Factors mediating HIV risk among female sex workers in Europe: a systematic review and ecological analysis

Determinants of Intention to Use HIV Pre-exposure Prophylaxis and Condom Use Among a Sample of Cisgender Female Sex Workers Working Mostly Outdoors in Madrid, Spain

There is scant knowledge regarding pre-exposure prophylaxis (PrEP) use among female sex workers (FSWs) in Europe. Spain recognized FSWs as a population at high risk of acquiring HIV and granted them subsidized access to PrEP when the medication first became nationally available in 2019. Nevertheless, FSWs represented just 0.2% of PrEP users in 2022. A total of 102 HIV-negative FSWs reached through field activities of local NGOs located in Madrid were interviewed between January and March 2022. Participants were selected through convenience sampling over a fixed recruitment period. FSWs completed a 73-item survey with questions about individual, occupational, social, and structural determinants. The objective of this study was to identify (1) the prevalence of intention to use oral PrEP and its determinants, and (2) the prevalence of inconsistent condom use, which is the risk factor that qualifies FSWs for subsidized PrEP in the national health system, and its determinants. Importantly, the study sample overrepresented street-based FSWs (71.6%). A quarter (25.5%) of the study participants used condoms inconsistently. PrEP awareness was low (9.8%), but intention to use PrEP was high (72.5%). Intention to use oral PrEP was significantly associated with feeling protected against HIV by taking PrEP and perceiving insufficient protection by condom use alone. Inconsistent condom use was significantly associated with frequent heroin/cocaine use, having clients who inject drugs, and willingness to take PrEP despite it not protecting 100% against HIV infection. FSWs, in this specific sample, are likely to benefit from targeted PrEP awareness campaigns and implementation projects that prioritize those who use drugs and are more likely to engage in condomless sex.

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.

Health inequalities in infectious diseases: a systematic overview of reviews

OBJECTIVES

The aim of this systematic overview of reviews was to synthesise available evidence on inequalities in infectious disease based on three dimensions of inequalities; inclusion health groups, protected characteristics and socioeconomic inequalities.

METHODS

We searched MEDLINE, Embase, Web of Science and OpenGrey databases in November 2021. We included reviews published from the year 2000 which examined inequalities in the incidence, prevalence or consequences of infectious diseases based on the dimensions of interest. Our search focused on tuberculosis, HIV, sexually transmitted infections, hepatitis C, vaccination and antimicrobial resistance. However, we also included eligible reviews of any other infectious diseases. We appraised the quality of reviews using the Assessment of Multiple Systematic Reviews V.2 (AMSTAR2) checklist. We conducted a narrative data synthesis.

RESULTS

We included 108 reviews in our synthesis covering all the dimensions of inequalities for most of the infectious disease topics of interest, however the quality and volume of review evidence and consistency of their findings varied. The existing literature reviews provide strong evidence that people in inclusion health groups and lower socioeconomic status are consistently at higher risk of infectious diseases, antimicrobial resistance and incomplete/delayed vaccination. In the protected characteristics dimension, ethnicity, and sexual orientation are important factors contributing to inequalities across the various infectious disease topics included in this overview of reviews.

CONCLUSION

We identified many reviews that provide evidence of various types of health inequalities in different infectious diseases, vaccination, and antimicrobial resistance. We also highlight areas where reviews may be lacking. The commonalities in the associations and their directions suggest it might be worth targeting interventions for some high risk-groups that may have benefits across multiple infectious disease outcomes rather than operating purely in infectious disease siloes.

HIV prevalence and associated factors among female sex workers in Iran: a bio-behavioral survey in 2020

Despite the overall decline in human immunodeficiency virus (HIV) prevalence, it remains unacceptably high in key populations. This study aimed to estimate prevalence of HIV infection and high-risk behaviors among female sex workers (FSWs). This study was a cross-sectional survey of FSWs conducted between December 2019 and August 2020 in eight geographically diverse cities in Iran. After providing informed consent, participants completed a bio-behavioral questionnaire and after completion of the interview, rapid diagnostic tests (RDT) and dried blood spots (DBS) were collected to determine HIV and syphilis status as per national guidelines, if the women consented. All analyzes were based on RDS adjustment. Weighting was done according to Giles'SS estimator. Among the 1515 FSWs, the overall prevalence of HIV and syphilis were 1.6% (95% CI: 0.8-2.3) and zero, respectively. The highest HIV prevalence was observed in Shiraz (5.1%) and Khorramabad city (1.6%). In addition, HIV-positive FSWs had a higher mean age at first sexual contact than HIV-negative FSWs (21.4 ± 5.6 vs. 17.2 ± 4.2 years). Injection drug use and a history of arrest or incarceration were associated with an increased odds of HIV infection (OR = 6.25; 95% CI: 1.90-20.55 and OR = 4.57; 95% CI: 1.64-12.72, respectively). Based on the results, strategies to improve early HIV diagnosis, harm reduction, and use of testing and treatment strategies are needed to reduce and control HIV infections.

Substance use and other correlates of HIV infection among transwomen and men who have sex with men in Perú: Implications for targeted HIV prevention strategies for transwomen

Characterization of HIV risk factors among transwomen and men who have sex with men (MSM) should be assessed separately and independently. However, due to several constraints, these populations continue to be conflated in clinical research and data. There are limited datasets globally powered to make such comparisons. The study aimed to use one of the largest surveys of transwomen and MSM in Latin America to determine differences in HIV risk and related correlates between the two populations. Secondary data analysis was completed using a cross-sectional biobehavioral survey of 4413 MSM and 714 transwomen living in Perú. Chi Square analysis of selected HIV correlates was conducted to examine differences between transwomen and MSM. Additionally, stratified binary logistic regression was used to split data for further comparative analyses of correlates associated with transwomen and MSM separately. HIV prevalence among transwomen was two-fold greater than among MSM (14.9% vs. 7.0%, p<0.001). Transwomen had a higher prevalence of most HIV risk factors assessed, including presence of alcohol dependence (16.4% vs. 19.0%; p < .001) and drug use in the past 3 months (17.0% vs. 14.9%). MSM were more likely to use marijuana (68.0% vs. 50.0%, p < .001), and transwomen were more likely to engage in inhaled cocaine use (70.0% vs. 51.1%, p < .001). The regression exposed differences in correlates driving sub-epidemics in transwomen vs. MSM, with a trend of substance use increasing HIV risk for transwomen only. Transwomen were more likely to be HIV-infected and had different risk factors from MSM. Targeted prevention strategies are needed for transwomen that are at highest risk. Additionally, further research is needed to determine if these observations in Perú regarding substance use patterns and the role of substance use in HIV risk relate to other trans populations globally.

