Physical and Sexual Violence Affecting Female Sex Workers in Abidjan, Côte d'Ivoire: Prevalence, and the Relationship with the Work Environment, HIV, and Access to Health Services

Empowerment and utilization of HIV testing among partnered women in Zambia: Evidence from the Zambia demographic and health survey 2018

In Zambia, women are disproportionally more affected by HIV compared to men. This has mainly been attributed to harmful gender norms that enhance male dominance and disempower women, preventing them from exercising their right to negotiate for safe sex and utilizing HIV prevention services such as HIV testing. This study examined associations between empowerment and HIV testing among married and partnered women. We analyzed secondary data from the couple's recode of the 2018 Zambia demographic and health survey. Univariable and multivariable logistic regression analysis was conducted, and p<0.05 was considered statistically significant. We included a total of 5,328 married and partnered women in the analysis, of which 5057 (94.9%) had undergone an HIV test before. After adjusting for confounders, decision-making was the only independent predictor of HIV testing among measures of empowerment. Women who were highly empowered in decision-making were more likely to have undergone an HIV test compared to those who were less empowered (AOR = 2.1; 95% CI: 1.5, 2.9). Women aged 20-29 years (AOR = 2.4; 95% CI: 1.6, 3.6), 30-39 years (AOR = 5.3; 95% CI: 3.4, 8.2), or 40-49 years (AOR = 2.9; 95% CI: 1.9, 4.7), those with primary education (AOR = 2.4; 95% CI: 1.7, 3.4) or secondary and higher (AOR = 4.1; 95% CI: 2.3, 7.2), rich women (AOR = 2.4; 95% CI: 1.5, 3.7) or women with middle wealth (AOR = 1.5; 95% CI: 1.1, 2.2) and those who gave birth in the last 5 years (AOR = 3.3; 95% CI: 2.5, 4.5) were more likely to have been tested for HIV. This study highlights the critical influence of women's empowerment in decision-making on HIV testing. Additionally, level of education, wealth, age, and having given birth before are essential factors to consider in promoting HIV testing among women in Zambia.

Gynecological health care services utilization and violence among female sex workers in Togo in 2021

BACKGROUND

Female Sex Workers (FSW) in Sub Saharan Africa face multiple challenges increasing their vulnerability to poor health, particularly poor sexual and reproductive (SRH) health outcomes and violence. The aim of this study was to assess the use of gynecology health care services and factors associated with its use as well as experiences of violence among FSW in Togo.

METHOD

A cross-sectional study was carried out in 2021 among FSW in two cities of Togo. A snowball sampling method was used and initial seeds were identified in each site in collaboration with FSW non-governmental organizations. A logistic regression was performed to identify factors associated with the use of a SRH service and violence.

RESULTS

A total of 447 FSW with a median age of 30 [IQR: (24-38)] participated in this study and 43.4% of them had reached at least secondary school. Among them, 29.1% reported having been to a gynecological consultation over the previous year. Factors associated with a gynecological consultation included: living in the Lomé capital city (aOR = 0.35, 95%CI 0.22-0.54), and an experience of condom breakage or slippage (aOR = 2.00; 95%CI 1.19-2.64). The majority reported at least one lifetime pregnancy (87.9%), 39.8% reported ever having an unintended pregnancy and 67.6% of them ever had an abortion. Finally, 61.1% indicated being victims of physical, sexual, or emotional violence in the previous six months. Sex workers living in Lomé (aOR = 1.78; 95%CI 1.16-2.73); a history of abortion (aOR = 1.53; 95%CI 1.03-2.31) and having more than 15 clients per week (aOR = 4.87; 95% CI 1.99-11.94), were more likely to experience violence.

CONCLUSION

There is an under-utilization of health care services among FSW in Togo in addition to overall poor sexual and reproductive health outcomes with a high prevalence of gender-based violence. Those results highlight the importance of continued advocacy for the integration of SRH care with HIV prevention services geared toward FSW as well as a holistic approach to SRH care with innovative ways to prevent violence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Causes of preventable death among children of female sex worker mothers in low- and middle-income countries: A community knowledge approach investigation

Background

Female sex workers (FSW) in low- and middle-income countries (LMIC) are disproportionately vulnerable to poor health, social, and economic outcomes. The children of female sex workers (CFSW) experience health risks based on these challenging circumstances and the unique conditions to which they are exposed. Although country child mortality data exist, little is known about the causes of death among CFSW specifically, thereby severely limiting an effective public health response to the needs of this high-risk group of children.

Methods

The Community Knowledge Approach (CKA) was employed between January and October 2019 to survey a criterion sample of 1280 FSW participants across 24 cities in eight LMIC countries. Participants meeting pre-determined criteria provided detailed reports of deaths among the CFSW within their community of peers. Newborn deaths were gleaned from FSW maternal death reports where the infants also died following birth.

Results

Of the 668 child deaths reported, 589 were included in the analysis. Nutritional deficiencies comprised the leading cause of mortality accounting for 20.7% of deaths, followed closely by accidents (20.0%), particularly house fires, overdoses (19.4%), communicable diseases (18.5%), and homicides (9.8%). Other reported causes of death included neonatal conditions, respiratory illnesses, and suicides.

Conclusions

The causes of CFSW death in these eight countries are preventable with improved protections. Governments, intergovernmental organisations like the United Nations, nongovernmental stakeholder organisations (e.g. sex worker organisations), and funders can implement targeted policies and programmes to protect CFSW and assist vulnerable FSW who are pregnant and raising children. Further research is needed to identify effective child welfare safeguards for CFSW.

Reducing Partner Violence Against Women who Exchange Sex and use Drugs through a Combination Microfinance and HIV Risk Reduction Intervention: A Cluster Randomized Trial

Women who exchange sex and use drugs (WESUD) are at high risk for HIV infection and partner violence. The few tested interventions at the intersection of HIV and IPV show mixed results. This analysis examined the impact of a combination HIV risk reduction (HIVRR) and microfinance (MF) intervention on reported paying and intimate partner violence against WESUD in Kazakhstan. This cluster randomized controlled trial enrolled 354 women from 2015 to 2018 and randomized them to either a combination of HIVRR and MF intervention or HIVRR alone. Outcomes were assessed at four time points over 15 months. Logistic regression within a Bayesian approach assessed change in odds ratio (OR) of recent physical, psychological, or sexual violence perpetrated by current or past intimate partners; and paying partners/clients by study arm over time. Compared to the control arm, the combination intervention decreased the odds of participants experiencing physical violence from past intimate partners by 14% (OR = 0.861, p = 0.049). Women in the intervention group reported significantly lower rates of sexual violence from paying partners (HIVRR + MF - HIVRR: 25.9%; OR = 0.741, p = 0.019) at 12-month follow-up. No significant differences in rates from current intimate partners were found. A combination HIVRR and microfinance intervention may reduce gender-based violence from paying and intimate partners among WESUD above and beyond HIVRR interventions alone. Future research should examine how microfinance reduces partner violence and how to implement combination interventions in diverse settings.

