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Cheah YK, Suleiman A, Ramly M. HIV Knowledge and Its Associated Sociodemographic Factors among Female Sex Workers in Malaysia. Malays J Med Sci 2024; 31:160-172. [PMID: 38984243 PMCID: PMC11229571 DOI: 10.21315/mjms2024.31.3.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/16/2023] [Indexed: 07/11/2024] Open
Abstract
Background Female sex workers (FSWs) have a high risk of human immunodeficiency virus (HIV) infection. In spite of the alarming fact that a large proportion of FSWs does not have adequate HIV knowledge, the association between sociodemographic factors and HIV knowledge among FSWs have yet to be thoroughly explored in the context of Malaysia. The aims of this study are the following: i) to determine HIV knowledge and ii) to examine the associated factors of HIV knowledge. Methods An observational cross-sectional study was conducted. Data from the Integrated Biological and Behavioral Surveillance Survey (IBBS) 2017 (n = 630) were used. The survey was carried out in all states in Malaysia and its duration was 4 months (from March 2017 to June 2017). Ordered probit regressions were utilised to shed light on the association between sociodemographic variables and levels of HIV knowledge. Results A large proportion of FSWs had middle-level HIV knowledge (44.1%). FSWs with tertiary-level education were 19.5% more likely to have high-level HIV knowledge compared to those without formal education. The probability of having low-level HIV knowledge was 6.8% lower among FSWs with monthly incomes of RM1,500-RM1,999 than those having incomes of ≤ RM499. Being single instead of married was associated with 7.6%-8% lower probabilities of having low- and middle-level HIV knowledge. Conclusion Public health interventions to improve FSWs' HIV knowledge need to take into consideration the role of sociodemographic factors.
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Affiliation(s)
- Yong Kang Cheah
- School of Economics, Finance and Banking, College of Business, Universiti Utara Malaysia, Kedah, Malaysia
| | - Anita Suleiman
- HIV/STI/Hepatitis C Sector, Ministry of Health Malaysia, Putrajaya, Malaysia
| | - Mazliza Ramly
- HIV/STI/Hepatitis C Sector, Ministry of Health Malaysia, Putrajaya, Malaysia
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2
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Liang B, Zhang F, Ou Y, Zhang P, Bao L, Mo S, Nong A, Wei D, Wu Z, Xie H, Yang Y, Liu D, Liang H, Ye L. Prevalence, Trends and Correlates of HIV, Syphilis and HCV Infection Among Chinese Local and Cross-border Migrant Female Sex Workers in the Sino-Vietnam Border Area of Guangxi, 2016-2021. AIDS Behav 2024; 28:1257-1269. [PMID: 37566152 DOI: 10.1007/s10461-023-04153-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/12/2023]
Abstract
Female sex workers (FSWs) are considered a high-risk group for sexually transmitted infections (STIs). However, limited data exist on the prevalence and trends of HIV, syphilis and HCV among FSWs in the Sino-Vietnam border area. To determine the prevalence, trends and correlates of STIs among Chinese local FSWs (CL-FSWs) and cross-border migrant FSWs (CM-FSWs), we conducted consecutive cross-sectional surveys from 2016 to 2021, recruiting 7747 CL-FSWs and 932 CM-FSWs. The overall HIV, syphilis and HCV prevalence declined from 1.0%, 8.8% and 1.7% to 0.1%, 0.9% and 0.3%, respectively. There was no significant downward trend in the overall HIV and syphilis prevalence. However, HCV prevalence showed a decreasing trend among CL-FSWs. CM-FSWs had higher HIV prevalence (2.5% vs. 0.6%). Similarities and differences in STIs-related factors existed between CM-FSWs and CL-FSWs. For instance, receiving HIV-related services in the last year reduced the risk of HIV infection (for CM-FSWs: aOR = 0.234, 95% CI: 0.055-0.993; for CL-FSWs: aOR = 0.182, 95% CI: 0.058-0.567). Serving male clients at least 50 years old increased the risk of syphilis infection (for CM-FSWs: aOR = 4.277, 95% CI: 1.535-11.917; for CL-FSWs: aOR = 1.404, 95% CI: 1.087-1.815). Moreover, CM-FSWs with past-year STIs history had a higher risk of HIV (aOR = 34.976, 95% CI: 5.338-229.176) and HCV infection (aOR = 17.649, 95% CI: 1.846-168.846), both of which were associated with multiple factors in CL-FSWs. It is therefore necessary to develop effective, accessible, high-quality and targeted interventions for CM-FSWs and CL-FSWs.