Spatial and Temporal Trends in HIV/AIDS Burden Among Worldwide Regions From 1990 to 2019: A Secondary Analysis of the Global Burden of Disease Study 2019

Purpose

HIV/AIDS is a critical public health concern worldwide. This article investigated the spatial and temporal trends in HIV/AIDS burden from 1990 to 2019.

Methods

Data were extracted from the Global Burden of Disease (GBD) Study 2019. The estimated annual percentage change (EAPC) and the age-standardized rate (ASR) were used to quantify the change in trends at the global, regional, and national levels.

Results

In terms of temporal trends, during the period 1990–2004, increasing trends in prevalence (EAPC = 7.47, 95% confidence interval [CI] 5.84, 9.12), death (EAPC = 10.85, 95% CI 8.90–12.84), and disability-adjusted life years (DALYs) (EAPC = 10.40, 95% CI 8.47–12.36) of HIV/AIDS were observed. During the period 2005–2019, the global trends in HIV/AIDS incidence, death, and DALYs of HIV/AIDS decreased, with the EAPCs of −2.68 (95% CI−2.82–−2.53), −6.73 (95% CI −6.98–−6.47), and −6.75 (95% CI −6.95–−6.54), respectively. However, the disease prevalence showed a slight increasing trend (EAPC = 0.71, 95% CI 0.54–0.87). In terms of spatial trends, over the past 15 years, trends in HIV/AIDS incidence of HIV/AIDS appeared upward in High-middle and High sociodemographic index (SDI) areas (EAPC = 6.51, 95% CI 5.50–7.53; EAPC = 2.31, 95% CI 2.02–2.60, respectively).

Conclusion

Decreasing trends in HIV/AIDS incidence, death, and DALYs have been observed worldwide over the past 15 years, especially in death and DALYs rates. However, the global population living with HIV/AIDS is still increasing. It is worth noting that an unfavorable trend emerged in High-middle and High SDI areas. Prevention and control of HIV/AIDS still need to be strengthened to counteract these concerning trends.

HIV, Chlamydia and gonorrhoea vulnerability depending to sex work site

INTRODUCTION

Women sex workers (WSW) are one of key population on the HIV and other sexually transmitted infections (STIs) monitoring and evaluation. Socioeconomic, structural factors and other factors associated with the workplace influence exposure to these infections. The objectives of this study were to describe and compare the social characteristics, risk behaviours and HIV, chlamydia and gonorrhoeae prevalence according to sex work site (street or highway, clubs and flats).

METHODS

Cross-sectional study on 400 WSW in Catalonia. Socio-demographic, sex work and behavioral characteristics were collected through personal interview. Oral fluid and urine samples were collected to determine STI prevalence.

RESULTS

WSW that exercised in the street or highway presented more precarious conditions and a greater vulnerability related to socioeconomic factors: older population, with a lower education level and with less economic remuneration for their service. Other factors associated with lifestyle or behaviour was also observed: greater injecting drug use, longer sex work or vulnerabilities associated with structural or social determinants: less access to health services, higher proportion of forced relations and stay in prison. The overall HIV, chlamydia and gonorrhoeae prevalence was 3.0%, 1.8% and 0.5%, respectively and higher in women who exercised on the street or highway, 5.6%, 1.9% and 1.2%, respectively.

CONCLUSION

The information generated in this study will be useful for the design specific preventive interventions aimed at this group.

UK guideline for the use of HIV post-exposure prophylaxis 2021

We present the updated British Association for Sexual Health and HIV (BASHH) guidelines for post-exposure prophylaxis (PEP) to HIV following sexual exposures, occupational exposures and other nonoccupational exposures in the community. This serves as an update to the 2015 BASHH guideline on PEP following sexual exposures and the 2008 Expert Advisory Group on AIDS guidelines on HIV PEP. We aim to provide evidence-based guidance on best clinical practice in the provision, monitoring and support of PEP for the prevention of HIV acquisition following sexual, occupational and other nonoccupational exposures in the community. The guideline covers when to prescribe PEP, what antiretroviral agents to use and how to manage PEP. This includes (i) evidence of PEP efficacy; (ii) evidence relating to individual-level efficacy of antiretroviral therapy to prevent the sexual transmission of HIV; (iii) data on the detectable (transmissible) prevalence of HIV in specific populations; (iv) risk of HIV transmission following different types of sexual and occupational exposure; (v) baseline risk assessment; (vi) drug regimens and dosing schedules; (vii) monitoring PEP; (viii) baseline and follow-up blood-borne virus testing; (ix) the role of PEP within broader HIV prevention strategies, for example, HIV pre-exposure prophylaxis (PrEP). The guideline also covers special scenarios such as PEP in pregnancy, breastfeeding and chronic hepatitis B virus infection, and when PEP should be considered in people using HIV PrEP. The guidelines are aimed at clinical professionals directly involved in PEP provision and other stakeholders in the field. A proforma to assist PEP consultations is included. A public consultation process was undertaken prior to finalizing the recommendations.

ART uptake and adherence among female sex workers (FSW) globally: A scoping review

We conducted the first scoping literature review on ART uptake and adherence among Female Sex Workers (FSW), following PRISMA-ScR guidelines. Searches were conducted in PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting an ART uptake or adherence result among FSW aged 18 or older; peer-reviewed; published in English between 1996 and 2018. Our search identified 6,735 studies; 30 met eligibility requirements. ART uptake ranges from 0 to 100% and adherence ranges from 50-90%, depending on measurement methods. Uptake and adherence influencing factors are mapped onto a social ecological model (SEM). Knowledge and beliefs, substance use, food insecurity and sex-work engagement were negatively associated, while older age, relationships and social support were positively associated with ART uptake and adherence. Standardised methods to measure uptake and adherence prevalence must be established for data comparison. Evidence regarding ART uptake and adherence barriers and facilitators span multiple SEM levels, although more research is needed regarding structural and occupational level influencers. Results suggest that the multi-level ART uptake and adherence barriers faced by FSW require complex multi-level evidence-based interventions. Study findings can inform ART interventions, future research, and offer guidance to other support services with FSW, such as PrEP interventions.