Human rights and HIV: rhetoric or determinants?

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Multiple indicators of violence against female sex workers and its associated factors in Ghana: Evidence from the 2015 integrated bio-behavioral surveillance survey cross-sectional study

Background and Aims

Violence against female sex workers (FSWs) is a widespread phenomenon, especially in African nations like Ghana where sex work is outlawed primarily because of the pervasive worldview that sex work is a contravention of morality. Violence against FSWs deters them from accessing critical health services and heightens their risk of STIs including HIV infection. The study examined the prevalence and the associated factors of multiple indicators of violence against FSWs.

Methods

The study utilized a cross-sectional secondary data from the 2015 Integrated Bio-Behavioral Surveillance Survey conducted among FSWs and their nonpaying partners by Ghana AIDS Commission. We analysed data on a total of 4279 participants. Bivariate, and multivariable logistic regression analyses were utilized to identify factors associated with physical and sexual violence against FSWs. Data were analysed using Stata version 15.

Results

Of the 4279 FSWs, 433 (10%) and 1059 (25%) suffered physical and sexual violence, respectively. The predictors of physical violence are being a seater (adjusted odds ratio [aOR] = 0.53, 95% confidence interval [CI]: 0.36-0.74), aged ≥40 (aOR = 0.23, 95% CI: 0.08-0.64), nonuse of drugs (aOR = 0.56, 95% CI: 0.44-0.70), not using alcohol before sex (aOR = 0.69, 95% CI: 0.56-0.86) and petty business (aOR = 1.39, 95% CI: 1.05-1.82). Sexual violence was predicted by those aged 31-40 (aOR = 0.68, 95% CI: 0.49-0.94) and age ≥40 (aOR = 0.38, 95% CI: 0.22-0.66), currently married (aOR = 0.42, 95% CI: 0.27-0.67), having no living children (aOR = 0.69, 95% CI: 0.51-0.94), nonuse of drugs (aOR = 0.80, 95% CI: 0.68-0.94), and not using alcohol before sex (aOR = 0.74, 95% CI: 0.63-0.86). Region was associated with both physical and sexual violence. Both physical and sexual violence had negative consequences on consistency of condom use and condom failure among FSWs.

Conclusion

Physical and sexual violence against FSWs is pervasive, and a critical public health issue in Ghana. The identified associated factors could be considered as part of an overall strategy aimed at addressing the menace.

Venous thromboembolism in viral diseases: A comprehensive literature review

Venous thromboembolism (VTE) is known to be a common respiratory and/or cardiovascular complication in hospitalized patients with viral infections. Numerous studies have proven human immunodeficiency virus infection to be a prothrombotic condition. An elevated VTE risk has been observed in critically ill H1N1 influenza patients. VTE risk is remarkably higher in patients infected with the Hepatitis C virus in contrast to uninfected subjects. The elevation of D-dimer levels supported the association between Chikungunya and the Zika virus and the rise of clinical VTE risk. Varicella-zoster virus is a risk factor for both cellulitis and the consequent invasive bacterial disease which may take part in thrombotic initiation. Eventually, hospitalized patients infected with the coronavirus disease of 2019 (COVID-19), the cause of the ongoing worldwide pandemic, could mainly suffer from an anomalous risk of coagulation activation with enhanced venous thrombosis events and poor quality clinical course. Although the risk of VTE in nonhospitalized COVID-19 patients is not known yet, there are a large number of guidelines and studies on thromboprophylaxis administration for COVID-19 cases. This study aims to take a detailed look at the effect of viral diseases on VTE, the epidemiology of VTE in viral diseases, and the diagnosis and treatment of VTE.

The effects of intimate partner violence on women's risk of HIV acquisition and engagement in the HIV treatment and care cascade: a pooled analysis of nationally representative surveys in sub-Saharan Africa

BACKGROUND

Achieving the 95-95-95 targets for HIV diagnosis, treatment, and viral load suppression to end the HIV epidemic hinges on eliminating structural inequalities, including intimate partner violence (IPV). Sub-Saharan Africa has among the highest prevalence of IPV and HIV worldwide. We aimed to examine the effects of IPV on recent HIV infection and women's engagement in the HIV care cascade in sub-Saharan Africa.

METHODS

We did a retrospective pooled analysis of data from nationally representative, cross-sectional surveys with information on physical or sexual IPV (or both) and HIV testing, from Jan 1, 2000, to Dec 31, 2020. Relevant surveys were identified from data catalogues and previous large-scale reviews, and included the Demographic and Health Survey, the AIDS Indicator Survey, the Population-based HIV Impact Assessment, and the South Africa National HIV Prevalence, Incidence, Behavior and Communication Survey. Individual-level data on all female respondents who were ever-partnered (currently or formerly married or cohabiting) and aged 15 years or older were included. We used Poisson regression to estimate crude and adjusted prevalence ratios (PRs) for the association between past-year experience of physical or sexual IPV (or both), as the primary exposure, and recent HIV infection (measured with recency assays), as the primary outcome. We also assessed associations of past-year IPV with self-reported HIV testing (also in the past year), and antiretroviral therapy (ART) uptake and viral load suppression at the time of surveying. Models were adjusted for participant age, age at sexual debut (HIV recency analysis), urban or rural residency, partnership status, education, and survey-level fixed effects.

FINDINGS

57 surveys with data on self-reported HIV testing and past-year physical or sexual IPV were available from 30 countries, encompassing 280 259 ever-partnered women aged 15-64 years. 59 456 (21·2%) women had experienced physical or sexual IPV in the past year. Six surveys had information on recent HIV infection and seven had data on ART uptake and viral load suppression. The crude PR for recent HIV infection among women who had experienced past-year physical or sexual IPV, versus those who had not, was 3·51 (95% CI 1·64-7·51; n=19 179). The adjusted PR was 3·22 (1·51-6·85). Past-year physical or sexual IPV had minimal effect on self-reported HIV testing in the past year in crude analysis (PR 0·97 [0·96-0·98]; n=274 506) and adjusted analysis (adjusted PR 0·99 [0·98-1·01]). Results were inconclusive for the association of ART uptake with past-year IPV among women living with HIV (crude PR 0·90 [0·85-0·96], adjusted PR 0·96 [0·90-1·02]; n=5629). Women living with HIV who had experienced physical or sexual IPV in the past year were less likely to achieve viral load suppression than those who had not experienced past-year IPV (crude PR 0·85 [0·79-0·91], adjusted PR 0·91 [0·84-0·98], n=5627).

