced rape when trading sex; a third were involved in pornography before age 18 and they had less education if they entered the sex trade as a minor. In adjusted analyses, those entering the sex trade as a minor were significantly more likely than those entering the sex trade as an adult to report drug use prior to age 18 (AOR = 5.75, 95% CI = 2.53-13.09) to have ≥5 clients/day (past 12 months; AOR = 3.55, 95% CI = 1.56-8.08), to report receiving police assistance (AOR: 3.10, 95% CI = 1.26-7.54), and to have fewer experiences of police extortion (AOR = 0.35, 95% CI = 0.10-1.24). They were four times more likely to participate in pornography before the age of 18 (AOR = 4.08, 95% CI = 1.32, 12.60) and three times more likely to have been sexually abused as child (AOR = 2.93, 95% CI = 1.27, 7.54). Overall, entry as a minor was related to greater risk for victimization and an inability to protect oneself from STI/HIV.

Paid sex among men in sub-Saharan Africa: Analysis of the demographic and health survey

Background

Paying for sex is regarded as a risky sexual behavior (RSB) among heterosexual men. Men paying for sex are considered to be a bridging population for sexually transmitted infections (STIs). Despite the link between paid sex and sexual and reproductive health outcomes such as STIs, little is known about the prevalence and factors associated with paid sex among men in sub-Saharan Africa. This study examined the prevalence of paid sex and the socio-demographic factors associated with it among men in sub-Saharan Africa.

Methods

The study made use of pooled data from the Demographic and Health Surveys (DHS) conducted from January 1, 2010 to December 3, 2016 in 27 countries in sub-Saharan Africa. Binary and multivariable logistic regression models were used to investigate the relationship between the explanatory and the outcome variables.

Results

The results of the study showed that of the 139,427 men who participated in the study, 4.3% reported they had paid for sex in the 12 months preceding the survey. Men in Mozambique had the highest proportion (13.6%) of paying for sex in the 12 months preceding the survey. The results of the multivariable analysis indicated that men from DR Congo [AOR = 9.74; 95% CI = 7.45-12.73], men who had completed only primary level of education [AOR = 1.31; 95% CI = 1.18-1.45], men aged 25-34 years [AOR = 2.84; 95% CI = 2.26-3.56], men belonging to "other" religious groups [AOR = 1.20; 95% CI = 1.09-1.32] and men who were employed [AOR = 1.73; 95% CI = 1.58-1.90] had higher odds of paying for sex. Men who were divorced [AOR = 4.52; 95% = 3.89-5.25], men who read newspaper/magazine almost every day [AOR = 1.34; 95% CI = 1.12-1.63], men who listened to radio almost every day [AOR = 1.19; 95% CI = 1.05-1.36] and men who watched television at least once a week [AOR = 1.10; 95% CI = 1.01-1.19] also had higher odds of paying for sex. On the other hand, men in rural areas [AOR = 0.88; 95%CI = 0.82-0.95], men in the richest wealth quintile [AOR = 0.83; 95%CI = 0.74-0.93] and those with tertiary level of education [AOR = 0.77; 95% CI = 0.65-0.90] had lower odds of paying for sex.

Conclusion

The odds of paid sex were high among men with only primary level of education, men aged 25-34, men who professed 'other' religious affiliation, men who are employed and men who are divorced. However, paid sex was low among men in the richest wealth quintile, men with tertiary level of education and men living in rural areas. This means that the decision to pay for sex is influenced by several social and demographic factors. Hence, these factors should be taken into consideration for sexual and reproductive health interventions and services. Policy and interventional measures should aim at reducing high-risk behavior of men who pay for sex.