HIV seroprevalence in five key populations in Europe: a systematic literature review, 2009 to 2019

Background

In Europe, HIV disproportionately affects men who have sex with men (MSM), people who inject drugs (PWID), prisoners, sex workers, and transgender people. Epidemiological data are primarily available from national HIV case surveillance systems that rarely capture information on sex work, gender identity or imprisonment. Surveillance of HIV prevalence in key populations often occurs as independent studies with no established mechanism for collating such information at the European level.

Aim

We assessed HIV prevalence in MSM, PWID, prisoners, sex workers, and transgender people in the 30 European Union/European Economic Area countries and the United Kingdom.

Methods

We conducted a systematic literature review of peer-reviewed studies published during 2009–19, by searching PubMed, Embase and the Cochrane Library. Data are presented in forest plots by country, as simple prevalence or pooled across multiple studies.

Results

Eighty-seven country- and population-specific studies were identified from 23 countries. The highest number of studies, and the largest variation in HIV prevalence, were identified for MSM, ranging from 2.4–29.0% (19 countries) and PWID, from 0.0–59.5% (13 countries). Prevalence ranged from 0.0–15.6% in prisoners (nine countries), 1.1–8.5% in sex workers (five countries) and was 10.9% in transgender people (one country). Individuals belonging to several key population groups had higher prevalence.

Conclusion

This review demonstrates that HIV prevalence is highly diverse across population groups and countries. People belonging to multiple key population groups are particularly vulnerable; however, more studies are needed, particularly for sex workers, transgender people and people with multiple risks.

HIV and associated factors among female sex workers in Tajikistan: Analysis from a national bio-behavioral survey

Tajikistan, a country of approximately nine million people, has a relatively small but quickly growing HIV epidemic. No peer-reviewed study has assessed factors associated with HIV, or associated risk factors, among female sex workers (FSWs) in Tajikistan. The purpose of the current study is to elucidate the factors associated with HIV status and risk factors in the Tajikistani context and add to the scant literature on risk factors among FSWs in Tajikistan and Central Asia. We used cross-sectional data from an HIV bio-behavioral survey (BBS) conducted among FSWs in the Republic of Tajikistan (n = 2174) in 2017. Using Respondent Driven Sampling Analysis Tool software, we calculated the prevalence of HIV, diagnosed cases, linkage to antiretroviral therapy (ART), and the prevalence of syphilis for FSWs in Tajikistan. Prevalence data were adjusted for network size and any clustering effects in the network. Further, using univariate and multivariable logistic regression, we determined correlates of HIV-positive status. Results were as follows: Of all FSWs in Tajikistan, 2.6% (95% CI: 1.7-3.8%) are HIV positive, 2.3% (95% CI: 1.4-3.5%) are diagnosed and aware of their status, and 2.0% (95% CI: 1.2-3.1%) are on ART. About 5.7% (95% CI: 4.5-7.4%) of FSWs in Tajikistan have ever had syphilis, and 0.8% (95% CI: 0.4-1.3%) have active syphilis infections. The epidemic of injection drug use was found to be strongly synergistic with HIV infection as having had sex with a person who injects drugs was shown to be strongly associated with HIV-positive status (OR: 5.2; 95% CI: 2.6-10.2) in the multivariable model. While this study estimates that HIV prevalence among Tajikistani FSWs is relatively low, it is likely an underestimated due to selection and social desirability biases. To curb the small, but potentially volatile, HIV epidemic among FSWs, the government should consider targeted testing and linkage-to-care efforts for FSWs who inject drugs or who have people who inject drugs partners. Services should also be prioritized in Gorno-Badakhshan, which has a higher number of FSWs per capita relative to other regions. Additionally, the link between HIV and experiences of stigma, violence, and discrimination against FSWs should motivate advocates to protect Tajikistani FSWs from these experiences.

Seroprevalence and Associated Factors of Human Immunodeficiency Virus, Treponema pallidum, Hepatitis B Virus, and Hepatitis C Virus among Female Sex Workers in Dessie City, Northeast Ethiopia

Introduction

Sexually transmitted infections (STIs) are prevalent in Ethiopia and elsewhere among different population groups particularly among female sex workers (FSWs). Because of their work and their behavior, FSWs are at high risk to acquire STIs. The aim of the study was to assess the seroprevalence and associated factors of HIV, HBV, HCV, and T. pallidum among FSWs in Dessie City, Northeast Ethiopia.

Methods

This cross-sectional study was conducted in Dessie City, Amhara Region, Northeastern Ethiopia, from November 2017 to April 2018. A total of 360 FSWs whose age is greater than or equal to 18 years and who are willing to participate were recruited by simple random sampling technique. Interview-based questionnaire was administered, and 5 ml of venous blood from each participant was drawn under aseptic conditions. The rapid test was performed to obtain the result of the four STIs (HIV, T. pallidum, HBV, and HCV). The collected data were entered and analyzed by SPSS version 20.0. From the bivariable analysis, variables having P value < 0.2 were retained into multivariable analysis. From the multivariable analysis, variables with P value < 0.05 were affirmed as statistically associated factors. Adjusted odds ratios and their 95% confidence intervals were used as indicators of the strength of association.

Results

Majority of study participants were urban dwellers, 10 (2.8%) respondents were married, 61 (16.9%) have more than two children, and more than half of them were at the age range between 18 and 27 years. Any infection with STIs was 84 (23.3%), whereas 27 (7.5%), 47 (13.1%), 2 (0.6%), and 45 (12.5%) study participants were positive for laboratory test of HIV, HBV, HCV, and T. pallidum, respectively. Marital status, sharing of sharp materials, breakage of condom, number of customers per week, genital discharge, and pain had significant association with any STI.