INTERPRETATION

Past-year physical or sexual IPV was associated with recent HIV acquisition and less frequent viral load suppression. Preventing IPV is inherently imperative but eliminating IPV could contribute to ending the HIV epidemic.

FUNDING

Canadian Institutes of Health Research, the Canada Research Chairs Program, and Fonds de recherche du Québec-Santé.

TRANSLATIONS

For the French, Spanish and Portuguese translations of the abstract see Supplementary Materials section.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Stigma and healthcare access among men who have sex with men and transgender women who have sex with men in Senegal

Objectives:

Cisgender gay, bisexual, and other men who have sex with men and transgender women experience HIV incidence disparities in Senegal. These analyses determined how depression and different stigma mechanisms related to sexual behavior are associated with healthcare access, sexually transmitted infection testing, and HIV testing among cisgender gay, bisexual, and other men who have sex with men and transgender women across three cities in western Senegal.

Methods:

Logistic regression assessed the relationship of three stigma scales (stigma from family and friends, anticipated healthcare stigma, and general social stigma) and depression with these outcomes.

Results:

Depression and stigma were not associated with healthcare access, sexually transmitted infection testing, or HIV testing. However, individuals who had disclosed their sexual identity to a medical provider were more likely to test for HIV.

Conclusions:

Sexual behavior stigma experienced by cisgender gay, bisexual, and other men who have sex with men and trans women in Senegal may not limit access to routine healthcare, but may limit disclosure of sexual orientation and practices, limiting access to appropriate HIV prevention services.

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

Background

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

Methods

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

Results

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

Conclusion

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

HIV Testing Approaches to Optimize Prevention and Treatment for Key and Priority Populations in Malawi

Background

Despite progress in improving antiretroviral therapy (ART) for people with HIV in Malawi, the burden of HIV infections and HIV treatment outcomes among key populations is suboptimal. Client-centered differentiated service delivery approaches may facilitate addressing HIV prevention and treatment needs of key populations in Malawi.

Methods

De-identified program data routinely collected as part of the LINKAGES project–Malawi were assembled from October 2017 to September 2019. HIV case finding was compared across different testing modalities for each population. Poisson regression was used to estimate the association between testing modalities and ART initiation.

Results

Of the 18 397 people included in analyses, 10627 (58%) were female sex workers (FSWs), 2219 (12%) were men who have sex with men (MSM), and 4970 (27%) were clients of FSWs. HIV case finding varied by modality and population, with index testing and enhanced peer outreach demonstrating high yield despite reaching relatively few individuals. FSWs who tested positive through risk network referral testing were more likely to initiate ART within 30 days compared with those who tested positive through clinic-based testing (adjusted risk ratio [aRR], 1.50; 95% CI, 1.23–1.82). For MSM, index testing (aRR, 1.45; 95% CI, 1.06–2.00) and testing through a drop-in center (aRR, 1.82; 95% CI, 1.19–2.78) were associated with 30-day ART initiation.

Conclusions

These data suggest that differentiated HIV testing and outreach approaches tailored to the needs of different key populations may facilitate improved ART initiation in Malawi. Achieving 0 new infections by 2030 suggests the need to adapt treatment strategies given individual and structural barriers to treatment for key populations with HIV in high-prevalence settings.

Exploring the dynamics of workplace typologies for sex workers in Eastern Ukraine

We examine the typologies of workplaces for sex workers in Dnipro, Ukraine as part of the larger Dynamics Study, which explores the influence of conflict on sex work. We conducted a cross-sectional survey with 560 women from September 2017 to October 2018. The results of our study demonstrate a diverse sex work environment with heterogeneity across workplace typologies in terms of remuneration, workload, and safety. Women working in higher prestige typologies earned a higher hourly wage, however client volume also varied which resulted in comparable monthly earnings from sex work across almost all workplace types. While sex workers in Dnipro earn a higher monthly wage than the city mean, they also report experiencing high rates of violence and a lack of personal safety at work. Sex workers in all workplaces, with the exception of those working in art clubs, experienced physical and sexual violence perpetrated by law enforcement officers and sex partners. By understanding more about sex work workplaces, programmes may be better tailored to meet the needs of sex workers and respond to changing work environments due to ongoing conflict and COVID-19 pandemic.

High HIV Prevalence and Low HIV-Service Engagement Among Young Women Who Sell Sex: A Pooled Analysis Across 9 Sub-Saharan African Countries

BACKGROUND

Epidemiological data are needed to characterize the age-specific HIV burden and engagement in HIV services among young, marginalized women in sub-Saharan Africa.

SETTING

Women aged ≥18 years who reported selling sex were recruited across 9 countries in Southern, Central, and West Africa through respondent driven sampling (N = 6592).

METHODS

Individual-level data were pooled and age-specific HIV prevalence and antiretroviral therapy (ART) coverage were estimated for each region using generalized linear mixed models. HIV-service engagement outcomes (prior HIV testing, HIV status awareness, and ART use) were compared among women living with HIV across age strata (18-19, 20-24, and ≥25 years) using generalized estimating equations.

RESULTS

By age 18%-19%, 45.4% [95% confidence interval (CI): 37.9 to 53.0], 5.8% (95% CI: 4.3 to 7.8), and 4.0% (95% CI: 2.9 to 5.4) of young women who sell sex were living with HIV in Southern, Central, and West Africa respectively. Prevalence sharply increased during early adulthood in all regions, but ART coverage was suboptimal across age groups. Compared with adult women ≥25, young women aged 18-19 were less likely to have previously tested for HIV [prevalence ratio (PR) 0.76; 95% CI: 0.72 to 0.80], less likely to already be aware of their HIV status (PR 0.48; 95% CI: 0.35 to 0.64), and less likely to be taking ART (PR 0.67; 95% CI: 0.59 to 0.75).

CONCLUSIONS

HIV prevalence was already high by age 18-19 in this pooled analysis, demonstrating the need for prevention efforts that reach women who sell sex early in their adolescence. ART coverage remained low, with women in the youngest age group the least engaged in HIV-related services. Addressing barriers to HIV service delivery among young women who sell sex is central to a comprehensive HIV response.