"Self-testing sounds more private, rather than going to the clinic and everybody will find out": Facilitators and barriers regarding HIV testing among men who purchase sex in Bali, Indonesia

In many Asian countries, men who purchase sex account for the largest single network of people which often face elevated HIV risk in relation to the general population. However, high proportions of these men have never undertaken HIV testing. We assessed barriers to and facilitators of HIV testing among men who purchase sex in Indonesia, including the acceptability of HIV self-testing. A qualitative study was conducted during December 2016-January 2017 at fourteen sex-work venues and one voluntary HIV counselling and testing (VCT) clinic in Bali. Interviews were conducted with men who purchase sex exploring the men's views on HIV testing. Data were examined using thematic analysis. Twenty-nine men participated in the study. The themes that emerged regarding the barriers to HIV testing included fear of potential shame, embarrassment, and confidentiality breach in accessing HIV testing; fear of social exclusion if the test result was positive; self-treatment and prevention; the distance to a clinic; time constraints; and fear of an invasive testing method. Factors that were seen as facilitating a test were the convenience of time and place; the provision of speedy results; and privacy. Participants expressed interest in HIV self-testing and preferred it to clinic-based testing due to the privacy and confidentiality of the results. The findings support the introduction of an HIV self-testing strategy among this group to improve access to HIV testing.

The UALE project: a cross-sectional approach for trends in HIV/STI prevalence among key populations attending STI clinics in Guatemala

OBJECTIVE

To describe and compare trends in prevalence, sexual behaviour and HIV transmission knowledge data related to sexually transmitted infections (STI) and HIV in patients attending three STI clinics over an 8-year period in Escuintla Department, Guatemala.

METHODS

STI clinic attendees were classified into transmission groups as follows: female sex workers (FSW), men who have sex with men (MSM) and 'high-risk heterosexuals' (HRH). Annual cross-sectional analysis and multivariable Poisson regression adjusted for sociodemographic variables were used for prevalence comparisons and adjusted prevalence trends for HIV/STI outcomes and used for adjusted trends in proportions in sexual behaviour and HIV transmission knowledge outcomes. Endocervical swabs were obtained to detect trichomonas, chlamydia and neisseria infections. Serologies for syphilis and HIV were performed using rapid tests. For reactive HIV samples, positivity was confirmed by an ELISA. All reactive syphilis samples were further confirmed for diagnosis of active syphilis disease.

RESULTS

From a total of 4027 clinic attendees, 3213 (79.78%) were FSW, 229 (5.69%) were MSM and 585 (14.53%) were HRH. The proportion of FSW, MSM and HRH who had a single visit was 56.42%, 57.23% and 91.10%, respectively. Overall, HIV prevalence was 2.10% in FSW, 8.17% in MSM and 4.12% in HRH. Prevalence trends in HIV and syphilis decreased in FSW. Prevalence trends in gonorrhoea did not decrease over time neither in FSW nor in HRH. Chlamydia and trichomonas infections in HRH showed an increase prevalence trend. In FSW, trends in condom use in last sexual intercourse with regular and occasional clients were above 93%.

CONCLUSIONS

FSW show a decreasing trend in HIV, syphilis and chlamydia prevalence. Gonorrhoea prevalence in FSW and HRH did not decrease over time. HRH is a hard to engage population with low follow-up rates and high potential to act as a bridge population.

Trend and Factors Associated with Condom Use Among Male Clients of Female Sex Workers in Hong Kong: Findings of 13 Serial Behavioural Surveillance Surveys

This study investigated the trend and associated factors of condom use among male clients of female sex workers (CFSW) in Hong Kong. A total of 25,443 males of the general population were screened to identify 2,330 CFSW via 13 rounds of population-based serial cross-sectional telephone surveys during 1998 through 2015. Over time, there were no significant changes in condom use with various types of female sex partners (p ranged 0. 219-0.837) and prevalence of self-reported STI (p = 0.975) in the past 6 months. Decrease in the prevalence of non-regular sex partners (p < 0.001) and increase in perceived efficacy of condom use for HIV prevention (p = 0.028) were observed. Perceived efficacy of condom use for HIV prevention and self-reported STI experience were significantly associated with condom use with various types of female sex partners in the past 6 months. No evident improvement for condom use was found. Tailored intervention programs are warranted.

Heterosexual men who purchase sex and attended an STI clinic in Israel: characteristics and sexual behavior

Background

Commercial sex shares a role in HIV and sexually transmitted infections (STI) transmission. Men who pay for sex (MPS) may transmit HIV/STI to other populations which are low-risk. This study aimed to test our hypothesis that MPS engage in high-risk sexual behaviors associated with HIV/STI transmission more so than non-MPS.