Conclusions

In comparison with different research works in Ethiopia and abroad, the prevalence of any STI, HIV, HBV, and T. pallidum was found to be relatively high. Preventive approach and appropriate treatment of STIs should be developed. Concerned body should work together to alleviate the problem by counseling and recruiting them on other productive job sectors in the country.

Loss to follow-up among female sex workers in Zambia: findings from a five-year HIV-incidence cohort

HIV-incidence studies are used to identify at-risk populations for HIV-prevention trials and interventions, but loss to follow-up (LTFU) can bias results if participants who remain differ from those who drop out. We investigated the incidence of and factors associated with LTFU among Zambian female sex workers (FSWs) in an HIV-incidence cohort from 2012 to 2017. Enrolled participants returned at month one, month three and quarterly thereafter. FSWs were considered LTFU if they missed six consecutive months, or if their last visit was six months before the study end date. Of 420 FSWs, 139 (33%) were LTFU at a rate of 15.7 per 100 person years. In multivariable analysis, LTFU was greater for FSWs who never used alcohol, began sex work above the age of consent, and had a lower volume of new clients. Our study appeared to retain FSWs in most need of HIV-prevention services offered at follow-up.

HIV, Chlamydia and gonorrhoea vulnerability depending to sex work site

INTRODUCTION

Women sex workers (WSW) are one of key population on the HIV and other sexually transmitted infections (STIs) monitoring and evaluation. Socioeconomic, structural factors and other factors associated with the workplace influence exposure to these infections. The objectives of this study were to describe and compare the social characteristics, risk behaviours and HIV, Chlamydia and gonorrhoeae prevalence according to sex work site (street or highway, clubs and flats).

METHODS

Cross-sectional study on 400WSW in Catalonia. Socio-demographic, sex work and behavioral characteristics were collected through personal interview. Oral fluid and urine samples were collected to determine STI prevalence.

RESULTS

WSW that exercised in the street or highway presented more precarious conditions and a greater vulnerability related to socioeconomic factors: older population, with a lower education level and with less economic remuneration for their service. Other factors associated with lifestyle or behaviour was also observed: greater injecting drug use, longer sex work or vulnerabilities associated with structural or social determinants: less access to health services, higher proportion of forced relations and stay in prison. The overall HIV, Chlamydia and gonorrhoeae prevalence was 3.0%, 1.8% and 0.5%, respectively, and higher in women who exercised on the street or highway: 5.6%, 1.9% and 1.2%, respectively.

CONCLUSION

The information generated in this study will be useful for the design specific preventive interventions aimed at this group.

Effect of female sex work-targeted community-based interventions along the HIV treatment cascade in sub-Saharan Africa: a systematic review protocol

INTRODUCTION

Female sex workers (FSWs) are a known high-risk group that are at increased risk of HIV transmission due to exposure to multiple sexual partners and inability to negotiate safe sex attributed to challenging economic circumstances. Previous systematic reviews have examined the effectiveness of HIV interventions prioritising FSWs and have shown that targeted interventions improve access to HIV prevention and treatment services. Interventions that increase FSWs' uptake of services are well documented; however, evidence on specific interventions aimed at improving FSWs' continuity in HIV care along the treatment cascade is lacking. This systematic review aims to document the performance of community-based interventions along the HIV treatment cascade.

METHODS AND ANALYSIS

We will use a sensitive search strategy for electronic bibliographic databases, bibliographies of included articles and grey literature sources. In addition, the Joint United Nations Programme on HIV/AIDS and the WHO websites, peer-reviewed conference papers and grey literature sources will be searched for additional reports of sex work programmes. We will include randomised controlled trials, cross-sectional surveys and cohort interventions where community-based HIV services were provided to FSWs and measure the performance of the HIV intervention on one or more cascade stages. We will conduct a systematic review of studies published from 2004 to present within the sub-Saharan Africa region. We will report quantitative study outcomes of HIV testing and diagnosis, linkage to care, initiation on antiretroviral therapy and viral suppression. We will analyse the data using the random-effects meta-analysis method, and funnel plots will be used to assess the publication bias.

ETHICS AND DISSEMINATION

This systematic review will not require ethical approval; we will publish data from manuscripts. The results of this study will be disseminated in peer-reviewed journals and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020157623.

Prevalence and factors associated with HIV epidemic among female sex workers in Pakistan: results of the fifth round of integrated biological and behavioural surveillance

OBJECTIVES

We examined data collected as part of the fifth round of integrated biological and behavioural surveillance to determine the prevalence and factors associated with HIV infection among female sex workers (FSWs) in Pakistan.

METHODS

FSWs were defined as 'all females, age 13 years and above, who receive money or goods in exchange for sexual services, regardless of the site of operation'. Data were collected between October 2016 and January 2017 in 18 cities using multistage sampling techniques to randomly select FSWs from spots facilitated by peers. Behavioural data were collected by interviewers using structured questionnaires, which was followed by obtaining finger prick blood samples tested for HIV using two rapid tests. Multivariate logistic regression analysis was done to assess independent associations of potential correlates using HIV status as dependent variable.

RESULTS

We invited 5728 FSWs to participate, of which 68 refused to participate (refusal rate=1.2%). Of the 5660 FSWs who participated, 121 were HIV seropositive (weighted HIV prevalence 2.3%; 95% CI 1.9% to 2.7%) mostly concentrated within cities in Sindh. Multivariate analysis showed being uneducated/illiterate (adjusted OR (aOR) 2.1; 95% CI 1.4 to 3.4), directly dealing with clients without a pimp (aOR 1.8; 95% CI 1.1 to 2.8), non-use of condom with clients (aOR 1.8; 95% CI 1.1 to 2.8), having sexual contact with people who inject drugs (PWID) (aOR 2.2; 95% CI 1.3 to 3.7) and non-participation in HIV programmes (aOR 1.7; 95% CI 1.0 to 3.1) as factors independently associated with HIV seropositivity.