Lifetime and past-month substance use and injection among street-based female sex workers in Iran

BACKGROUND

Street-based female sex workers (FSWs) are highly at risk of HIV and other harms associated with sex work. We assessed the prevalence of non-injection and injection drug use and their associated factors among street-based FSWs in Iran.

METHODS

We recruited 898 FSWs from 414 venues across 19 major cities in Iran between October 2016 and March 2017. Correlates of lifetime and past-month non-injection and injection drug use were assessed through multivariable logistic regression models. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were reported.

RESULTS

Lifetime and past-month non-injection drug use were reported by 60.3% (95% CI 51, 84) and 47.2% (95% CI 38, 67) of FSWs, respectively. The prevalence of lifetime and past-month injection drug use were 8.6% (95% CI 6.9, 10.7) and 3.7% (95% CI 2.6, 5.2), respectively. Recent non-injection drug use was associated with divorced marital status (AOR 2.00, 95% CI 1.07, 3.74), temporary marriage (AOR 4.31 [1.79, 10.40]), had > 30 clients per month (AOR 2.76 [1.29, 5.90]), ever alcohol use (AOR 3.03 [1.92, 6.79]), and history of incarceration (AOR 7.65 [3.89, 15.30]). Similarly, lifetime injection drug use was associated with ever alcohol use (AOR 2.74 [1.20-6.20]), ever incarceration (AOR 5.06 [2.48-10.28]), and ever group sex (AOR 2.44 [1.21-4.92]).

CONCLUSIONS

Non-injection and injection drug use are prevalent among street-based FSWs in Iran. Further prevention programs are needed to address and reduce harms associated with drug use among this vulnerable population in Iran.

Underreporting of Violence to Police among Women Sex Workers in Canada: Amplified Inequities for Im/migrant and In-Call Workers Prior to and Following End-Demand Legislation

Sex workers globally face high levels of violence. In Canada, im/migrant sex workers who work in indoor venues may be uniquely targeted by police due to immigration policies, racialized policing, and the conflation of trafficking and sex work. In 2014, Canada passed end-demand legislation that purportedly encourages sex workers to report violence to police; however, little research has evaluated its impact. Using interrupted time series and multivariable logistic regression, we examined proportions of reporting violent incidents to police among sex workers who had experienced workplace violence (2010-2017), including potential changes prior to and following end-demand legislation. We then modeled the independent effects of im/migrant status and place of work on reporting violence. Among sex workers who experienced recent violence during the 7.5-year study (n=367), 38.2% of all participants and 12.7% of im/migrants reported violence to police, and there was no significant change in violence reporting after end-demand legislation. Our results suggest that end-demand laws do not remove barriers to justice faced by sex workers and instead actually perpetuate harms, particularly for racialized im/migrant and indoor workers. Policy reforms to decriminalize sex work, address discriminatory policing, and promote access to safety and justice are urgently needed.

Peer Recruitment Strategies for Female Sex Workers Not Engaged in HIV Prevention and Treatment Services in Côte d'Ivoire: Program Data Analysis

Background

In the context of the mostly generalized HIV epidemic in Côte d’Ivoire, key populations bear a higher burden of HIV than that borne by the general reproductive-aged population. Mathematical models have demonstrated the significant potential impact and cost-effectiveness of improving the coverage of HIV prevention and treatment services for key populations in Côte d’Ivoire. However, in 2019, coverage of these services remained limited by multiple intersecting stigmas affecting key populations, necessitating the study of innovative implementation strategies to better meet the needs of those most marginalized. Here, we leverage programmatic data to compare the effectiveness of the enhanced and traditional peer outreach approaches in reaching and providing community HIV testing to female sex workers not readily engaged in HIV prevention and treatment services in Côte d’Ivoire.

Objective

The aim of this study was to describe the characteristics of female sex workers reached by the LINKAGES project in Côte d’Ivoire with enhanced peer outreach and traditional peer outreach and to compare HIV-related outcomes between the women reached by both strategies.

Methods

Deidentified routine programmatic data collected as part of LINKAGES Côte d’Ivoire between October 2017 and April 2018 were used in these analyses. Demographic characteristics and HIV indicators including HIV testing history, HIV case-finding, linkage to HIV treatment, and treatment initiation were assessed using descriptive statistics. Differences in these indicators were compared by outreach strategy using Pearson chi-square tests.

Results

There were 9761 women reached with enhanced peer outreach and routine peer outreach included in these analyses. The overall case-finding rate in the sample was 7.8% (698/8851). Compared with women reached by routine outreach, those reached by enhanced peer outreach were more likely to have previously been tested for HIV (enhanced: 1695/2509, 67.6%; routine: 4302/7252, 60.0%; χ²₁=43.8; P=.001). The enhanced peer outreach approach was associated with a higher HIV case-finding rate (enhanced: 269/2507 10.7%; routine: 429/6344, 6.8%; χ²₁=32.3; P=.001), higher proportion of linkage to treatment (enhanced: 258/269, 95.9%; routine: 306/429, 71.3%; χ²₁=64.4; P=.001), and higher proportion of treatment initiation (enhanced: 212/269, 78.8%; routine: 315/429, 73.3%; χ²₁=2.6; P=.11). Women reached by both approaches were categorized as high risk for HIV-related behaviors such as condomless sex and number of sex acts in the previous week.

Conclusions

These analyses suggest that the novel peer-referral strategy, the enhanced peer outreach approach, was effective in reaching female sex workeres in Côte d’Ivoire with demonstrated acquisition risks for HIV and who had not been effectively engaged by routine outreach approaches. Scaling up novel strategies such as enhanced peer outreach in the context of differentiated service models may be needed to optimize HIV prevention and treatment outcomes for key populations in Côte d’Ivoire.

Associations Between Economic Factors and Condom Use Behavior Among Female Sex Workers in Dakar and Mbour, Senegal

Condom use remains a mainstay of HIV prevention programs around the world. However, data characterizing economic determinants of condom use among female sex workers (FSW) are limited, including in Senegal. We recruited 718 FSWs via respondent-driven sampling. Bivariate and multivariable regressions were conducted to assess the associations between economic variables and condom use at last sex. Paying rent (aRR: 1.07, 95%CI 1.01-1.13) was positively associated with condom use at last sex with new clients. No statistically significant associations were found between condom use and financial responsibility for dependent children, having additional source of income, sharing sex work earnings, or the ability to borrow from other FSWs, regardless of sexual partner types. The relationship between economic marginalization and consistent condom use among sex workers is complex reinforcing the need for behavioral economic research and prevention to be integrated into HIV prevention and treatment research and programs.