Methods

This cross-sectional study included heterosexual men who attended an STI clinic between 2003 and 2010. Demographic, clinical, behavioral and laboratory data were compared between MPS and non-MPS to identify factors associated with high-risk sexual behavior and STI-burden.

Results

Of the first visits of 6156 heterosexual men who attended the STI-clinic during the study period, 1649 (26.7%) were MPS. MPS were more commonly older, married and non-Israeli born compared with non-MPS. MPS were more likely to engage in risk-behaviors associated with HIV/STI-transmission, including a greater number of lifetime sexual partners, substance use and previous STI diagnoses.

Determinants associated with STI-diagnoses at the current visit included being non-Israeli born, presenting with STI symptoms, reporting a greater number of lifetime sexual partners and having sexual encounters with non-Israeli individuals.

Conclusions

Approximately 25% of all men who attended the clinic were MPS. They were more likely to engage in risk-behaviors associated with HIV/STI transmission compared to non-MPS. These findings highlight the need to establish interventions for MPS that both continue to encourage condom use and address the potential perils pertaining to risky sexual behaviors.

Barriers to HIV testing among male clients of female sex workers in Indonesia

BACKGROUND

Frequent engagement of men in sexual encounters with female sex workers (FSWs) without using condoms places them at a high risk for HIV infection. HIV testing has been noted to be among important strategies to prevent HIV transmission and acquisition. However, it is known that not all men willingly undertake an HIV test as a way to prevent HIV transmission and/or acquisition. This study aimed to identify barriers to accessing HIV testing services among men who are clients of FSWs (clients) in Belu and Malaka districts, Indonesia.

METHODS

A qualitative inquiry employing face to face open ended interviews was conducted from January to April 2017. The participants (n = 42) were clients of FSWs recruited using purposive and snowball sampling techniques. Data were analysed using a qualitative data analysis framework.

RESULTS

Findings indicated three main barriers of accessing HIV testing services by clients. These included: (1) personal barriers (lack of knowledge of HIV/AIDS and HIV testing availability, and unwillingness to undergo HIV testing due to low self-perceived risk of HIV and fear of the test result); (2) health care service provision barriers (lack of trust in health professionals and limited availability of medication including antiretroviral (ARV)); and (3) social barriers (stigma and discrimination, and the lack of social supports).

CONCLUSIONS

These findings indicated multilevelled barriers to accessing HIV testing services among participants, who are known to be among key population groups in HIV care. Actions to improve HIV/AIDS-related health services accessibility are required. The dissemination of the knowledge and information on HIV/AIDS and improved available of HIV/AIDS-related services are necessary actions to improve the personal levelled barriers. System wide barriers will need improved practices and health policies to provide patients friendly and accessible services. The societal levelled barriers will need a more broad societal approach including raising awareness in the community and enhanced discussions about HIV/AIDS issues in order to normalise HIV in the society.

High condom use but low HIV testing uptake reported by men who purchase sex in Bali, Indonesia

Men who purchase sex (MWPS) have long been considered as one of the population groups at risk of HIV transmission. However, while HIV-related interventions have been targeted towards this group, few studies have directly recruited MWPS to measure the impact of such interventions. This study aimed to fill the gap for Indonesia by identifying the level and predictors of condom use and HIV testing among MWPS, to inform prevention strategies. A cross-sectional study was conducted by surveying 200 MWPS in Bali, Indonesia in 2015. A structured questionnaire was administered to collect the data. Self-reported condom use on the occasion of last paid sex was very high (88.5%), while a history of HIV testing was low (8.1%). None of the variables identified in this study were associated with condom use at last paid sex. Men were more likely to report a history of HIV testing if they: perceived themselves to be at high risk of HIV, had a higher level of HIV-related knowledge, reported a history of genital ulcers or urethral discharge in the past 12 months, or were aware that confidential HIV testing was available. Implications and limitations of this study are discussed.