CONCLUSIONS

We found a weighted national HIV prevalence of 2.3% and identified factors independently associated with HIV in FSWs. The country needs to scale up HIV prevention programmes to improve coverage, prioritising FSWs who are illiterate, work independently and have PWID as sex partners. Emphasis should be laid on strategies to improve condom use with both regular and non-regular partners.

Associations Between Violence and HIV Risk Behaviors Differ by Perpetrator Among Russian Sex Workers

Violence is associated with HIV and HIV risk behaviors among female sex workers (FSW). However, few studies assess multiple forms of violence and multiple HIV risk behaviors to build a comprehensive picture of how violence is implicated in HIV risk. Using respondent-driven sampling, 754 FSW were recruited in the Russian Federation. Surveys collected data on lifetime exposure to client, police, intimate partner, and pimp violence, as well as recent HIV risk behavior in the forms of injecting drug use (IDU), and inconsistent condom use with intimate partners and clients. Multivariable log-binomial and Poisson regression were used to assess associations between violence and HIV risk behavior outcomes. Lifetime client (31.7%), police (16.0%), intimate partner (15.7%), and pimp (11.4%) violence were prevalent. IDU (10.7%) and inconsistent condom use with intimate partners (45.1%) and clients (22.5%) were common. Intimate partner violence (IPV) and client violence were associated with IDU (ARR_IPV 2.12, 95% CI 1.10, 4.10; ARR_Client 2.75, 95% CI 1.19, 6.32), IPV and police violence were associated with inconsistent condom use with intimate partners (ARR_IPV 1.10, 95% CI 1.01, 1.19; ARR_Police 1.11, 95% CI 1.01, 1.21), and IPV and police violence were associated with inconsistent condom use with clients (ARR_IPV 1.49, 95% CI 1.02, 2.17; ARR_Police 1.65, 95% CI 1.19, 2.29). Each perpetrator-specific type of violence was associated with a unique set of HIV risk behaviors. Comprehensive violence prevention programming that addresses multiple perpetrators of violence against FSW, including clients, intimate partners and police, is critical for reducing sexual and drug-related HIV risk in FSW.

Interpersonal and structural factors associated with receptive syringe-sharing among a prospective cohort of female sex workers who inject drugs

AIMS

To determine the interpersonal and structural factors associated with receptive syringe sharing (RSS) among female sex workers who inject drugs (FSW-IDU), a group at high risk of HIV/hepatitis C virus (HCV) acquisition.

DESIGN

Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) study, a prospective cohort study.

SETTING

Baltimore, MD, USA PARTICIPANTS: One hundred and eighty FSW-IDU; mean age = 33 years, 77.1% white and 62.9% in a relationship/married.

MEASUREMENTS

Surveys were conducted between April 2016 and February 2018. The main outcome was recent RSS (past 3 months). In addition to socio-demographic characteristics and drug use behaviors, we assessed factors at the interpersonal level, including injection practices, intimate partner and client drug use and exposure to violence. Structural-level factors included methods of syringe access.

FINDINGS

Nearly all FSW-IDU used heroin (97.1%) or crack cocaine (89.7%). Recent RSS was reported by 18.3%. Syringes were accessed from needle exchange programs (64.6%), pharmacies (29.7%), street sellers (30.3%) or personal networks (29.1%). Some FSW-IDU had clients or intimate partners who injected drugs (26.3 and 26.9%, respectively). Longitudinal factors independently associated with RSS in the multi-level mixed-effects model were recent client violence [adjusted odds ratio (aOR) = 2.17, 95% confidence interval (CI) = 1.09-4.33], having an intimate partner who injected drugs (aOR = 2.18, 95% CI = 0.98-4.85), being injected by others (aOR = 4.95, 95% CI = 2.42-10.10) and obtaining syringes from a street seller (aOR = 1.88, 95% CI = 0.94-3.78) or from a member of their personal network (aOR = 4.43, 95% CI = 2.21-8.90).

CONCLUSIONS

Client violence, intimate partner injection drug use, being injected by others and obtaining syringes from personal connections appear to increase parenteral HIV/HCV risk among female sex workers who inject drugs.

Preventing sexually transmitted and blood borne infections (STBBIs) among sex workers: a critical review of the evidence on determinants and interventions in high-income countries

Background

Across diverse regions globally, sex workers continue to face a disproportionate burden of HIV and other sexually transmitted and blood borne infections (STBBIs). Evidence suggests that behavioural and biomedical interventions are only moderately successful in reducing STBBIs at the population level, leading to calls for increased structural and community-led interventions. Given that structural approaches to mitigating STBBI risk beyond HIV among sex workers in high-income settings remain poorly understood, this critical review aimed to provide a comprehensive synthesis of the global research and literature on determinants of HIV and other STBBIs and promising intervention practices for sex workers of all genders in high-income countries.

Methods

We searched for publications over the last decade (January 2005–March 2016) among sex workers (cis women, cis men, and trans individuals). Data obtained from quantitative peer-reviewed studies were triangulated with publicly available reports and qualitative/ethnographic research where quantitative evidence was limited.

Results

Research demonstrates consistent evidence of the direct and indirect impacts of structural factors (e.g., violence, stigma, criminalization, poor working conditions) on increasing risk for STBBIs among sex workers, further compounded by individual and interpersonal factors (e.g., mental health, substance use, unprotected sex). Sub-optimal access to health and STBBI prevention services remains concerning. Full decriminalization of sex work has been shown to have the largest potential to avert new infections in sex work, through reducing workplace violence and increasing access to safer workspaces. Promising practices and strategies that should be scaled-up and evaluated to prevent STBBIs are highlighted.

Conclusions

The high burden of STBBIs among sex workers across high-income settings is of major concern. This review uniquely contributes to our understanding of multilevel factors that potentiate and mitigate STBBI risk for sex workers of all genders. Research suggests that multipronged structural and community-led approaches are paramount to addressing STBBI burden, and are necessary to realizing health and human rights for sex workers. Given the heterogeneity of sex worker populations, and distinct vulnerabilities faced by cis men and trans sex workers, further research utilizing mixed-methods should be implemented to delineate the intersections of risk and ameliorate critical health inequalities.