Female Sex Workers' Experiences of Violence and Substance Use on the Haitian, Dominican Republic Border

Background

Female sex workers (FSW) are socially and economically marginalized, and this vulnerability can be exacerbated when they hold the intersectional identity of also being an immigrant, such as in the case of Haitian FSWs in the Dominican Republic.

Objective

Considering that half of migratory young women and girls relocating across the Latin American and Caribbean region do so without their families, increasing the likelihood of experiencing abuses, our primary objective was to test the hypothesis that Haitian FSWs in the Dominican Republic have higher odds of being physically abused by sexual partners compared to Haitian FSWs in Haiti.

Methods

We conducted bivariate analyses and multivariate analyses on 2014 Hispaniola Sex Workers Study (N = 232).

Findings

Approximately 80% of Haitian FSWs in the Dominican Republic reported experiencing violence by a regular partner (80.3%), compared with 60.0% of Haitian FSWs in Haiti (χ2 = 11.34, p < 0.001). Controlling for socio-demographics, substance use, childhood abuse, and sexual behaviors, Haitian FSWs in Haiti maintained lower odds of experiencing violence by a regular partner (OR:0.37, p < 0.01) and higher odds of experiencing violence from a coworker (OR:6.38, p < 0.001) compared to FSWs in the Dominican Republic. Using sex to avoid arrest is associated with higher odds of experiencing violence by a client and violence by a coworker (OR:2.18, p < 0.05; OR:3.74, p < 0.001; respectively). Accepting payment in the form of drugs/alcohol is associated with higher odds of experiencing physical violence by a regular partner but lower odds of experiencing violence by a client (OR:3.99, p < 0.05; OR:0.43, p < 0.05; respectively).

Conclusions

Assuming health is a human right, then practitioners and scholars must actively collaborate to fortify vulnerable populations against injurious structural and sociocultural forces examining the intersectionality and compound effects of multiple stigmatized identities, in this study being an FSW and an immigrant, that moderate the potential positive effects of public health interventions.

Harms of Workplace Inspections for Im/Migrant Sex Workers in In-Call Establishments: Enhanced Barriers to Health Access in a Canadian Setting

Given shifting sex work criminalization and enforcement in Canada, this study examined worrying about workplace inspections by authorities amongst indoor sex workers in Vancouver (2014-2017). Data were drawn from a community-based prospective cohort of sex workers (AESHA). Bivariate and multivariable logistic regression were used to investigate factors associated with worry about inspections. 23.9% of participants experienced workplace inspections; 51.6% worried about inspections. In multivariable analyses, worrying about inspections was associated with recent im/migration [adjusted odds ratio (AOR) 3.13; 95% confidence interval (CI) 1.77-5.53], police harassment (AOR 3.49; 95% CI 1.92-6.34), and workplace violence (AOR 1.66, 95% CI 1.09-2.51). In a multivariable confounder model, worry was independently associated with barriers to health access (AOR 1.45, 95% CI 1.06-1.98). Im/migrant indoor workers are disproportionately impacted by concerns about workplace inspections, which was independently linked to enhanced barriers to health access. Current criminalization measures may exacerbate health inequities among im/migrant sex workers.

The role of sex work laws and stigmas in increasing HIV risks among sex workers

Globally HIV incidence is slowing, however HIV epidemics among sex workers are stable or increasing in many settings. While laws governing sex work are considered structural determinants of HIV, individual-level data assessing this relationship are limited. In this study, individual-level data are used to assess the relationships of sex work laws and stigmas in increasing HIV risk among female sex workers, and examine the mechanisms by which stigma affects HIV across diverse legal contexts in countries across sub-Saharan Africa. Interviewer-administered socio-behavioral questionnaires and biological testing were conducted with 7259 female sex workers between 2011-2018 across 10 sub-Saharan African countries. These data suggest that increasingly punitive and non-protective laws are associated with prevalent HIV infection and that stigmas and sex work laws may synergistically increase HIV risks. Taken together, these data highlight the fundamental role of evidence-based and human-rights affirming policies towards sex work as part of an effective HIV response.

Using Social Networks to Understand and Overcome Implementation Barriers in the Global HIV Response

BACKGROUND

Despite the development of several efficacious HIV prevention and treatment methods in the past 2 decades, HIV continues to spread globally. Uptake of interventions is nonrandomly distributed across populations. Such inequality is socially patterned and reinforced by homophily arising from both social selection (becoming friends with similar people) and influence (becoming similar to friends).

METHODS

We conducted a narrative review to describe how social network analysis methods-including egocentric, sociocentric, and respondent-driven sampling designs-provide tools to measure key populations, to understand how epidemics spread, and to evaluate intervention take-up.

RESULTS

Social network analysis-informed designs can improve intervention effectiveness by reaching otherwise inaccessible populations. They can also improve intervention efficiency by maximizing spillovers, through social ties, to at-risk but susceptible individuals. Social network analysis-informed designs thus have the potential to be both more effective and less unequal in their effects, compared with social network analysis-naïve approaches. Although social network analysis-informed designs are often resource-intensive, we believe they provide unique insights that can help reach those most in need of HIV prevention and treatment interventions.

CONCLUSION

Increased collection of social network data during both research and implementation work would provide important information to improve the roll-out of existing studies in the present and to inform the design of more data-efficient, social network analysis-informed interventions in the future. Doing so will improve the reach of interventions, especially to key populations, and to maximize intervention impact once delivered.

Unweighted regression models perform better than weighted regression techniques for respondent-driven sampling data: results from a simulation study

Background

It is unclear whether weighted or unweighted regression is preferred in the analysis of data derived from respondent driven sampling. Our objective was to evaluate the validity of various regression models, with and without weights and with various controls for clustering in the estimation of the risk of group membership from data collected using respondent-driven sampling (RDS).

Methods

Twelve networked populations, with varying levels of homophily and prevalence, based on a known distribution of a continuous predictor were simulated using 1000 RDS samples from each population. Weighted and unweighted binomial and Poisson general linear models, with and without various clustering controls and standard error adjustments were modelled for each sample and evaluated with respect to validity, bias and coverage rate. Population prevalence was also estimated.

