Typology of older female sex workers and sexual risk for HIV infection in China: a qualitative study

"A little love is enough for me to live my life…": Precarity and resilience among older sex workers in India

Most research on sex workers globally has focused on cis women sex workers vulnerabilities including violence, risk for HIV/AIDS, and stigma. Despite the plethora of studies on the topic, older sex workers are significantly underrepresented in research. We used a phenomenological approach to highlight street and home-based sex workers' experiences. Using a purposive sampling strategy, 39 cis women sex workers were recruited from Karnataka, India and data were collected using in-depth interviews and focus group discussions. Findings revealed a range of changes in sex workers' lives as they aged, financial instability, lack of alternate livelihood options, and limited access to governmental benefits and social security. Participant narratives challenged the notion of anticipated traditional familial support especially from their grown children. Findings were replete with instances of sex workers' personal agency to confront personal and professional challenges. Peer networks formed the biggest forms of support as were sex workers' connections with local community-based groups. There is an urgent need for helping professionals to recognize the ongoing marginalization faced by older sex workers. It is critical to address concerns broadly along with inequities in terms of access and power as experienced by older sex workers. Finally, examining the differential impact of ageism, structural barriers including neglect by the State, violence, and stigma that follow sex workers is vital.

I'm a 45-year-old woman in the body of an 80-year-old: The multiple losses of living and aging in the shadow of prostitution

INTRODUCTION

Research on aging women who are involved in prostitution is currently limited, both in terms of the number of studies conducted and their scope. Nevertheless, the available research suggests that women who are aging while involved in prostitution may confront some unique challenges. Thus, the study aims to explore the experiences of aging as narrated by Arab women in prostitution, using Intersectionality as a theoretical framework.

METHOD

Interpretive phenomenological analysis was used, and semistructured interviews were performed with 12 participants.

FINDINGS

Four themes emerged: "I'm a 45-year-old woman in the body of an 80-year-old:" Loss of physical and mental health; "There is no retirement plan in prostitution: Economic and social losses; As they were taken, my soul went with them too: The loss of the parenting experience and motherhood"; and "I'm going to get older with the disgust clinging to me:" The loss of authentic identity and dignity.

CONCLUSION

The findings demonstrate how aging serves to exacerbate overlapping forms of discrimination and marginalization.

CLINICAL RELEVANCE

Healthcare professionals, including nurses caring for older women in prostitution, should be aware of their unique circumstances, considering the social, economic, and healthcare obstacles they face. By being cognizant of these factors, healthcare practitioners can provide meaningful assistance in their pursuit of improved quality of life.

Prostitution in the shadow of life-long sexual abuse: Arab women's retrospective experiences

The present study uses the life-course and intersectionality perspectives to explore the meaning that aging Arab women attribute to their lived experiences of life-long sexual abuse in the shadow of engaging in prostitution. Interpretive phenomenological analysis was used to analyze the narratives of 10 older Arab women in Israel who were engaged in prostitution. Four themes emerged: experiencing childhood in the shadow of sexual abuse, becoming a prostitute, being entrapped in prostitution, and settling accounts with the native culture. Women aging in prostitution experience a harsh reality of abuse and loss. The present study points to multiple channels of abuse throughout the life course, from childhood until old age.

Biobehavioral survey using time location sampling among female sex workers living in Ghana in 2020

Background

The HIV epidemic in Ghana is characterized as a mix of a low-level generalized epidemic with significant contributions from transmission among female sex workers (FSW) and their clients. This study seeks to identify and describe key characteristics and sexual behaviors of FSW and estimate the prevalence of HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus (HBV) among FSW in Ghana.

Method

A total of 7,000 FSW were recruited for the study using Time Location Sampling (TLS) approach with 5,990 (85.6%) participants completing both biological and the behavioral aspects of the study. A structured questionnaire was administered to respondents to assess several factors, such as background characteristics, sexual risk behaviors, condom usage, HIV/AIDS knowledge, opinions, and attitudes. Trained staff conducted face-to-face interviews using mobile data collection software (REDCap) after provision of specimens for HIV and STI testing. Descriptive statistics such as medians, ranges, charts, and percentages are performed and presented. Also included, are bivariate analyses to establish relationships between FSW type and other relevant characteristics of the study.

Results

Among the 7,000 (100%) FSW sampled from all regions, 6,773 took part in the behavioral and 6,217 the biological. There were 783 (11.2%) respondents who took part only in the behavioral and 227 (3.2%) only in the biological. Most were young, with a median age of 26 years, majority had never been married or were widowed/divorced and a quarter had no education or had only primary education. Majority (74.8%) of FSW first sold sex at age 25 years or less with a median age of 20 years. Most (84.8%) of the FSW indicated that they entered sex work for money, either for self or family and had an average of eleven (11) sexual partners per week. More than half (55.2%) of the FSW were new entrants who had been in sex work for less than 5 years before the study. Consistent condom use with paying clients was generally unsatisfactory (71%), and was however, very low (24%) with their intimate partners or boyfriends. Only about half (54.6%) of FSW have been exposed to HIV prevention services in the last three months preceding the survey, and this varies across regions. Overall, comprehensive knowledge about HIV and AIDS was low. Only 35% of FSW had comprehensive knowledge. HIV prevalence was 4.6% and was higher among seaters (brothel-based) and older FSW who had been sex work for a longer period. The HIV prevalence from the previous bio-behavioral survey (BBS) in 2015 and 2011 were estimated to be 6.9 and 11.1%, respectively.