Structural interventions and social suffering: Responding to amphetamine-type stimulant use among female entertainment and sex workers in Cambodia

BACKGROUND

In Cambodia, HIV infection remains high among female entertainment and sex workers (FESW) and the use of amphetamine-type stimulants (ATS) is an independent risk factor for unprotected sex and sexually transmitted infections among this group. For decades public health approaches to HIV prevention in low and middle income countries (LMIC) have attempted to target the macro-power relations that shape risk behaviour with structural interventions. Recent research has highlighted that interventions that combine ATS risk reduction, in the form of financial incentives for abstinence, with existing HIV prevention programmes, may also play an important role. However, whether this approach goes far enough as a response to structural drivers of risk requires further examination.

METHODS

Semi-structured in-depth interviews were conducted with 30 FESW (mean age 25 years) from five provinces in Cambodia, as part of formative research for the implementation of the Cambodia Integrated HIV and Drug Prevention (CIPI) trial. The aim was to explore the contexts and drivers of ATS use. Data were analysed using grounded theory.

RESULTS

In addition to increasing occupational functionality, ATS were used to control pervasive feelings of 'sadness' in relation to the lived experience of poverty, family and relationship problems. Feeling sad could be viewed as an expression of social suffering, in response to competing priorities and seemingly inescapable constraints imposed by a lack of options for income generation, gender inequalities and stigma. Participants expressed interest in microenterprise (ME) opportunities, particularly vocational training, that could create new work opportunities beyond sex work and ATS use.

CONCLUSION

In addition to reducing ATS use, HIV prevention interventions need to target sources of sadness and social suffering as drivers of risk among FESW in this context. The inclusion of ME opportunities in HIV prevention, to alleviate social suffering, warrants further investigation through qualitative and ethnographic research.

HIV Testing and Counseling Among Female Sex Workers: A Systematic Literature Review

HIV testing uptake continues to be low among Female Sex Workers (FSWs). We synthesizes evidence on barriers and facilitators to HIV testing among FSW as well as frequencies of testing, willingness to test, and return rates to collect results. We systematically searched the MEDLINE/PubMed, EMBASE, SCOPUS databases for articles published in English between January 2000 and November 2017. Out of 5036 references screened, we retained 36 papers. The two barriers to HIV testing most commonly reported were financial and time costs—including low income, transportation costs, time constraints, and formal/informal payments—as well as the stigma and discrimination ascribed to HIV positive people and sex workers. Social support facilitated testing with consistently higher uptake amongst married FSWs and women who were encouraged to test by peers and managers. The consistent finding that social support facilitated HIV testing calls for its inclusion into current HIV testing strategies addressed at FSW.

To prescribe, or not to prescribe: decision making in HIV-1 post-exposure prophylaxis

OBJECTIVES

We investigated the trend in usage of post-exposure prophylaxis (PEP) after HIV-1 risk exposure and evaluated PEP prescription decision making of physicians according to guidelines.

METHODS

All PEP consultations from January 2014 to December 2016 in patients presenting at the University Hospital of Cologne (Germany) were retrospectively analysed. HIV risk contacts included sexual and occupational exposure. The European AIDS Clinical Society (EACS) Guidelines for HIV PEP (version 9.0, 2017) were used for assessment.

RESULTS

A total of 649 patients presented at the emergency department (ED) or the clinic for infectious diseases (IDC) for PEP consultations. A continuous increase in the number of PEP requests was recorded: 189 in 2014, 208 in 2015 and 252 in 2016. PEP consultations in men who have sex with men (MSM) showed a remarkable increase in 2016 (2014, n = 96; 2015, n = 101; 2016, n = 152). Decisions taken by physicians with a specialization in infectious diseases (n = 547) included 61 (11%) guideline-discordant prescriptions [2014: 14% (n = 22); 2015: 9% (n = 16); 2016: 11% (n = 23)]. Among these, sexual exposure accounted for 45 (74%) cases, including 15 cases of nonconsensual sex, while occupational exposure accounted for 14 (23%) cases and other exposure two cases (3%). The main reason for guideline-discordant PEP prescriptions was emotional stress of the patient (n = 37/61).

CONCLUSIONS

PEP prescriptions are increasing and decision making is influenced by patients' emotional stress, but PEP prescriptions should be strictly administered according to risk assessment.

A typology of female sex work in the Metropolitan Region of Santiago, Chile

In Chile, sex work takes place covertly in a variety of venues and locations. Formative research using time-location sampling methods is important in order to understand the nature of this diversity. This study used qualitative methods to develop a typology of female sex work in the Metropolitan Region of Santiago, Chile, using semi-structured interviews, focus groups and ethnographic fieldwork during visits to sex work venues. The study identified seven types of venue, which reflect the context and regulatory framework of the country and the structural vulnerabilities that affect female sex workers in Chile. These venues and locations include: cafés con piernas (coffee with legs); nightclubs, topless bars and cabarets; brothels; hotels; street and highway soliciting; massage parlours; and private residences. Formative research methods were helpful in identifying and characterising the venues and locations in which sex work occurred. Barriers to accessing and mapping specific locations were also identified. Recommendations for addressing these barriers include working with non-governmental organisations to map venues and initiate contact with the populations of interest. A comprehensive typology of sex work in the Metropolitan Region of Santiago, Chile, is an essential element for future time-location sampling and bio-behavioural research in the context of second-generation surveillance for HIV and sexually transmitted infections in Chile.

Impact of sex work on risk behaviours and their association with HIV positivity among people who inject drugs in Eastern Central Canada: cross-sectional results from an open cohort study

OBJECTIVES

The objectives of this study were: (1) to examine the correlates of HIV positivity among participants who injected drugs and engaged in sex work (PWID-SWs) in the SurvUDI network between 2004 and 2016, after stratification by sex, and (2) to compare these correlates with those of sexually active participants who did not engage in sex work (PWID non-SWs).

DESIGN AND SETTING

This biobehavioural survey is an open cohort of services where participants who had injected in the past 6 months were recruited mainly through harm reduction programmes in Eastern Central Canada.

PARTICIPANTS

Data from 5476 participants (9223 visits in total; 785 not included in multivariate analyses due to missing values) were included.