Results

In the regression analysis, the unweighted log-link (Poisson) models maintained the nominal type-I error rate across all populations. Bias was substantial and type-I error rates unacceptably high for weighted binomial regression. Coverage rates for the estimation of prevalence were highest using RDS-weighted logistic regression, except at low prevalence (10%) where unweighted models are recommended.

Conclusions

Caution is warranted when undertaking regression analysis of RDS data. Even when reported degree is accurate, low reported degree can unduly influence regression estimates. Unweighted Poisson regression is therefore recommended.

HIV risks and needs related to the Sustainable Development Goals among female sex workers who were commercially sexually exploited as children in Lesotho

Introduction

Sustainable Development Goals (SDGs) about gender equality; decent work; and peace, justice, and strong institutions include a focus on eradicating trafficking and sexual exploitation of and violence against women and children. In Lesotho, 86% of women have experienced gender‐based violence. In addition, overall HIV prevalence is among the highest globally, and higher among adolescent girls than boys. Moreover, nearly three quarters of female sex workers (FSW) are estimated to be living with HIV in Lesotho. In this context, sexually exploited children may be particularly vulnerable to violence and HIV acquisition risks. This study's objective is to examine the prevalence and correlates of experiencing sexual exploitation as a child among FSW in Lesotho.

Methods

FSW (≥18 years) recruited through respondent‐driven sampling in Maseru and Maputsoe from February to September 2014 completed HIV and syphilis testing and an interviewer‐administered survey, including a question about the age at which they started providing sex for money. This study examined correlates of experiencing sexual exploitation as a child (<18 years) through multivariable logistic regression analyses for each city, controlling for current age.

Results

Across both cities, 20.0% (142/710) of participants were sexually exploited as children. Among them, 65.5% (93/142) tested positive for HIV and 31.0% (44/142) for syphilis, which was similar to those who started selling sex as adults, after adjusting for current age. Participants who experienced child sexual exploitation were more likely to have been forced to have sex before age 18 than those who started selling sex as adults (Maseru‐adjusted odds ratio (aOR): 3.52, 95% Confidence Interval (CI): 1.61 to 7.66, p = 0.002; Maputsoe‐aOR: 4.39, 95% CI: 1.22 to 15.75, p = 0.023). In Maseru, participants who were sexually exploited as children were more likely to avoid carrying condoms to prevent trouble with police (aOR: 3.18, 95% CI: 1.50 to 6.75, p = 0.003).

Conclusions

Risk determinants for HIV and violence among sexually exploited children can be studied retrospectively through research with adult FSW. Further research working directly with sexually exploited children will improve understanding of their needs. Preventing commercial sexual exploitation of children and addressing the social and healthcare needs of those who are exploited are necessary to fully achieve SDGs 5, 8 and 16 and an AIDS‐Free Generation.

Lifetime experiences of gender-based violence, depression and condom use among female sex workers in Cameroon

BACKGROUND

In general populations, consistent data highlight the relationships among violence, HIV risk behavior and depression; however, these patterns are not well understood among female sex workers (FSWs). We examined the relationship between FSWs' experiences with sexual violence and consistent condom use as a key HIV risk behavior and explored mental health as a potential mediator.

METHODS

In total, 2,165 FSWs were recruited via respondent-driven sampling in Cameroon in 2016. The women answered questions about violence, condom use and mental health.

RESULTS

Inconsistent condom use with clients was reported by 23.5% of participants (508/2,165). Lifetime sexual violence was prevalent with 33.0% (713/2,163) of participants. Almost 50% (1,067/2,143) of respondents had some level of depression. Sexual violence was significantly associated with inconsistent condom use (adjusted risk ratio (aRR) 1.4, 95% confidence interval (CI) (1.2-1.6)). Of FSWs with no depression, 24.9% (267/1,071) reported sexual violence, versus 56.1% (32/57) of respondents with severe depression (p < .01). Severe depression significantly increased risk of condomless sex (aRR 1.8, 95% CI (1.3-2.6)); in mediation analysis, both sexual violence and severe depression remained significant predictors of condomless sex (aRR 1.4, 95% CI (1.2, 1.6) and aRR 1.7, 95% CI (1.2-2.4), respectively). Depression did not mediate the relationship between sexual violence and condom use.

CONCLUSION

Sexual violence and depression are prevalent and independently associated with condom nonuse with clients among FSWs in Cameroon. Results highlight the need for interventions to address mental health as well as gender-based violence for FSWs.

Single Mothers and Female Sex Workers in Zambia Have Similar Risk Profiles

The aim of the study was to compare reproductive health and high-risk behaviors in female sex workers (FSWs) and single mothers (SMs) in Zambia's two largest cities, Lusaka and Ndola. FSWs were invited from known community hot spots, and sexually active HIV- SMs were referred from infant vaccination services for free and anonymous screening and treatment for HIV and other sexually transmitted infections (STIs) and long acting reversible contraception. A subset completed an interviewer-administered survey. From 2012 to 2016, 1,893 women (1,377 FSWs and 516 HIV- SMs) responded to referrals. HIV prevalence was 50% in Lusaka and 33% in Ndola FSWs. Positive syphilis serology (rapid plasmin reagin) was found in 29%-31% of HIV+ FSWs and 9%-12% of HIV- FSWs and SMs. Trichomonas was more common in Ndola (11%-12%), compared with Lusaka (3%-7%). Antiretroviral therapy (ART) use among HIV+ FSWs was 9%-15%. In all groups, consistent condom use (8%-11%) and modern contraceptive use (35%-65%) were low. Low literacy and reported coercion at first sexual intercourse were common in both FSWs and SMs, as was alcohol use during sex among FSWs. Zambian FSWs and SMs have low condom use and high HIV/STI and unplanned pregnancy risk. Many FSWs and half of SMs are ≥25 years of age, and thus too old for HIV prevention services targeting "adolescent girls and young women" (aged 15-24). Tailored and targeted reproductive health services are needed to reduce HIV, STI, and unplanned pregnancy in these vulnerable women.