Conclusion

Compared to the results from the previous studies, the findings give an indication that Ghana is making significant progress in reducing the burden of HIV among FSW in the country. However, risky behaviors such as low consistent condom use, low coverage of HIV services across the regions, and low comprehensive knowledge could reverse the gains made so far. Immediate actions should be taken to expand coverage of HIV services to all locations. Efforts must be made to reach out to the new entrants while also addressing strongly held myths and misconceptions about HIV.

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

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

A Confounding Discourse Analysis of Vietnamese Sex Workers' Talk in the City of Kaiyuan, China

BACKGROUND

Vietnamese female sex workers (VFSWs) cross the border into Kaiyuan City, Yunnan Province yearly. However, very little is known about both the health and psychological issues VFSWs experience. The objectives of this study were to explore the dominant discourses that emerged from the VFSWs' talk. The interviews occurred between May 2018 and June 2018 with 20 VFSWs who worked in Kaiyuan City, China. The English translated transcripts were analyzed using an eclectic feminist method of discourse analysis. Two discourses emerged. First, "Agency when working in Karaoke Bars and other Indoor Venues", and second, "Negative Impacts on Psychological Well-being and Other Problems from Migration." As for Discourse 1, the VFSWs positioned themselves as having agency over choosing their clientele as well as agency over what they were willing to negotiate with their clients to establish boundaries of their bodies. As for the Discourse 2, while there was a discourse of agency in their work there was also a contrasting, confounding discourse around the negative impact on psychological well-being and reports of stress as a migrant worker. Discourse 1 and Discourse 2 are confounding. When analyzed together, the discourses suggest that the impacts on psychological well-being may be more related to the migrant status of the women, supporting the notion of systemically influenced agency.

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

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.

Stigma in a Collectivistic Culture: Social Network of Female Sex Workers in China

In this egocentric network study, we explored Chinese collectivism in relation to social network characteristics and sex work-related stigma among mid-age female sex workers (FSWs). Respondent-driven sampling was used to recruit 1245 mid-age FSWs from three cities in China. We found that a one standard deviation (SD) increase in FSWs' collectivism was associated with a 0.18 SD decrease in social support (95% CI - 0.32, - 0.04), a 0.20 SD decrease in network effective size (i.e., the diversity of a social network; 95% CI - 0.30, - 0.10), and a 0.21 SD decrease in network betweenness (i.e., the "bridging potential" of egos within their networks; 95% CI - 0.33, - 0.09). Among participants who perceived more sex work stigma, the association between collectivism and FSWs' network betweenness was attenuated. In a collective culture emphasizing group values and honor, belonging to a less interconnected social network may give FSWs a structural advantage to cope with stigma and secure social support.

Characteristics of low-tier female sex workers who engage in commercial sex with old male clients in Zhejiang province, China: a cross-sectional study

OBJECTIVES

To characterise low-tier female sex workers (FSWs) who engage in commercial sex with old male clients (OMCs).

DESIGN

Cross-sectional study.

SETTING

Twenty-one counties in Zhejiang province, China.

PARTICIPANTS

A total of 2647 low-tier FSWs who participated in our survey from September to November 2013, and responded to the question regarding whether they engaged in commercial sex with OMCs during the previous month.

MAIN OUTCOME MEASURES

Data on sociodemographic characteristics, sexual behaviours, risk perception of HIV/sexually transmitted infection (STI), ever exposure to an HIV prevention service and degree of self-efficacy regarding condom use were collected via a face-to-face questionnaire administered by trained interviewers.

RESULTS

Of the 2647 participants, 1165 (44.0%) had engaged in commercial sex with OMCs in the previous month. Low-tier FSWs working out of roadside shops, those who had engaged in sex work for longer, those with a larger number of clients, those who had engaged in anal or oral sex during the previous month, those currently using contraception measures, those who had STI symptoms and those who had been exposed to HIV prevention services during the previous 6 months were more likely to engage in commercial sex with OMCs. FSWs with a high level of education; those working out of small venues other than streets, hair salons and roadside shops; those who charged more for commercial sex; those who had sex with young clients during the previous month and those who had seen a doctor during the previous 6 months were less likely to engage in commercial sex with OMCs.

CONCLUSIONS

Low-tier FSWs who engaged in commercial sex with OMCs reported more risky behaviours than those who did not engage in this behaviour. Attention should be paid to these behaviours in future interventions targeting low-tier FSWs.

"You need money to get high, and that's the easiest and fastest way:" A typology of sex work and health behaviours among people who inject drugs

BACKGROUND

In the United States, the criminalization and stigmatization of drug use and sex work contribute to infectious disease transmission and healthcare disengagement. People who inject drugs (PWID) and engage in sex work experience exacerbated HIV risk. In the context of the ongoing HIV and overdose epidemics little research describes why PWID engage in sex work and its relative HIV risk. To inform intervention needs, we aimed to create a typology of sex work among PWID with a focus on HIV risk and healthcare utilization behaviours.

METHODS

We drew from in-depth interviews conducted across Massachusetts and Rhode Island from 2016-2019. Participants were ≥18 years old and self-reported past-month injection drug use and HIV-negative status. Using data from individuals reporting sex work experience (n=33/78), we utilized the framework method to develop a typology of perspectives on sex work engagement and attributes pertaining to HIV risk and healthcare utilization behaviours.