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Affiliation(s)
- Bingyu Liang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, Guangxi, 530021, China
- Collaborative Innovation Center of Regenerative Medicine and Medical Bioresource Development and Application Co-constructed by the Province and Ministry, Life Sciences Institute, Guangxi Medical University, Nanning, Guangxi, 530021, China
| | - Fei Zhang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, Guangxi, 530021, China
- Collaborative Innovation Center of Regenerative Medicine and Medical Bioresource Development and Application Co-constructed by the Province and Ministry, Life Sciences Institute, Guangxi Medical University, Nanning, Guangxi, 530021, China
| | - Yanyun Ou
- Chongzuo Center for Disease Control and Prevention, Chongzuo, Guangxi, 532200, China
| | - Peidong Zhang
- Fangchenggang Center for Disease Control and Prevention, Fangchenggang, Guangxi, 538000, China
| | - Lijuan Bao
- Chongzuo Center for Disease Control and Prevention, Chongzuo, Guangxi, 532200, China
| | - Shide Mo
- Fangchenggang Center for Disease Control and Prevention, Fangchenggang, Guangxi, 538000, China
| | - Aidan Nong
- Chongzuo Center for Disease Control and Prevention, Chongzuo, Guangxi, 532200, China
| | - Dongmei Wei
- Chongzuo Center for Disease Control and Prevention, Chongzuo, Guangxi, 532200, China
| | - Zhenxian Wu
- Chongzuo Center for Disease Control and Prevention, Chongzuo, Guangxi, 532200, China
| | - Hai Xie
- Fangchenggang Center for Disease Control and Prevention, Fangchenggang, Guangxi, 538000, China
| | - Yuan Yang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, Guangxi, 530021, China
- Collaborative Innovation Center of Regenerative Medicine and Medical Bioresource Development and Application Co-constructed by the Province and Ministry, Life Sciences Institute, Guangxi Medical University, Nanning, Guangxi, 530021, China
| | - Deping Liu
- Chongzuo Center for Disease Control and Prevention, Chongzuo, Guangxi, 532200, China.
| | - Hao Liang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, Guangxi, 530021, China.
- Collaborative Innovation Center of Regenerative Medicine and Medical Bioresource Development and Application Co-constructed by the Province and Ministry, Life Sciences Institute, Guangxi Medical University, Nanning, Guangxi, 530021, China.
| | - Li Ye
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, Guangxi, 530021, China.
- Collaborative Innovation Center of Regenerative Medicine and Medical Bioresource Development and Application Co-constructed by the Province and Ministry, Life Sciences Institute, Guangxi Medical University, Nanning, Guangxi, 530021, China.