Unseen, unheard and unprotected: prevalence and correlates of violence among female sex workers in Mozambique

Violence against women, including female sex workers, is a public health concern worldwide. This is the first study in Mozambique to estimate the prevalence of and factors associated with physical and sexual violence against female sex workers. We used data collected from 1,250 women recruited using respondent-driven sampling in the cities of Maputo, Beira and Nampula in 2011-12. Participants were 15 years of age and reported having had sex for money in the preceding six months. Prevalence of physical or sexual violence (defined as being hit or battered or raped or forced to have sex within the last 6 months) ranged from 10.0% to 25.6%. Strangers (37.0%) and acquaintances (31.2%) were reported to be the most frequent perpetrators of sexual violence. Among participants who experienced sexual violence, 65.9% and 87.0% did not seek medical care and police assistance, respectively. Physical or sexual violence was associated with city (adjusted odds ratio [AOR] 2.6 and 2.0 Nampula and Beira vs Maputo), age (AOR 1.9, aged 15-24 years vs aged 25 and older), unprotected sex with last client (AOR 1.6) and self-reported sexually transmitted infections (AOR 2.1). The high prevalence of violence found confirms the need for interventions to mitigate this problem.

Prevalence and correlates of physical violence and rape among female sex workers in Ethiopia: a cross-sectional study with respondent-driven sampling from 11 major towns

OBJECTIVE

This study examined the prevalence and correlates of physical violence and rape among female sex workers (FSWs) in Ethiopia.

DESIGN

A cross-sectional study using respondent-driven sampling technique.

SETTING

Eleven major towns in Ethiopia.

PARTICIPANTS

4900 FSWs.

MAIN OUTCOME MEASURES

The prevalence of experiences of physical beating and rape.

RESULTS

Among FSWs, 17.5% reported physical beating within the last year and 15.2% reported rape since they started selling sex. FSWs aged 35+ years (AOR 0.59, 95% CI 0.38 to 0.92) were less exposed to physical beating than those aged 15-24 years. FSWs working on the street (AOR 1.92, 95% CI 1.53 to 2.39), in red-light houses (AOR 1.63, 95% CI 1.12 to 2.38) and in local drinking houses (AOR 1.35, 95% CI 1.02 to 1.78) experienced more physical beating than FSWs working in bars/hotels. FSWs who consumed alcohol four or more days in a week (AOR 1.92, 95% CI 1.21 to 3.04), and who chewed khat frequently experienced more physical violence. Rape was associated with having a low monthly income, drinking alcohol four or more days per week (AOR 2.33, 95% CI 1.47 to 3.7), experience of heavy episodic drinking in a month (AOR 1.71, 95% CI 1.24 to 2.38) and chewing khat 3-4 days per week (AOR 2.15, 95% CI 1.55 to 2.98). Condom breakage was more frequent among FSWs who reported both physical beating (AOR 1.51, 95% CI 1.25 to 1.84) and rape (AOR 1.26, 95% CI 1.03 to 1.55).

CONCLUSION

FSWs in Ethiopia are vulnerable to physical and sexual violence, and the risk increases when they are younger, street-based and high consumers of alcohol or khat. Therefore, targeted efforts are needed for prevention and harm reduction.

Gender-based violence and engagement in biomedical HIV prevention, care and treatment: a scoping review

Background

While gender-based violence (GBV) has been shown to increase women’s risk of HIV acquisition, the role of GBV in the HIV testing to care continuum is less clear. Clarifying how GBV may act as a barrier to accessing HIV services, treatment and care - such as anti-retroviral treatment (ART) or pre-exposure prophylaxis (PrEP) - will not only provide insights into how to best meet individual women’s HIV care needs, but also inform public health oriented HIV epidemic control strategies.

Methods

Through a comprehensive scoping review, we synthesized and analyzed existing evidence regarding the influence of GBV on engagement in PrEP and the HIV care continuum among women living with HIV, including members of key populations (female sex workers, transgender women and women who use drugs). We explored PubMed, Scopus and Web of Science for peer-reviewed studies published in 2003–2017. Of the 279 sources identified, a subset of 51 sources met the criteria and were included in the scoping review.

Results

Studies were identified from 17 countries. The majority of studies utilized quantitative cross-sectional designs (n = 33), with the rest using longitudinal (n = 4), qualitative (n = 10) or mixed methods (n = 4) designs. Taken together, findings suggest that GBV impedes women’s uptake of HIV testing, care, and treatment, yet this can vary across different geographic and epidemic settings. Substantial gaps in the literature do still exist, including studies on the impact of GBV on engagement in PrEP, and research among key populations.

Conclusions

This scoping review contributes to our knowledge regarding the role GBV plays in women’s engagement in PrEP and the HIV care continuum. Findings reveal the need for more longitudinal research to provide insights into the causal pathways linking GBV and HIV care and treatment outcomes. Research is also needed to illuminate the impact of GBV on PrEP use and adherence as well as the impact of GBV on engagement along the HIV care continuum among key populations. It is critical that programs and research keep pace with these findings in order to reduce the global burden of GBV and HIV among women.

Characterising unmet HIV prevention and treatment needs among young female sex workers and young men who have sex with men in Cameroon: a cross-sectional analysis

BACKGROUND

In Cameroon, female sex workers (FSWs) and men who have sex with men (MSM) carry disproportionately high burdens of HIV. Despite specific vulnerabilities and health needs, young key populations remain understudied and underserved in Cameroon owing to legal, ethical, and social challenges. We aimed to assess and compare HIV-related behavioural and structural risks and coverage of HIV prevention and treatment services between young and older key populations to inform implementation strategies.

METHODS

FSWs and MSM aged 18 years or older were recruited through respondent-driven-sampling for a biobehavioural survey carried out in five Cameroonian cities. Prevalence of HIV, risk, stigma, and health service engagement were compared between young (18-24 years) and older (≥25 years) key populations. Multivariable Poisson regression models, disaggregated by key population, were constructed to estimate prevalence ratios (PR) by age group for HIV service engagement.

FINDINGS

Participants were recruited between Nov 30, 2015, and Oct 12, 2016. Among FSWs, 724 (32%) of 2255 were aged 18-24 years, and median age of first transactional or compensated sex was 22 years (IQR 19-28). Among MSM, 840 (63%) of 1323 were aged 18-24 years, and median age of first anal sex was 18 years (IQR 17-21). RDS-adjusted HIV prevalence was 8·5% (95% CI 4·7-15·2) among young FSWs and 12·9% (9·5-18·2) among young MSM. HIV viral suppression (<1000 copies per mL) was evident in 24 (43%) of 56 young and 292 (61%) of 479 older FSWs (p=0·0091) and 40 (34%) of 119 of young and 64 (42%) of 153 older MSM (p=0·17). Young FSWs were less likely than older FSWs to report recent peer education (PR 0·65, 95% CI 0·48-0·88), or membership of an FSW community-based organisation (PR 0·69, 0·55-0·86) and were more likely to report untreated sexually transmitted infection symptoms in the past year (PR 1·29, 1·03-1·61). Young MSM were less likely than older MSM to report an HIV test in the past year (PR 0·88, 0·78-0·98), recent peer education (PR 0·77, 0·62-0·95) and receipt of free condoms (PR 0·77, 0·67-0·89). By key population, condom use and recent experiences of stigma and violence were similar between age groups (p>0·05).