RESULTS

We uncovered varying perspectives on sex work and associated HIV risks and prevention needs. A typology included three groups who viewed their sex work engagement as a (1) consistent job, (2) income supplement, or (3) survival method to abate withdrawal symptoms. The first group described more consistent sexual and injection behaviours to mitigate HIV risk than the second group. The third group appeared particularly vulnerable to HIV, describing inconsistent condom use and frequent sharing of injection equipment, low healthcare utilization, and limited disclosure of sex work and injection drug use to healthcare providers.

CONCLUSION

Findings highlight distinct perspectives on sex work among PWID involved in it and corresponding perceptions of HIV risk and healthcare utilization behaviours. Understanding the nuances in sex work engagement among PWID can inform interventions to prevent infectious disease transmission, including efforts to further connect this marginalized population to harm reduction, health, and low barrier opioid treatment services.

Sexual Behavior With Noncommercial Partners: A Concurrent Partnership Study Among Middle-Aged Female Sex Workers in China

Female sex workers (FSWs) often engage in concurrent partnerships, meaning they have multiple sexual relationships at the same time. The objective of this study was to investigate sexual concurrency and its associations with condom use and syphilitic infections among FSWs over age 35. Respondent-driven sampling was used to recruit 1,245 FSWs in Nanning, Hefei, and Qingdao, China. FSWs were asked to report whether they had concurrent partners in the past six months. Concurrency was defined as engagement in sex with commercial clients and (1) husbands and boyfriends (n = 167); (2) husbands only (n = 301); or (3) boyfriends only (n = 469). FSWs with only commercial clients were used as the comparison group (n = 308). Across all groups, the percentage of FSWs with prevalent and active syphilis ranged from 19.6% to 25.6% and 9.1% to 11.5%, respectively. Condom use was low with noncommercial sexual partners and was more likely to be used when FSWs' boyfriends had other partners. Three components of the theory of planned behavior were significantly associated with consistent condom use. Concurrent relationships may lead to increased transmission of syphilis at the workplace and family levels. Effective interventions should target concurrency with both commercial and noncommercial partners.

Mitigating circumstances: A model-based analysis of associations between risk environment and infrequent condom use among Chinese street-based sex workers

Background

Little is known about how freelance street-based sex workers navigate condom use while soliciting. Traditional behavioural model may fail to account for the complex risk environment that most street-based sex workers work within. We examine first the association of self-efficacy and the infrequent condom use, then we investigated the roles of clients and venues frequented on this association.

Method

Using a purposive chain-referral sampling method, we surveyed 248 street-based sex workers in Shanghai. The survey focused on sex workers HIV risk factors, sex work patterns, HIV knowledge, and related HIV self-efficacy. Clients types and behaviours, and characteristics of the venues frequented by these commercial sex workers were also collected. We conducted a series of multiple logistic regression models to explore how the association between a sex worker’s self-efficacy with infrequent condom use change as client and venue characteristics were added to the models.

Results

We find that within the basic model, low self-efficacy was marginally associated with infrequent condom use (54.9% vs. 45.1%, AOR = 1.70, 95% CI = 0.95–3.03). As client- and venue- characteristics were added, the associations between self-efficacy and condom use were strengthened (AOR = 2.10 95% CI = 1.12–3.91 and 2.54 95% CI = 1.24–5.19 respectively). Those who reported middle-tiered income were more likely to report infrequent condom use compared to their peers of high income (AOR = 3.92 95% CI = 1.32–11.70) whereas such difference was not found between low income and high income sex workers. Visiting multiple venues and having migrant workers as clients were also associated with infrequent condom use.

Conclusion

Our findings suggest sex worker’s self-efficacy matters in their HIV risk behaviours only when environment characteristics were adjusted. Risk environment for street-based sex workers are complex. Programming addressing behavioural changes among female sex workers should adopt holistic, multilevel models with the consideration of risk environments.

Can Burt's Theory of Structural Holes be Applied to Study Social Support Among Mid-Age Female Sex Workers? A Multi-Site Egocentric Network Study in China

The epidemic of HIV/AIDS continues to spread among older adults and mid-age female sex workers (FSWs) over 35 years old. We used egocentric network data collected from three study sites in China to examine the applicability of Burt's Theory of Social Holes to study social support among mid-age FSWs. Using respondent-driven sampling, 1245 eligible mid-age FSWs were interviewed. Network structural holes were measured by network constraint and effective size. Three types of social networks were identified: family networks, workplace networks, and non-FSW networks. A larger effective size was significantly associated with a higher level of social support [regression coefficient (β) 5.43-10.59] across the three study samples. In contrast, a greater constraint was significantly associated with a lower level of social support (β -9.33 to -66.76). This study documents the applicability of the Theory of Structural Holes in studying network support among marginalized populations, such as FSWs.

Sexual and reproductive health outcomes among female sex workers in Johannesburg and Pretoria, South Africa: Recommendations for public health programmes

BACKGROUND

The sexual and reproductive health (SRH) status of female sex workers is influenced by a wide range of demographic, behavioural and structural factors. These factors vary considerably across and even within settings. Adopting an overly standardised approach to sex worker programmes may compromise its impact on some sub-groups in local areas.