Behavioral and Psychosocial Correlates of HIV Testing Among Male Clients of Female Sex Workers in Tijuana, Mexico

We use data collected from a sample of 400 male clients of female sex workers (FSW) to examine their HIV testing behavior. We present frequencies of HIV testing and used bivariate and multivariable analyses to assess its socio-demographic, behavioral, and psychosocial correlates. We found that the majority (55 %) of male clients of FSW in Tijuana, Mexico had never had an HIV test and the prevalence of HIV testing within the past year was low (9 %). In multivariable analyses, significant correlates of having ever tested for HIV were higher age, higher HIV knowledge score, lower sexual compulsiveness score, lower misogynistic attitudes score, having a condom break during sex with a FSW, and higher frequency of sex with a FSW while she was high. Our findings represent an important starting point for developing effective interventions to address the need to promote HIV testing among this population.

Prevalence of Alcohol Use, Sexual Risk Behavior, and HIV Among Russians in High-Risk Settings: a Systematic Review and Meta-Analysis

PURPOSE

The purpose of this study was to examine the (a) prevalence of and (b) association between alcohol, risky sex, and HIV among Russians at risk for primary or secondary HIV transmission.

METHOD

Electronic databases were searched to locate studies that sampled Russians, assessed alcohol use, and included either a behavioral measure of risk or a biological measure of HIV. Weighted mean (logit) effect sizes were calculated using random-effects assumptions. Moderator analyses were conducted using meta-regression.

RESULTS

Studies (19) sampled 12,916 Russians (M age = 29; 36 % women). Participants were recruited from clinical (52 %; e.g., sexually transmitted infection (STI) clinic, drug treatment), other high-risk community settings (32 %; e.g., sexual/drug networks), or both (16 %). Findings indicate that a substantial proportion of the participants used alcohol (77 %; 55 % heavy drinking). One half of participants reported using condoms (52 %), but only 29 % used condoms consistently. Most participants reported drinking before sex (64 %). Of the studies testing for HIV, 10 % of participants tested positive. Meta-regression analyses indicated that hazardous/harmful alcohol use was associated with increased risky behaviors (i.e., multiple partners, inconsistent condom use).

CONCLUSION

These findings support the need for and potential benefit of addressing alcohol use in HIV prevention programming in Russia.

Correlates of Double Risk of HIV Acquisition and Transmission Among Women who Inject Drugs in St. Petersburg, Russia

Russia continues to experience a growing HIV epidemic, and women account for an increasing proportion of new HIV diagnoses in the country. This study aims to provide up-to-date information on factors associated with unsafe sex and drug use behaviors among women who inject drugs in St. Petersburg, Russia. In this community-based sample of 500 women who inject drugs, 64% tested positive for HIV. Women reported the following: 21% reported injection risk, 22% reported sexual risk, and 18% reported double risk. Multivariable analyses using logistic multinomial regression showed that older age is associated with increased risk behaviors. Involvement in transactional sex is associated with injection risk [aOR = 1.59 (1.02, 2.48)] but protective against sexual risk [aOR = 0.11 (0.06, 0.19)]. Exposure to sexual violence is associated with increased injection risk [aOR = 1.78 (1.01, 3.14)] and double risk [aOR = 3.38 (1.50, 7.63)]. These findings indicate the need to address both the unsafe injection and sexual risks among women who inject drugs in Russia.

Declining Inconsistent Condom Use but Increasing HIV and Syphilis Prevalence Among Older Male Clients of Female Sex Workers: Analysis From Sentinel Surveillance Sites (2010-2015), Guangxi, China