METHODS

Participants completed an interviewer-administered questionnaire and provided saliva samples for anti-HIV antibody testing. Generalised estimating equations taking into account multiple participations were used.

RESULTS

Baseline HIV prevalence was higher among SWs compared with non-SWs (women: 13.0% vs 7.7%; P<0.001, and men: 17.4% vs 10.8%; P<0.001). PWID-SWs were particularly susceptible to HIV infection as a result of higher levels of vulnerability factors and injection risk behaviours. They also presented different risk-taking patterns than their non-SWs counterparts, as shown by differences in correlates of HIV positivity. Additionally, the importance of sex work for HIV infection varies according to gender, as suggested by a large proportion of injection risk behaviours associated with HIV among women and, conversely, a stronger association between sexual behaviours and HIV positivity observed among men.

CONCLUSION

These results suggest that sex work has an impact on the risk of HIV acquisition and that risk behaviours vary according to gender. Public health practitioners should take those specificities into account when designing HIV prevention interventions aimed at PWIDs.

Experiences of structural vulnerability among exotic dancers in Baltimore, Maryland: Co-occurring social and economic antecedents of HIV/STI risk

BACKGROUND

Women who grow up in economic scarcity often face limited opportunities for upward mobility, as a result of challenges securing stable housing, quality education, and steady employment. Chronic instability may limit the capacity of women to protect themselves against HIV/STI-related harm when engaging in sexual activity or drug use. Characterizing the structural contexts that facilitate HIV/STI risk among women are critical to effective design and implementation of drug and sexual harm reduction interventions.

METHODS

Semi-structured in-depth interviews were completed with 25 female exotic dancers working in Baltimore City and County exotic dance clubs July 2014-May 2015. Using thematic analysis, interviews were examined to understand the nature of structural vulnerability experienced by dancers during their early lives through the initial months of exotic dancing, including an examination of the roles of drug use and social relationships in engagement of sexual risk behavior.

RESULTS

Dancers depicted early experiences of social and economic disadvantage, which accumulated through early adulthood. Substance use emerged as an important subject for the majority of women, operating cyclically as both precursor to and product of accumulating social and economic hardship. Dancers revealed social strategies that buffered the effects of structural vulnerability and minimized exposure to workplace-related drug and sexual harms.

CONCLUSION

This study provides insight on an understudied group of at-risk women with a unique demographic profile. Findings illustrate how the effects of structural vulnerability, substance abuse, social strategies, and opportunities for economic gain through sexual services in the workplace converge to produce varying levels of HIV/STI risk among exotic dancers.

Correlates of health care utilization under targeted interventions: The case of female sex workers in Andhra Pradesh, India

Accessibility and frequency of use of health care services among female sex workers (FSWs) are constrained by various factors. In this analysis, we examined the correlates of frequency of using health care services under targeted interventions among FSWs. A sample of FSWs (N = 1,973) was obtained from a second round (2012) of Behavioral Tracking Survey, conducted in five districts of Andhra Pradesh, a high-HIV-prevalence state in southern India. We used negative binomial regression models to analyze frequency of utilization of health care services among FSWs. Based on our analysis, we suggest that various predisposing and enabling factors were found to be significantly associated with the visit to NGO clinics for treatment of any health problem, any sexually transmitted infection symptom, and the number of condoms received from the peer worker or condom depot. We suggest the need for further research with respect to various correlates of frequency of using health care among FSWs to develop effective intervention strategies in countries that have high HIV prevalence among FSWs and targeted interventions need more diligent implementation to reach the unreached.

HIV prevalence and high-risk behaviour of young brothel and non-brothel based female sex workers in Nigeria

Background

Female sex workers (FSWs) have been identified as a core group in the transmission of HIV and other sexually transmitted infections (STIs). Young FSWs are particularly more vulnerable to HIV due to the combination of vulnerabilities associated with their youth and the sex work they engage in. This study aims to give more insight into HIV prevalence and sexual risk behaviour of young FSWs in Nigeria, by focusing on the differences between BB and NBB young FSWs.

Methods

Data was obtained from the Nigeria Integrated Biological and Behavioural Surveillance Survey (IBBSS) for high-risk groups conducted in 2010. IBBSS is a quantitative survey conducted amongst identified high-risk sub populations within Nigeria. HIV prevalence and risk behaviour data for young BB and NBB FSWs aged 15–24 years for nine states was extracted and analysed.

Results

A total of 1796 FSWs aged 15–24 years were interviewed during the survey, 746 (41.5%) were BB while 1050 (58.5%) were NBB. The HIV prevalence was higher among BB FSWs compared to the NBB FSWs (21.0% vs. 15.5%). BB FSWs reported less condom use with boyfriends and casual partners than NBB FSWs (26.3% vs. 45.5%) and (55.1% vs. 61.1%) respectively while risk of HIV infection due to injecting drug use was higher in NBB compared to BB FSWs (6.6% vs. 1.2%).

Conclusion

Existing and future interventions on HIV prevention should focus on empowering young FSWs with innovative and sustainable approaches aimed at improving their health and wellbeing.

Criminalizing Sex Work Clients and Rushed Negotiations among Sex Workers Who Use Drugs in a Canadian Setting

Previous research indicates that criminalization of sex work is associated with harms among sex workers. In 2013, the Vancouver Police Department changed their sex work policy to no longer target sex workers while continuing to target clients and third parties in an effort to increase the safety of sex workers (similar to "end-demand sex work" approaches being adopted in a number of countries globally). We sought to investigate the trends and correlates of rushing negotiations with clients due to police presence among 359 sex workers who use drugs in Vancouver before and after the guideline change. Data were derived from three prospective cohort studies of people who use drugs in Vancouver between 2008 and 2014. We used sex-stratified multivariable generalized estimating equation models. The crude percentages of sex workers who use drugs reporting rushing client negotiations changed from 8.9% before the guideline change to 14.8% after the guideline change among 259 women, and from 8.6 to 7.1% among 100 men. In multivariable analyses, there was a significant increase in reports of rushing client negotiation after the guideline change among women (p = 0.04). Other variables that were independently associated with increased odds of rushing client negotiation included experiencing client-perpetrated violence (among both men and women) and non-heterosexual orientation (among women) (all p < 0.05). These findings indicate that despite the policing guideline change, rushed client negotiation due to police presence appeared to have increased among our sample of female sex workers who use drugs. It was also associated with client-perpetrated violence and other markers of vulnerability. These findings lend further evidence that criminalizing the purchase of sexual services does not protect the health and safety of sex workers.