METHODS

Records of female sex workers attending clinic-, community-, or hotel-based health services in Johannesburg (n = 1422 women) and Pretoria (n = 408 women), South Africa were analysed. We describe the population's characteristics and identified factors associated with sexual and reproductive health outcomes, namely HIV status; previous symptomatic sexually transmitted infection (STI); modern contraceptive use and number of child dependents.

RESULTS

The women in Johannesburg were less likely than those in Pretoria to have HIV (42.2% vs 52.9%), or previous symptomatic STIs (44.3% vs. 8.3%), and were 1.4 fold less likely to have child dependents (20.1% vs. 15.3%). About 43% of women in Johannesburg were Zimbabwean and 40% in Pretoria. Of concern, only about 15% of women in both sites were using modern contraceptives. Johannesburg women were also more likely to access health services at a hotel (85.0% vs. 80.6%) or clinic (5.7% vs. 0.5%), to have completed secondary education (57.1% vs. 36.0%), and moved house more than twice during the past year (19.6 vs. 2.0%). In both cities, risk of HIV rose rapidly with age (23.8%-58.2% vs. 22.0%-64.8%). Of interest, HIV prevalence was considerably higher in those with consistent condom use with one's main partner than inconsistent users.

CONCLUSIONS

Sex worker populations are heterogeneous. Local health programmes must prioritise services that reflect the variety and complexity of sex worker needs and behaviours, and should be designed in consultation with sex workers. Segmenting sex worker populations according to age, country of origin and place of service delivery, and training healthcare providers accordingly, could help prevent new HIV infections, improve adherence to antiretroviral treatment and increase uptake of SRH services.

How do male sex workers on Craigslist differ from those on Rentboy? A comparison of two samples

Much contemporary focus on male-for-male sex work has been with men who place advertisements on profile-based sex work websites. Less is known about men who sell sex via online bulletin boards. We compared two samples of men who were selling sex: a 2014-2015 survey of men on Craigslist.org (n = 95) and a 2013 study of men on Rentboy.com (n = 418). In multivariable modelling, compared to Rentboy, Craigslist participants had a significantly higher odds of being non-White (AOR = 5.32), gay identified (AOR = 2.32), making less than US$20,000 a year (AOR = 3.77), having used marijuana in the past 12 months (AOR = 3.41). Furthermore, compared to Rentboy, Craigslist participants had significantly lower odds of escorting full-time (AOR = .24), kissing (AOR = .23) or having anal insertive sex (AOR = .36) with their last male client, that their last paid encounter exceeded 1 hour in duration (AOR = .49) or having been paid over US$200 for that encounter (AOR = .19), and fewer clients in the past 30 days (AOR = .95). Craigslist participants were at greater economic disadvantage compared to men from Rentboy; however, they were less likely to engage in HIV risk behaviours (anal sex and condomless anal sex). These samples may represent distinct populations along the continuum of sex work.

Sexual risk behaviors, HIV, and syphilis among female sex workers in Nepal

Purpose

Female sex workers (FSWs) are a key-affected population susceptible to acquiring HIV and sexually transmitted infections (STIs), as well as transmitting the virus to others. The aim of the study was to assess HIV and syphilis prevalence among FSWs in Nepal and to examine factors associated with it.

Materials and methods

The study was based on Integrated Biological and Behavioral Surveillance (IBBS) surveys among FSWs in Nepal from 2004 to 2015. Statistical analysis used chi-squared test to assess statistically significant risk factors for HIV and syphilis. Logistic regression models were used to identify the most important determinants for each outcome.

Results

A total of 5,958 FSWs were tested, and among them, 100 (1.7%) were HIV positive and 230 (3.9%) were syphilis positive. The multivariate analysis revealed that syphilis was higher among those street-based, aged ≥35 years, illiterate, and with a duration of sex work of >3 years. HIV was higher among those aged ≥35 years, illiterate, street-based, and with a duration of sex work >3 years. Syphilis was strongly correlated with HIV.

Conclusion

HIV epidemic among FSWs in Nepal appears in the stagnant trend, whereas STI epidemic has increased in recent years. The high influencing factors for HIV and syphilis prevalence were advanced age, street-based, lower education, and longer duration of sex work. Urgent efforts, as part of routine HIV/STI prevention and intervention, are required to reduce the high burden of syphilis among FSWs.

Correlates of unprotected sex with male clients among female sex workers in 13 Mexican cities

This study examined correlates of unprotected vaginal and anal sex (UVA) with male clients among female sex workers (FSWs). Baseline data were gathered from 1089 FSWs recruited from 13 cities across Mexico enrolled in an evidence-based sexual risk reduction intervention. We used generalised estimating equations (GEE) to predict total UVA while controlling for the nested structure of the data. Total UVA with clients in the past month was examined in relation to selected sociodemographic, substance-use, and micro- and macro-environmental factors. A greater number of UVA acts was associated with three micro-level environmental factors (i.e. never getting condoms for free, unaffordability of condoms, greater number of clients per month), and three macro-level environmental factors (i.e. lower health and higher education indices, greater population size of city). These findings suggest the development of social and structural approaches to HIV prevention for FSWs in Mexico, including modification of venue-based policies that pressure FSWs to maximise client volume, changes to the work environment that promote availability and affordability of condoms, and improved population health. Moreover, our findings call for the development of context-specific HIV interventions that take into account variations in the sexual risk behaviours and HIV risk environments of FSWs throughout Mexico.