Clients of female sex workers (CFSWs) are a bridge population for the spread of HIV and syphilis to low or average risk heterosexuals. Most studies have examined the point prevalence of these infections in CFSWs. Limited evidence suggests that older age CFSWs are at a higher risk of acquiring sexually transmitted diseases compared with younger clients. Thus, we sought to describe long-term trends in HIV, syphilis, and hepatitis C (HCV) to better understand how these infections differ by sex worker classification and client age. We also examined trends in HIV, syphilis, and HCV among categories of female sex workers (FSWs).We conducted serial cross-sectional studies from 2010 to 2015 in Guangxi autonomous region, China. We collected demographic and behavior variables. FSWs and their clients were tested for HIV, syphilis, and HCV antibodies. Positive HIV and syphilis serologies were confirmed by Western blot and rapid plasma regain, respectively. Clients were categorized as middle age (40-49 years) and older clients (≥50 years). FSWs were categorized as high-tier, middle-tier, or low-tier based on the payment amount charged for sex and their work venue. Chi-square test for trends was used for testing changes in prevalence over time.By 2015, low-tier FSWs (LTFSWs) accounted for almost half of all FSWs; and they had the highest HIV prevalence at 1.4%. HIV prevalence declined significantly for FSWs (high-tier FSW, P = 0.003; middle-tier FSWs; P = 0.021; LTFSWs, P < 0.001). Syphilis infections significantly declined for FSWs (P < 0.001) but only to 7.3% for LTFSWs. HCV and intravenous drug use were uncommon in FSWs. HIV prevalence increased for older age clients (1.3%-2.0%, P = 0.159) while syphilis prevalence remained stable. HCV infections were halved among older clients in 3 years (1.7%-0.8%, P < 0.001). Condom use during the last sexual encounter increased for FSWs and CFSWs. Few clients reported sex with men or intravenous drug use. Clients preferred LTFSWs, especially older clients (81.9%).Our results suggest that HIV and syphilis infections are increasing in older clients who prefer LTFSWs. HIV and syphilis are likely increasing in Guangxi Province through heterosexual transmission.

Correlates of Lifetime History of Purchasing Sex Services by Men in Saint Petersburg and Leningrad Oblast, Russia

Commercial sex workers (CSWs) in the Russian Federation are at high risk of HIV infection and transmission as a result of unsafe sexual and injecting behaviors. Their clients might be at increased risk of acquiring HIV; however, little is known about the population of men purchasing sex services. This study aims to investigate factors associated with a history of purchasing sex services by men in Saint Petersburg and Leningrad Oblast, Russian Federation. Data were collected as part of a cross-sectional study offering free anonymous rapid HIV testing in Saint Petersburg and Leningrad Oblast in 2014; in total, 3565 men aged 18 years and older provided information about their behaviors associated with risk of acquiring HIV during face-to-face interviews. Prevalence of CSW use in our study was 23.9%. Multivariable analyses using log-binomial regression were stratified by self-reported HIV testing during the 12 months preceding the study interview. In both strata, older age, multiple sex partners, and a history of sex with an injection drug user (IDU) were associated with an elevated prevalence ratio (PR) for history of purchasing sex services, although the strength of the association differed by strata. Among men who reported recent HIV testing, condom use (PR = 1.22, 90% confidence interval (CI) 1.0, 1.48) was associated with a history of purchasing sex services, and among men who did not report recent HIV testing, having a consistent sex partner was associated with purchasing sex services (PR = 1.23, 90% CI 1.1, 1.37). The high prevalence of CSW service use and associations found in this study raise serious concerns about potential for sexual HIV transmission and should be investigated more closely.

Buffering Syndemic Effects in a Sexual Risk-Reduction Intervention for Male Clients of Female Sex Workers: Results From a Randomized Controlled Trial

OBJECTIVES

We sought to test the efficacy of a sexual risk intervention for male clients of female sex workers (FSWs) and examine whether efficacy was moderated by syndemic risk.

METHODS

From 2010 to 2014, we conducted a 2-arm randomized controlled trial (60-minute, theory-based, safer sex intervention versus a didactic time-equivalent attention control) that included 400 male clients of FSWs on the US-Mexico border with follow-up at 4, 8, and 12 months. We measured 5 syndemic risk factors, including substance use and depression. Primary outcomes were sexually transmitted infections incidence and total unprotected sex with FSWs.

RESULTS

Although participants in both groups became safer, there was no significant difference in behavior change between groups. However, baseline syndemic risk moderated intervention efficacy. At baseline, there was a positive association between syndemic risk and unprotected sex. Then at 12 months, longitudinal analyses showed the association depended on intervention participation (B = -0.71; 95% confidence interval [CI] = -1.22, -0.20; P = .007). Among control participants there still existed this modest association (B = 0.36; 95% CI = -0.49, 1.22; P = .09); among intervention participants there was a significant negative association (B = -0.35; 95% CI = -0.63, -0.06; P = .02).

CONCLUSION

A brief intervention might attenuate syndemic risks among clients of FSWs. Other populations experiencing syndemic problems may also benefit from such programs.