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3
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Systematic Review of Hepatitis C Virus Prevalence in the WHO Western Pacific Region. Viruses 2022; 14:v14071548. [PMID: 35891529 PMCID: PMC9320901 DOI: 10.3390/v14071548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This review aimed to identify hepatitis C virus (HCV) prevalence estimates among the general population and six key populations (people who inject drugs, men who have sex with men, sex workers, prisoners/detainees, Indigenous people, and migrants) in the World Health Organization Western Pacific Region (WHO WPR). METHODS Original research articles published between 2016 and 2020 were identified from bibliographic databases. Publications were retrieved, replicas removed, and abstracts screened. Retained full texts were assessed and excluded if inclusion criteria were not met. Methodological quality was assessed using the Johanna Briggs Institute critical appraisal checklist for prevalence data. Data on HCV exposure and active infection were extracted and aggregated and forest plots generated for each population by country. RESULTS There were no HCV prevalence estimates in any population for more than half of WPR countries and territories. Among the 76 estimates, 97% presented prevalence of exposure and 33% prevalence of active infection. General population viraemic prevalence was 1% or less, except in Mongolia. Results confirm the endemic nature of HCV among people who inject drugs, with estimates of exposure ranging from 30% in Cambodia to 76% in Hong Kong. CONCLUSIONS Countries require detailed knowledge of HCV prevalence in diverse populations to evaluate the impact of efforts to support WHO HCV elimination goals. Results provide baseline estimates from which to monitor and evaluate progress and by which to benchmark future elimination efforts.
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Liang B, Huang Q, Ou Y, Zhang F, Zhang P, Nong A, Mo S, Wu Z, Xie H, Liang H, Liu J, Jiang J, Liang H, Liu D, Ye L. Trends and associated factors in the uptake of HIV testing among female sex workers in Sino-Vietnam border areas in Guangxi, China: a cross-sectional study. BMC Infect Dis 2022; 22:479. [PMID: 35590271 PMCID: PMC9118634 DOI: 10.1186/s12879-022-07459-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background HIV testing is a primary prevention strategy against the HIV epidemic and an entry point for HIV/AIDS-related care, prevention and treatment. This study aimed to estimate the uptake of HIV testing among Sino-Vietnam female sex workers (FSWs) in Guangxi, China, from 2016 to 2018, and to identify the factors influencing HIV testing uptake. Methods A cross-sectional survey was conducted among FSWs in two Sino-Vietnam border cities of Guangxi, China. The survey was conducted through face-to-face interview, the data were collected by a structured questionnaire, and HIV-1 infection was detected simultaneously. Logistic regression analysis was used to determine the factors associated with uptake of HIV testing. Results In total, 4565 Chinese local FSWs (CL-FSWs) and 636 cross-border migrant Vietnamese FSWs (CMV-FSWs) were recruited into this study. HIV-1 prevalence in CL-FSWs and CMV-FSWs was 0.70% and 3.14%, respectively. The rate of self-reported uptake of HIV testing in CL-FSWs and CMV-FSWs was 54.56% and 45.44%, respectively. The rates of self-reported uptake of HIV testing declined in both groups from 2016 to 2018. Logistic regression analysis indicated that a number of factors, including socio-demographic characteristics (age < 35 years, higher education, location in Chongzuo City), behaviour factors (having received free AIDS education, condom distribution services and peer education services, high risk sexual behaviours such as inconsistent condom use, having regular commercial sexual partners, etc.), psychological factors (perception of vulnerability to HIV/STIs, perception of risk for HIV infection) were the factors significantly related to uptake of HIV testing. Conclusion In recent years, the rate of HIV testing uptake among Sino-Vietnam border FSWs in Guangxi, China was low, which may be an important reason for the high HIV-1 prevalence among FSWs in the region. A number of factors were identified to be associated with HIV-1 testing uptake, suggesting that HIV testing prevention strategies in this region could include accelerating AIDS education training, raising personal awareness of HIV testing, and improving accessibility of HIV testing. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07459-3.
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Affiliation(s)
- Bingyu Liang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Sciences Institute, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Qianni Huang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Yanyun Ou
- Chongzuo Center for Disease Control and Prevention, Chongzuo, 532200, Guangxi, China
| | - Fei Zhang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Peidong Zhang
- Fangchenggang Center for Disease Control and Prevention, Fangchenggang, 538000, Guangxi, China
| | - Aidan Nong
- Chongzuo Center for Disease Control and Prevention, Chongzuo, 532200, Guangxi, China
| | - Shide Mo
- Fangchenggang Center for Disease Control and Prevention, Fangchenggang, 538000, Guangxi, China
| | - Zhenxian Wu
- Chongzuo Center for Disease Control and Prevention, Chongzuo, 532200, Guangxi, China
| | - Hai Xie
- Fangchenggang Center for Disease Control and Prevention, Fangchenggang, 538000, Guangxi, China
| | - Huayue Liang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Sciences Institute, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Jie Liu
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Sciences Institute, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Junjun Jiang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Sciences Institute, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Hao Liang
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Sciences Institute, Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Deping Liu
- Chongzuo Center for Disease Control and Prevention, Chongzuo, 532200, Guangxi, China.