Bias in Self-Reported Condom Use: Association Between Over-Reported Condom Use and Syphilis in a Three-Site Study in China

This study examined over-reporting bias in self-reported condom use and assessed its association with syphilis. A survey was conducted among 1245 female sex workers (FSWs) in three cities in China. Respondent's over-reported condom use was defined as reporting no unprotected sex for the past 24 h but testing positive for prostate specific antigen. The proportion of prevalent syphilis and active syphilis was 23 and 10 % respectively among FSWs. The proportion of over-reported condom use with sex clients only was 27-45 % among the three study sites. The proportion of over-reported condom use with all sex partners (clients, husbands, or boyfriends) was 26-46 %. FSWs who had active or prevalent syphilis were more likely to over report condom use. Self-reported condom use may not be a valid tool to measure the efficacy of HIV/STI intervention because the bias is associated with the outcome measure, i.e., syphilis.

Syphilis among middle-aged female sex workers in China: a three-site cross-sectional study

OBJECTIVES

This study addresses the lack of empirical studies about the epidemic of syphilis among middle-aged female sex workers (FSWs). The objectives of this study were to investigate prevalence of syphilis, and its potential risk factors among middle-aged FSWs in China.

DESIGN

A cross-sectional study with respondent-driven sampling (RDS).

SETTING

A multisite study conducted at three Chinese cites (Nanning, Hefei, and Qingdao) with different levels of sexually transmitted diseases in 2014.

PARTICIPANTS

1245 middle-aged female sex workers who were over 35 years old (about 400 per study site).

MAIN OUTCOME MEASURES

Unprotected commercial sex, and syphilis and HIV infection were biologically tested and measured.

RESULTS

The RDS-adjusted prevalence of active syphilis was 17.3% in Hefei, 9.9% in Qingdao, and 5.4% in Nanning. The RDS-adjusted prevalence of prevalent syphilis was between 6.8% and 33.6% in the three cities. The proportion of unprotected sex in the past 48 h verified by the prostate-specific antigen test (PSA) was between 27.8% and 42.4%. Multiple log-binomial regression analyses indicate that middle-aged FSWs who had 5 or more clients in the past week prior to interviews and engaged in unprotected sex were more likely to be active syphilitic cases. Middle-aged FSWs who had rural residency were less likely to be active syphilitic cases.

CONCLUSIONS

In contrast with previous studies that reported low prevalence of syphilis and high prevalence of protected sex among FSWs in China, both the prevalence of syphilis and unprotected sex were high among middle-aged FSWs. Evidence-based intervention programmes should be developed and evaluated among this vulnerable population in China and other countries with similar settings.

Male Escorts' and Male Clients' Sexual Behavior During Their Last Commercial Sexual Encounter: Comparing and Contrasting Findings from Two Online Studies

Much of what is known about commercial sexual encounters between men is based on data gathered from escorts. With few exceptions, studies have not compared male clients' reports of behavior during commercial sexual encounters with male escorts'. The present study draws from two datasets, a 2012 survey of clients (n = 495) and a 2013 survey of escorts (n = 387)--both used virtually identical measures of sexual behavior during the most recent commercial sexual encounter. For clients and escorts, the majority eschewed having sex without a condom, and kissing and oral sex were among the most common behaviors reported. Using logistic regression, both samples were compared across 15 sexual behaviors, finding significant differences in six--the escort sample had greater odds of reporting their last commercial sexual encounter involved watching the client masturbate, viewing porn, role play (dad/son, dominant/submissive), and having prior sexual experience with their commercial partner. The escort sample had lower odds of reporting that the client watched the escort masturbate, and being told partner's HIV status. In multivariable modeling, both samples did not significantly differ in reports of condomless anal sex. Male-male commercial sexual encounters appear to be involved in a wide range of sexual behaviors, many of which convey low-to-no risk of HIV transmission.

Egocentric Network and Condom Use Among Mid-Age Female Sex Workers in China: A Multilevel Modeling Analysis

The epidemics of sexually transmitted infections (STIs) have spread among older adults in the world, including China. This study addresses the deficiency of studies about the multiple contextual influences on condom use among mid-age female sex workers (FSWs) over 35 years old. A combination of an egocentric network design and multilevel modeling was used to investigate factors of condom use over mid-age FSWs (egos) particular relationships with sexual partners (alters). Of the 1245 mid-age FSWs interviewed, 73% (907) reported having at least one sexual partner who would provide social support to egos. This generated a total of 1300 ego-alter sex ties in egos' support networks. Condoms were consistently used among one-third of sex ties. At the ego level, condoms were more likely to be used consistently if egos received a middle school education or above, had stronger perceived behavioral control for condom use, or consistently used condoms with other sex clients who were not in their support networks. At the alter level, condoms were not consistently used over spousal ties compared to other ties. Condoms were less likely to be used among alters whom ego trusted and provided emotional support. Cross-level factors (egos' attitudes toward condom use and emotional support from alters) documented a significant positive interaction on consistent condom use. Given the low frequency of condom use, future interventions should focus on mid-age FSWs and their partners within and beyond their support networks.

Intimate-Partner and Client-Initiated Violence among Female Street-Based Sex Workers in China: Does a Support Network Help?