Association between Pregnancy and Active Injection Drug Use and Sex Work among Women Injection Drug Users in Saint Petersburg, Russia

Widespread use of unsafe sexual practices among women injecting drugs both practicing and not practicing sex work leads to high levels of unplanned pregnancies in this population. The goal of this study was to investigate the association between pregnancy and active drug use and sex work. Data were collected using a convenience sample of 500 women in Saint Petersburg, Russia, in 2013. All women had recent experience of drug use, of which 200 were pregnant at the time of the study. The study consisted of a structured interview followed by a rapid HIV test. Pregnancy was protective against both active drug use and sex work. For HIV-positive women, these associations were stronger than for HIV-negative women: drug use prevalence ratio (PR) was 0.59 vs 0.85; for sex work, the PRs were 0.36 vs 0.64. Higher levels of education were associated with a lower prevalence ratio for active drug use and sex work in all models. Having children was not associated with active drug use or sex work. Pregnancy might be an optimal time for conducting interventions aimed at cessation of drug use and sex work among women injecting drugs.

Current and recent drug use intensifies sexual and structural HIV risk outcomes among female sex workers in the Russian Federation

BACKGROUND

Female sex workers (FSW) and people who inject drugs (PWID) are at high risk for HIV infection, with FSW-PWID at even greater risk. HIV-related research often focuses on the primary mode of transmission - sexual or parenteral transmission for FSW and PWID, respectively - with less known on how sex work and injection drug use (IDU) are collectively associated with the risk environment experienced by sex workers. We investigated this relationship among FSW in three Russian cities.

METHODS

In 2011, FSWs (N=754) in Tomsk, Krasnoyarsk, and Kazan were recruited via respondent-driven sampling and completed a survey and rapid HIV screening. Multivariable models evaluated the role of injection history (classified as active: last 6 months, former: prior to last 6 months, and never) with a set of sexual and structural HIV risk outcomes.

RESULTS

IDU was common: 11% actively injected drugs and 11% were former injectors. HIV infection was most prevalent among active injectors (AOR: 6.7; 95% CI: 2.4-18.9) and former injectors (AOR:4.5; 95%CI: 1.7-11.6), compared to non-injectors. Some 6-8% of non-injecting FSWs reported recent physical or sexual client violence and 23% police extortion. Compared to these non-injectors, active injecting was associated with unprotected anal sex (AOR: 2.8, 95%CI: 1.2-6.4), client violence (AOR: 7.3, 95%CI: 2.1-24.7), and police extortion (AOR: 3.0 95%CI: 1.5-5.9%). Self-reported sexual and structural risk outcomes were also more prevalent among active compared to former injectors; however, few differences existed between former and non-injectors.

CONCLUSIONS

FSW experience sexual, structural, and HIV risk outcomes and these risks are amplified for actively injecting FSWs. FSW who stopped injecting drugs demonstrated risk profiles closer to those of sex workers who had no history of injection. HIV prevention programs and outreach can provide opportunities to include harm reduction interventions and linkage to treatment for FSW to move FSWs towards lower risk environments.

HIV infection among female sex workers in concentrated and high prevalence epidemics: why a structural determinants framework is needed

PURPOSE OF REVIEW

This article reviews the current state of the epidemiological literature on female sex work and HIV from the past 18 months. We offer a conceptual framework for structural HIV determinants and sex work that unpacks intersecting structural, interpersonal, and individual biological and behavioural factors.

RECENT FINDINGS

Our review suggests that despite the heavy HIV burden among female sex workers (FSWs) globally, data on the structural determinants shaping HIV transmission dynamics have only begun to emerge. Emerging research suggests that factors operating at macrostructural (e.g., migration, stigma, criminalized laws), community organization (e.g., empowerment) and work environment levels (e.g., violence, policing, access to condoms HIV testing, HAART) act dynamically with interpersonal (e.g., dyad factors, sexual networks) and individual biological and behavioural factors to confer risks or protections for HIV transmission in female sex work.