| | - Li Ye
- Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China. .,Guangxi Collaborative Innovation Center for Biomedicine, Life Sciences Institute, Guangxi Medical University, Nanning, 530021, Guangxi, China.
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Yu J, Nehl EJ, Dinh VP, Liang B, Son NV, Meng D, Zhang Y, Jiang J, Huang J, Ning C, Liao Y, Chen H, Zang N, Chen R, Liu D, Ye L, Liang H. Vietnamese female sex workers in rural cross-border areas of Guangxi, China: migration and HIV/STI risk behaviors. AIDS Care 2020; 32:1515-1523. [PMID: 32008356 DOI: 10.1080/09540121.2020.1719968] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
China's HIV/AIDS epidemic continues to grow in rural and less developed areas. This consecutive cross-sectional study examines demographic and behavioral factors associated with HIV/STI infection, Hepatitis C (HCV) and other sexually transmitted infections (STIs) among Vietnamese female sex workers (FSW), a vulnerable population who cross into Guangxi, China. This study is a secondary data analysis of 303 Vietnamese and 4,348 Chinese FSWs recruited over seven years from two Chinese counties that border Vietnam. Logistic regression models compared demographics, HIV/STI status, HIV/AIDS-related knowledge, attitudes, and risk behaviors between Vietnamese FSWs and Chinese FSWs. Compared with Chinese FSWs, Vietnamese FSWs were younger, had attained lower education levels, were highly mobile, more likely to report using drugs, and were more vulnerable to HIV/STIs. Younger age, less educational attainment, shorter time in their current working location, no voluntary HIV testing in the last year, greater drug use, and not using condoms for all commercial sex in the last month were associated with higher HIV/STIs. In conclusion, several factors were associated with HIV/STI risk in Vietnamese cross-border FSWs. There is a pressing need to improve support systems for Vietnamese cross-border FSW and health system cooperation across the Chinese/Vietnamese border.
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Affiliation(s)
- Jun Yu
- Guangxi Key Laboratory of AIDS Prevention and Treatment & Guangxi Universities Key Laboratory of Prevention and Control of Highly Prevalent Disease, School of Public Health, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Eric J Nehl
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Van Phu Dinh
- HaTinh Medical College, Ha Tinh City, Ha Tinh Province, Vietnam
| | - Bingyu Liang
- Guangxi Key Laboratory of AIDS Prevention and Treatment & Guangxi Universities Key Laboratory of Prevention and Control of Highly Prevalent Disease, School of Public Health, Guangxi Medical University, Nanning, Guangxi, People's Republic of China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Science Institute, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Nguyen Van Son
- Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen City, Vietnam
| | - Donghua Meng
- Ningming Center for Disease Control and Prevention, Guangxi, Ningming County, People's Republic of China
| | - Yi Zhang
- Longzou Center for Disease Control and Prevention, Guangxi, People's Republic of China
| | - Junjun Jiang
- Guangxi Key Laboratory of AIDS Prevention and Treatment & Guangxi Universities Key Laboratory of Prevention and Control of Highly Prevalent Disease, School of Public Health, Guangxi Medical University, Nanning, Guangxi, People's Republic of China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Science Institute, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Jiegang Huang
- Guangxi Key Laboratory of AIDS Prevention and Treatment & Guangxi Universities Key Laboratory of Prevention and Control of Highly Prevalent Disease, School of Public Health, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Chuanyi Ning
- Guangxi Key Laboratory of AIDS Prevention and Treatment & Guangxi Universities Key Laboratory of Prevention and Control of Highly Prevalent Disease, School of Public Health, Guangxi Medical University, Nanning, Guangxi, People's Republic of China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Science Institute, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Yanyan Liao
- Guangxi Key Laboratory of AIDS Prevention and Treatment & Guangxi Universities Key Laboratory of Prevention and Control of Highly Prevalent Disease, School of Public Health, Guangxi Medical University, Nanning, Guangxi, People's Republic of China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Science Institute, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Hui Chen