Background

Globally, female street-based sex workers are vulnerable to gender-based violence. Previous research has shown having a peer social network can reduce sex workers’ risks of victimization. However, mechanisms of how social network impacts violence among female street-based sex workers are still far from clear.

Methods

Our study was based on data abstracted from a paper-and-pencil survey administered among 218 female street-based sex workers in Shanghai, China. We focused on self-reported client-initiated violence and intimate-partner violence in emotional, physical, and sexual forms. Social networks were characterized by the size and sources of financial and psychosocial support (e.g. family, friends, and peers). Multi-variable logistic regression was used to estimate adjusted odds ratios (AOR) of each type of violence exposure by social network structure after the adjustment of age, education, and years in Shanghai.

Results

The street-based female sex workers in our study were primarily rural-to-urban migrants (95.7%) with an average age of 41 years old. 24.3% and 62.8% of the sex workers reported intimate-partner violence and client-initiated violence respectively. Lack of financial support, as defined by having only one individual or none in her peer support system to help financially, was significantly associated with self-reported intimate-partner violence (AOR: 2.5; 95% CI: 1.1–5.9). Respondents who reported client-initiated violence, by contrast, were more likely to report lacked psychosocial support from family (AOR: 2.2, 95% CI: 1.0–4.6) and peers (AOR: 5.1, 95% CI: 2.2–11).

Conclusion

This study is one of the first to systematically analyze the associations between social network and gender-based violence among street-based female sex worker. We reported a high prevalence of both types of gender-based violence and their complex associations with family, friends, and peer support network. Policies with goals to reduce violence against women may apply these findings to leverage social network in the interventions against gender-based violence.

Factors associated with women's entry into the sex industry: findings from interviews conducted with female sex workers in Chinese detention centres

BACKGROUND

To date, limited research has been conducted to identify the personal and contextual factors that contribute to women's entry into the sex industry in China.

METHODS

The reasons for and factors associated with voluntary entry into the sex industry were explored through in-depth interviews conducted with 38 Chinese women who were held in detention centres for selling sex.

RESULTS

Women's personal accounts reveal that entry into sex work is influenced by life aspirations, family responsibilities and social connections, which facilitate mobility to a new urban environment in which they encounter opportunities and challenges. Findings highlight the complex interactions between individual and contextual factors in relation to women's entry into sex work.

CONCLUSIONS

In a rapidly developing country such as China, entry into sex work may appeal to women of low socioeconomic status, particularly young women who have recently migrated to urban areas. For members of this mobile and relatively disadvantaged population, comprehensive social services and support are urgently needed.

HIV risk practices by female sex workers according to workplace

OBJECTIVE To investigate differences in HIV infection- related risk practices by Female Sex Workers according to workplace and the effects of homophily on estimating HIV prevalence. METHODS Data from 2,523 women, recruited using Respondent-Driven Sampling, were used for the study carried out in 10 Brazilian cities in 2008-2009. The study included female sex workers aged 18 and over. The questionnaire was completed by the subjects and included questions on characteristics of professional activity, sexual practices, use of drugs, HIV testing, and access to health services. HIV quick tests were conducted. The participants were classified in two groups according to place of work: on the street or indoor venues, like nightclubs and saunas. To compare variable distributions by place of work, we used Chi-square homogeneity tests, taking into consideration unequal selection probabilities as well as the structure of dependence between observations. We tested the effect of homophily by workplace on estimated HIV prevalence. RESULTS The highest HIV risk practices were associated with: working on the streets, lower socioeconomic status, low regular smear test coverage, higher levels of crack use and higher levels of syphilis serological scars as well as higher prevalence of HIV infection. The effect of homophily was higher among sex workers in indoor venues. However, it did not affect the estimated prevalence of HIV, even after using a post-stratification by workplace procedure. CONCLUSIONS The findings suggest that strategies should focus on extending access to, and utilization of, health services. Prevention policies should be specifically aimed at street workers. Regarding the application of Respondent-Driven Sampling, the sample should be sufficient to estimate transition probabilities, as the network develops more quickly among sex workers in indoor venues.

Bridging the epidemic: a comprehensive analysis of prevalence and correlates of HIV, hepatitis C, and syphilis, and infection among female sex workers in Guangxi Province, China

INTRODUCTION

Female sex workers (FSWs) are at highest risk for contracting HIV and facilitating the current heterosexual HIV epidemic in Guangxi, China, yet little is known of the impact of recent harm reduction campaigns in the province. We analyzed sentinel surveillance data collected between 2010 and 2012 in Guangxi to explore correlations between the prevalence of HIV, hepatitis C (HCV), and syphilis and risk behaviors of different categories of FSWs in Guangxi.

METHODS

The sentinel surveillance data for 5,1790 FSWs in all 14 prefectures and 64 city/county regions of Guangxi, China from 2010 to 2012 were collected. Differences between three categories of FSWs (grouped by venue) and disease trends (HIV, HCV, and syphilis) by year were analyzed using bivariate and multivariate logistic regression analyses as to evaluate risk factors correlated with HIV, HCV, or syphilis infection.