SUMMARY

Future research should be guided by a Structural HIV Determinants Framework to better elucidate the complex and iterative effects of structural determinants with interpersonal and individual biological and behavioural factors on HIV transmission pathways among FSWs, and meet critical gaps in optimal access to HIV prevention, treatment, and care for FSWs globally.

Hazardous drinking and HIV-risk-related behavior among male clients of female sex workers in Tijuana, Mexico

BACKGROUND AND OBJECTIVES

Male clients of female sex workers (FSWs) are at high risk for HIV. Whereas the HIV risks of alcohol use are well understood, less is known about hazardous alcohol use among male clients of FSWs, particularly in Mexico. We sought to identify risk factors for hazardous alcohol use and test associations between hazardous alcohol use and HIV risk behavior among male clients in Tijuana.

METHOD

Male clients of FSWs in Tijuana (n = 400) completed a quantitative interview in 2008. The AUDIT was used to characterize hazardous alcohol use. Multivariate logistic regression was used to determine independent associations of demographic and HIV risk variables with hazardous alcohol use (vs. non-hazardous).

RESULTS

Forty percent of our sample met criteria for hazardous alcohol use. Variables independently associated with hazardous drinking were reporting any sexually transmitted infection (STI), having sex with a FSW while under the influence of alcohol, being younger than 36 years of age, living in Tijuana, and ever having been jailed. Hazardous drinkers were less likely ever to have been deported or to have shared injection drugs.

DISCUSSION AND CONCLUSIONS

Hazardous alcohol use is associated with HIV risk, including engaging in sex with FSWs while intoxicated and having an STI among male clients of FSWs in Tijuana.

SCIENTIFIC SIGNIFICANCE

We systematically described patterns and correlates of hazardous alcohol use among male clients of FSWs in Tijuana, Mexico. The results suggest that HIV/STI risk reduction interventions must target hazardous alcohol users, and be tailored to address alcohol use.

HIV transmission from drug injectors to partners who do not inject, and beyond: modelling the potential for a generalized heterosexual epidemic in St. Petersburg, Russia

BACKGROUND

HIV infection is prevalent among drug injectors in St. Petersburg and their non-injecting heterosexual partners (PIDUs). There are fears that sexual transmission of HIV from IDUs to PIDUs may portend a self-sustaining, heterosexual epidemic in Russia.

METHODS

Our model combines a network model of sexual partnerships of IDUs and non-IDUs to represent sexual transmission of HIV and a deterministic model for parenteral transmission among IDUs. Behavioural parameters were obtained from a survey of St. Petersburg IDUs and their sexual partners. We based our model fits on two scenarios for PIDU prevalence in 2006 (5.6% and 15.1%, calculated excluding and including HCV co-infected PIDUs respectively) and compared predictions for the general population HIV prevalence.

RESULTS

Results indicate that sexual transmission could sustain a non-IDU HIV epidemic. The model indicates that general population prevalence may be greater than current estimates imply. Parenteral transmission drives the epidemic and the PIDU bridge population plays a crucial role transferring infection to non-IDUs. The model indicates that the high PIDU prevalence is improbable because of the high risk behaviour this implies; the lower prevalence is possible.

CONCLUSION

The model implies that transmission through PIDUs will sustain a heterosexual epidemic, if prevalence among IDUs and PIDUs is as high as survey data suggest. We postulate that current estimates of population prevalence underestimate the extent of the HIV epidemic because they are based on the number of registered cases only. Curtailing transmission among injectors and PIDUs will be vital in controlling heterosexual transmission.

The influence of stigma and discrimination on female sex workers' access to HIV services in St. Petersburg, Russia

Stigma associated with HIV and risk behaviors is known to be a barrier to health care access for many populations. Less is known about female sex workers (FSW) in Russia, a population that is especially vulnerable to HIV-infection, and yet hard-to-reach for service providers. We administered a questionnaire to 139 FSW to better understand how stigma and discrimination influence HIV service utilization. Logistic regression analysis indicated that HIV-related stigma is negatively associated with uptake of HIV testing, while sex work-related stigma is positively associated with HIV testing. HIV-positive FSW are more likely than HIV-negative FSW to experience discrimination in health care settings. While decreasing societal stigma should be a long-term goal, programs that foster inclusion of marginalized populations in Russian health care settings are urgently needed.