- Guangxi Key Laboratory of AIDS Prevention and Treatment & Guangxi Universities Key Laboratory of Prevention and Control of Highly Prevalent Disease, School of Public Health, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Ning Zang
- Guangxi Key Laboratory of AIDS Prevention and Treatment & Guangxi Universities Key Laboratory of Prevention and Control of Highly Prevalent Disease, School of Public Health, Guangxi Medical University, Nanning, Guangxi, People's Republic of China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Science Institute, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Rongfeng Chen
- Guangxi Key Laboratory of AIDS Prevention and Treatment & Guangxi Universities Key Laboratory of Prevention and Control of Highly Prevalent Disease, School of Public Health, Guangxi Medical University, Nanning, Guangxi, People's Republic of China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Science Institute, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Deping Liu
- Chongzuo Center for Disease Control and Prevention, Chongzuo, Longzhou County, Guangxi, People's Republic of China
| | - Li Ye
- Guangxi Key Laboratory of AIDS Prevention and Treatment & Guangxi Universities Key Laboratory of Prevention and Control of Highly Prevalent Disease, School of Public Health, Guangxi Medical University, Nanning, Guangxi, People's Republic of China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Science Institute, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Hao Liang
- Guangxi Key Laboratory of AIDS Prevention and Treatment & Guangxi Universities Key Laboratory of Prevention and Control of Highly Prevalent Disease, School of Public Health, Guangxi Medical University, Nanning, Guangxi, People's Republic of China.,Guangxi Collaborative Innovation Center for Biomedicine, Life Science Institute, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
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Yu YJ, McCarty C, Wang B. Network and Individual Factors Associated with Drug Use among Female Sex Workers (FSWs) in Southern China: A Mixed-Method Approach. Subst Use Misuse 2018; 53:1763-1770. [PMID: 29461126 DOI: 10.1080/10826084.2018.1432650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Research on women who engage both in drug use and sex work has been limited, as most previous studies have focused on these risk behaviors separately. The current study examines the network properties as well as the demographic and behavioral factors associated with drug use among female sex workers (FSWs) in southern China. We collected survey data (n = 175) in the Hainan province during our 26 months of ethnographic fieldwork in China. Our analyses included Fisher's exact chi-square tests, independent-samples t-tests, Mann-Whitney U, binary logistic regression (LR), as well as ethnographic data analysis. Multivariate analysis showed that women who were younger age, single, more educated, and earning a higher income were more likely to use drugs. Pertaining to network properties, FSWs with a lower percentage of long-term clients (and men) in ego networks were more likely to use drugs; this would imply a mechanism by which drug-using FSWs are more at risk, as the women take a greater number of transient clients. In addition, FSWs who were influential network members (i.e., higher betweenness centrality) and were closely related to other network members (i.e., higher closeness centrality) were more likely to use drugs; this may suggest that drug use is a means of sustaining the high functionality of the workers. Our ethnographic data also showed that club drug use was easily accessible in entertainment venues and was often a means of socialization in FSW communities. Network characteristics correlated to HIV-related risks among FSWs should be further examined in future studies.
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Affiliation(s)
- Yeon Jung Yu
- a Department of Anthropology , Western Washington University , Bellingham , Washington , USA
| | - Christopher McCarty
- b Bureau of Economic and Business Research, University of Florida , Gainesville , Florida , USA
| | - Bo Wang
- c Departments of Quantitative Health Sciences and Emergency Medicine , The University of Massachusetts Medical School , Worcester , Massachusetts , USA
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