RESULTS

HIV and HCV prevalence remained constant across the three FSW categories; however, syphilis prevalence showed a significant increase from 5.7% to 7.3% for low-tier FSWs. Most cases with HIV, HCV, syphilis and intravenous drug use were seen in low-tier FSWs. Testing positive for HIV and syphilis were most correlated with being HCV positive (AOR 4.12 and AOR 4.36), only completing elementary school (AOR 3.71 and AOR 2.35), low tier venues (AOR 2.02 and AOR 2.00), and prior STI (AOR 1.40 and AOR 3.56), respectively. HCV infection was correlated with ever injecting drugs (AOR 60.65) and testing positive for syphilis (AOR 4.16) or HIV (AOR 3.74).

CONCLUSIONS

This study highlights that low tier FSWs with lower formal education levels are the most vulnerable population at risk for acquiring and transmitting HIV, HCV, and syphilis in Guangxi, China. Condom distribution with evolution to safer sex practices are the reasons to explain the non-increasing prevalence of HIV, HCV in Guangxi for 2010-2012.

Female streetwalkers' perspectives on migration and HIV/STI risks in a changing economic and social environment: a qualitative study in Shanghai, China

China's 30-year economic boom has created a unique social and economic market for commercial sex, as well as for a workforce of migrant women from rural China. This qualitative study explores the impact of the rapidly changing social and economic environment on migration patterns, knowledge of sexually transmitted infections (STIs), STI risk behaviours and health beliefs among female streetwalkers in Shanghai. Qualitative data were collected in 2010 through semi-structured in-depth interviews with 16 streetwalkers to characterise their migration passages, sexual health and behaviours, and peer networks. Many streetwalkers reported histories of childhood impoverishment, of family or partner violence or trauma, of migration consistent with the timeline and routes of economic development and of a scarcity in health, social or economic support. Their knowledge of the prevention and treatment of HIV and STIs was limited. They had little bargaining power on condom use and the majority resorted to vaginal douching and self-management with antibiotics as preventative measures. The study identifies streetwalkers' perspectives on the changing environment, their options and actions and, finally, HIV/STI risks that were unique to this hidden population.

Comparing male escorts' sexual behaviour with their last male client versus non-commercial male partner

Apart from research suggesting that male escorts are less likely to have condomless anal sex (CAS) with their male clients compared with male non-clients, little is known about how male escorts' behaviour differs between their clients and non-clients. In spring 2013, 387 Internet-based male escorts completed an online survey that included identical questions about their sexual behaviour with their last male client and male non-client. Encounters with non-commercial partners were significantly more likely to involve a greater range of sexual behaviours, including giving oral sex to partner, kissing, anal receptive sex and sex without condoms. These findings suggest that escorts may display a greater sexual repertoire with non-commercial partners compared to their clients. Encounters with non-commercial partners were also rated as more satisfying than with clients. Condomless anal sex was less common with clients, suggesting that escorts and clients may take active roles in mitigating risks for HIV and STI transmission with each other. Although the modal response for CAS was to abstain, more than half of participants reported CAS during at least one of the two encounters assessed. Behavioural and/or biomedical HIV-prevention strategies would be appropriate for some male escorts to reduce HIV transmission risk.

Family Network, Workplace Network, and Their Influence on Condom Use: A Qualitative Study Among Older Female Sex Workers in China

The objective of this study was to qualitatively explore the components of social networks and their influence on condom use among female sex workers (FSWs) aged 35 years and older in China. In-depth interviews with 63 older FSWs and 6 focus group interviews with pimps and owners of roadside salons and hotels were conducted in 3 Chinese cities. The mean age of participants was 42.6 years old (SD = 6.9 years) and the mean age of starting sex work was 38.6 years old (SD = 6.6 years). Two types of networks that influenced condom use were identified: family networks (relationship with children and husbands) and workplace networks (relationship with peers, clients, pimps, and owners). Relationships between older FSWs and their children negatively influenced condom use. Low levels of network support and norms regarding condom use were observed in the relationship between older FSWs and their clients, whereas positive social support and norms were prevalent among older FSWs who had frequent contact with peers. Norms for condom use existed among pimps and owners but were counterbalanced by monetary gains. Future human immunodeficiency virus (HIV) interventions for older FSWs should take the different features of social network components into consideration.

Men's constructions of masculinity and male sexuality through talk of buying sex

Commercial sex is an everyday occurrence across a range of contexts in South Africa. In this paper we turn our attention to the often-marginalised role of the buyers of sex by drawing on narrative interviews with male clients of female sex workers recruited through online advertisements in order to explore the ways in which heterosexual men construct, negotiate and perform their masculinity and sexuality through talking about their experiences of paying for sex. We highlight parallels between men's narratives of paying for sex and dominant discourses of gender and heterosexuality. We show how men draw on heteronormative sexual scripts in constructing and making sense of paid sexual encounters and how men are simultaneously able to construct and enact a particular idealised version of masculinity and male sexuality through their talk on paying for sex. Finally, we discuss how online resources could be used more extensively in future research with the male clients of sex workers.

Aphrodisiac use associated with HIV infection in elderly male clients of low-cost commercial sex venues in Guangxi, China: a matched case-control study

Background

Rising HIV infection rates have been observed among elderly people in Guangxi, China. Inexpensive aphrodisiacs are available for purchase in suburban and rural areas. This study aims to investigate the association between aphrodisiac use and increased HIV risk for middle-aged and elderly men in Guangxi.