INTERPRETATION

Young key populations have similar behavioural and structural risks to older populations but have lower coverage of HIV preventive and treatment services. Achieving an AIDS-free generation in Cameroon and elsewhere in the region necessitates overcoming social and legal challenges and delivering innovative, evidence-based, and human rights-affirming HIV prevention and treatment interventions for young key populations.

FUNDING

PEPFAR, USAID.

Third Parties (Venue Owners, Managers, Security, etc.) and Access to Occupational Health and Safety Among Sex Workers in a Canadian Setting: 2010-2016

OBJECTIVE

To determine the impact of engagement with third parties (i.e., managers, receptionists, or owners of in-call venues; advertisers; security; spotters; and others) on sex workers' occupational health access.

METHODS

We drew longitudinal data from An Evaluation of Sex Workers' Health Access, a community-based cohort of more than 900 women sex workers. We used multivariable logistic regression and generalized estimating equations to (1) examine factors correlated with accessing third-party administrative or security services and (2) evaluate the impact of third-party services on access to mobile condom distribution and sex worker and community-led services (2010-2016). Finally, we evaluated changes in accessing third-party services pre-post end-demand criminalization (2010-2017).

RESULTS

Im/migrant sex workers (persons with any type of legal status who were born in another country; adjusted odds ratio [AOR] = 2.32; 95% confidence interval [CI] = 1.35, 3.98) had higher odds of accessing third-party services. In confounder models, third-party services were independently correlated with increased access to mobile condom distribution (AOR = 1.84; 95% CI = 1.47, 2.31) and sex worker and community-led services (AOR = 1.61; 95% CI = 1.15, 2.24). End-demand criminalization was linked to a decrease in access to third-party services (AOR = 0.79; 95% CI = 0.63, 0.99).

CONCLUSIONS

This research suggests that access to administrative and security services from third parties increases sex workers' occupational health and safety. Policy reforms to ensure sex workers' labor rights, including access to hiring third parties, are recommended.

Experiences of gender-based violence among female sex workers, men who have sex with men, and transgender women in Latin America and the Caribbean: a qualitative study to inform HIV programming

BACKGROUND

Female sex workers, MSM, and transgender women-collectively referred to as key populations (KPs)-are disproportionately affected by gender-based violence (GBV) and HIV, yet little is known about the violence they face, its gender-based origins, and responses to GBV. The purpose of this study was to understand the nature and consequences of GBV experienced, to inform HIV policies and programming and to help protect KPs' human rights.

METHODS

Using a participatory approach, FSWs, MSM, and transgender women in Barbados, El Salvador, Trinidad and Tobago, and Haiti conducted 278 structured interviews with peers to understand their experiences of and responses to GBV. Responses to open-ended questions were coded in NVivo and analyzed using an applied thematic analysis.

RESULTS

Nearly all participants experienced some form of GBV. Emotional and economic GBV were the most commonly reported but approximately three-quarters of participants reported sexual and physical GBV and other human rights violations. The most common settings for GBV were at home, locations where sex work took place such as brothels, bars and on the street; public spaces such as parks, streets and public transport, health care centers, police stations and-for transgender women and MSM-religious settings and schools. The most common perpetrators of violence included: family, friends, peers and neighbors, strangers, intimate partners, sex work clients and other sex workers, health care workers, police, religious leaders and teachers. Consequences included emotional, physical, and sexual trauma; lack of access to legal, health, and other social services; and loss of income, employment, housing, and educational opportunities. Though many participants disclosed experiences of GBV to friends, colleagues and family, they rarely sought services following violence. Furthermore, less than a quarter of participants believed that GBV put them at risk of HIV.

CONCLUSIONS

Our study found that across the four study countries, FSWs, MSM, and transgender women experienced GBV from state and non-state actors throughout their lives, and much of this violence was directly connected to rigid and harmful gender norms. Through coordinated interventions that address both HIV and GBV, this region has the opportunity to reduce the national burden of HIV while also promoting key populations' human rights.

Experience of violence among street prostitutes: a qualitative study in Shiraz, Iran

Background:

Female Sex workers (FSWs) are a marginalized group. Although some studies have shown various types of violence against sex workers, it is a subject which needs more in-depth knowledge.

Methods:

This is a conventional content study conducted on 18 street sex workers in Shiraz, Iran.

Results:

The present study observed that sex workers had extensive experience in five forms of violence: physical, barbaric, psychological, sexual, deception and robbery. Moreover, violence was deep-rooted in their previous experiences prior to becoming a prostitute, leading to the formation of yet another type of violence, called hidden slavery with male or female pimps.

Conclusions:

To improve the general health of this group, it is recommended that they be supported by social institutions and be provided with psychological consultations.

Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies

BACKGROUND

Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur.

METHODS AND FINDINGS

We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing.

CONCLUSIONS

Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.

Anal Intercourse Among Female Sex Workers in Côte d'Ivoire: Prevalence, Determinants, and Model-Based Estimates of the Population-Level Impact on HIV Transmission

Current evidence suggests that anal intercourse (AI) during sex work is common in sub-Saharan Africa, but there have been few studies in which the contribution of heterosexual AI to human immunodeficiency virus (HIV) epidemics has been investigated. Using a respondent-driven sampling survey of female sex workers (FSWs; n = 466) in Abidjan, Côte d'Ivoire, in 2014, we estimated AI prevalence and frequency. Poisson regressions were used to identify AI determinants. Approximately 20% of FSWs engaged in AI during a normal week (95% confidence interval: 15, 26). Women who performed AI were generally younger, had been selling sex for longer, were born in Côte d'Ivoire, and reported higher sex-work income, more frequent sex in public places, and violence from clients than women not reporting AI. Condom use was lower, condom breakage/slippage more frequent, and use of water-based lubricants was less frequently reported for AI than for vaginal intercourse. Using a dynamic transmission model, we estimated that 22% (95% credible interval: 11, 37% of new HIV infections could have been averted among FSWs during 2000-2015 if AI had been substituted for vaginal intercourse. Despite representing a small fraction of all sex acts, AI is an underestimated source of HIV transmission. Increasing availability and uptake of condoms, lubricants, and pre-exposure prophylaxis for women engaging in AI could help mitigate HIV risk.