Methods

A matched case-control study of aphrodisiac use-associated HIV infection was performed among male subjects over 50 years old who were clients of low-cost commercial sex venues in Guangxi. The cases were defined as clients who were HIV-positive and two controls were selected for each case. The cases and the controls were matched on the visited sex venue, age (±3 years), number of years of purchasing sex (±3 years), and educational attainment. Subjects were interviewed and tested for HIV. Paired t-test or McNemar Chi-squared test were used to compare the characteristics between the cases and controls. A stepwise conditional logistic regression was used to identify risk factors associated with HIV infection.

Findings

This study enrolled 103 cases and 206 controls. Aphrodisiac use (P = 0.02, odds ratio (OR) = 1.81, 95% CI = 1.08–3.04), never using condom during commercial sex encounter (P = 0.03, odds ratio (OR) = 1.82, 95% CI = 1.08–3.07), and lacking a stable partner (P = 0.03, odds ratio (OR) = 1.76, 95% CI = 1.05–2.98) were found to be risk factors for HIV infection among the study groups. For subjects reporting aphrodisiac use, the frequency of purchasing sex was positively correlated with the frequency of aphrodisiac use (r = 0.3; p = 0.02).

Conclusions

Aphrodisiac use was significantly associated with increased HIV infection risk in men over 50 years old who purchased commercial sex in the suburban and rural areas of Guangxi. Further research and interventions should address the links between aphrodisiac use, commercial sex work, condom use, and increased HIV transmission.

Male clients' behaviours with and perspectives about their last male escort encounter: comparing repeat versus first-time hires

Research on men who have sex with men suggests that condomless anal intercourse occurs more frequently in established sexual relationships. While comparable data regarding male-for-male escorting is unavailable, research implies that many clients seek emotional as well as physical connections with the men they hire. In 2012, 495 male clients, recruited via daddysreviews.com completed an online survey about their last hiring experience. Most participants were from the USA (85.7%), the UK and Canada (3.2% each). In total, 75% of encounters involved an escort hired for the first time; 25% were with a previously hired escort ('repeat encounter'). The client's age, lifetime number of escorts hired and number hired in the past year were positively associated with the last encounter being a repeat encounter. Cuddling, sharing a meal, drinking alcohol, taking a walk, watching a show and shopping were also positively associated with repeat encounters. Conversely, none of the sexual behaviours were significantly associated with repeat encounters. Repeat encounters were significantly more likely to include non-sexual behaviours alongside sexual activities, but no more likely to involve condomless anal intercourse. Moreover, clients' knowledge of escorts' HIV status was not significantly associated with engaging in condomless anal intercourse with repeat encounters.

High prevalence of HIV and syphilis and associated factors among low-fee female sex workers in mainland China: a cross-sectional study

Background

The prevalence of HIV and syphilis among middle and high-fee female sex workers (FSWs) has been widely reported but little is known among low-fee FSWs. This study aims to determine the prevalence and associated factors of HIV and syphilis among low-fee FSWs in China.

Methods

A cross-sectional study design was used. A convenience sample of low-fee FSWs was recruited from venues by outreach workers in 12 cities. Structured questionnaire interviews and blood sampling for HIV and syphilis were carried out. Univariate and multivariate logistic regression were used for assessing potential associated factors.

Results

This study enrolled 781 low-fee FSWs. There were 37 (4.7%) HIV positive participants and 117 (15.0%) participants were infected with syphilis. Final multivariate analysis identified five factors associated with HIV infection: older age (OR:2.6, 95% CI:1.1-6.1), local household registration (OR:3.3, 95% CI:1.5-6.9), employed in Yunnan province (OR:2.7, 95% CI:1.1-6.7), soliciting in self-rented rooms and “market day” buildings (OR:3.9, 95% CI:1.5-10.0), injection drug use in the past 6 months (OR:13.5, 95% CI:4.5-40.1); and four factors associated with syphilis infection: older age (OR:1.8, 95% CI:1.2-2.9), employed in Yunnan province (OR:2.1, 95% CI:1.2-3.6), soliciting in self-rented rooms and “market day” buildings (OR:2.3, 95% CI:1.4-3.7) , and no consistent condom use with clients in the past 30 days (OR:1.6, 95% CI:1.0-2.6).

Conclusions

A high prevalence of HIV and syphilis were found among low-fee FSWs. Those soliciting in self-rented rooms and “market day” buildings with the lowest income, and injection drug users (IDUs) in this population should take priority in further intervention strategies.

Advancing the prevention agenda for HIV and other sexually transmitted infections in south China: social science research to inform effective public health interventions

Despite widespread biomedical advances in treatment and prevention, HIV and other sexually transmitted infections (STI) continue to affect a large portion of the world's population. The profoundly social nature of behaviorally driven epidemics and disparities across socioeconomic divides in the distribution of HIV/STI and care outcomes emphasize the need for innovative, multilevel interventions. Interdisciplinary approaches to HIV/STI control are needed to combine insights from the social and biological sciences and public health fields. In this concluding essay to a Special Issue on HIV/STI in south China, we describe the evolution of the region's HIV/STI epidemics and the government response, then synthesize findings from the 11 studies presented in this issue to extend seven recommendations for future HIV/STI prevention and care research in China. We discuss lessons learned from forging international collaborations between the social and biological sciences and public health to inform a shared research agenda to better meet the needs of those most affected by HIV and other STI.