Remaining Gap in HIV Testing Uptake Among Female Sex Workers in Iran

We estimated the prevalence of recent HIV testing (i.e., having an HIV test during the last 12 months and knew the results) among 1295 HIV-negative Iranian female sex workers (FSW) in 2015. Overall, 70.4% (95% confidence intervals: 59.6, 79.3) of the participants reported a recent HIV testing. Concerns about their HIV status (83.2%) was reported as the most common reason for HIV testing. Incarceration history, having >5 paying partners, having >1 non-paying partner, receiving harm reduction services, utilizing healthcare services, and knowing an HIV testing site were significantly associated with recent HIV testing. In contrast, outreach participants, having one non-paying sexual partner, and self-reported inconsistent condom use reduced the likelihood of recent HIV testing. HIV testing uptake showed a ~2.5 times increase among FSW since 2010. While these findings are promising and show improvement over a short period, HIV testing programs should be expanded particularly through mobile and outreach efforts.

Gender violence, poverty and HIV infection risk among persons engaged in the sex industry: cross-national analysis of the political economy of sex markets in 30 European and Central Asian countries

Objectives

Persons engaged in the sex industry are at greater risk of HIV and other sexually transmitted infections than the general population. One major factor is exposure to higher levels of risky sexual activity. Expanding condom use is a critical prevention strategy, but this requires negotiation with those buying sex, which takes place in the context of cultural and economic constraints. Impoverished individuals who fear violence are more likely to forego condoms.

Methods

Here we tested the hypotheses that poverty and fear of violence are two structural drivers of HIV infection risk in the sex industry. Using data from the European Centre for Disease Prevention and Control and the World Bank for 30 countries, we evaluated poverty, measured using the average income per day per person in the bottom 40% of the income distribution, and gender violence, measured using homicide rates in women and the proportion of women exposed to violence in the last 12 months and/or since age 16 years.

Results

We found that HIV prevalence among those in the sex industry was higher in countries where there were greater female homicide rates (β = 0.86; P = 0.018) and there was some evidence that self‐reported exposure to violence was also associated with higher HIV prevalence (β = 1.37; P = 0.043). Conversely, HIV prevalence was lower in countries where average incomes among the poorest were greater (β = −1.05; P = 0.046).

Conclusions

Our results are consistent with the theory that reducing poverty and exposure to violence may help reduce HIV infection risk among persons engaged in the sex industry.

National sex work policy and HIV prevalence among sex workers: an ecological regression analysis of 27 European countries

BACKGROUND

Sex workers are disproportionately affected by HIV compared with the general population. Most studies of HIV risk among sex workers have focused on individual-level risk factors, with few studies assessing potential structural determinants of HIV risk. In this Article, we examine whether criminal laws around sex work are associated with HIV prevalence among female sex workers.

METHOD

We estimate cross-sectional, ecological regression models with data from 27 European countries on HIV prevalence among sex workers from the European Centre for Disease Control; sex-work legislation from the US State Department's Country Reports on Human Rights Practices and country-specific legal documents; the rule of law and gross-domestic product per capita, adjusted for purchasing power, from the World Bank; and the prevalence of injecting drug use among sex workers. Although data from two countries include male sex workers, the numbers are so small that the findings here essentially pertain to prevalence in female sex workers.

FINDINGS

Countries that have legalised some aspects of sex work (n=17) have significantly lower HIV prevalence among sex workers than countries that criminalise all aspects of sex work (n=10; β=-2·09, 95% CI -0·80 to -3·37; p=0·003), even after controlling for the level of economic development (β=-1·86; p=0·038) and the proportion of sex workers who are injecting drug users (-1·93; p=0·026). We found that the relation between sex work policy and HIV among sex workers might be partly moderated by the effectiveness and fairness of enforcement, suggesting legalisation of some aspects of sex work could reduce HIV among sex workers to the greatest extent in countries where enforcement is fair and effective.

INTERPRETATION

Our findings suggest that the legalisation of some aspects of sex work might help reduce HIV prevalence in this high-risk group, particularly in countries where the judiciary is effective and fair.

FUNDING

European Centre for Disease Prevention and Control.

STI tests and proportion of positive tests in female sex workers attending local public health departments in Germany in 2010/11

BACKGROUND

In Germany, local public health departments (LPHD) are required to offer low-threshold access to confidential counselling and testing for sexually transmitted infections (STI) for sex workers. We collected data from LPHD in Germany to estimate the number of performed STI tests and the proportion of positive STI tests among attending female sex workers (FSW) in order to formulate recommendations for improving STI testing and care for FSW in Germany.

METHODS

We recruited LPHD across Germany to collect aggregated data on attending FSW between January 2010 and March 2011. Baseline characteristics, the number of attending FSW, STI tests (HIV, Chlamydia trachomatis, Neisseria gonorrhoea, syphilis and Trichomonas vaginalis) and the number of positive results were provided by participating LPHD. We described the number of STI tests per FSW visit and the proportion of positive test results, including interquartile range (IQR). We tested whether baseline characteristics of LPHD were associated with the proportion of positive test results.

RESULTS

Overall, 28 LPHD from 14 of the 16 federal states reported 9284 FSW visits over the study period, with a median of 188 FSW visits (IQR 45-440) per LPHD. Overall, a median of 77.1% (IQR 60.7-88.0) of visiting FSW received a test for Neisseria gonorrhoea, followed by HIV (66.0%, IQR 47.9-86.8), Chlamydia trachomatis (65.4%, IQR 50.7-83.6) and syphilis (61.6, IQR 48.6-78.6). In total, 22,914 STI tests were performed. The proportion of positive tests was 3.1% (IQR 1.3-4.8), with the highest proportion of positive tests for Chlamydia trachomatis (6.8%, IQR 2.5-10.4), followed by Neisseria gonorrhoea (3.2%, IQR 0.0-5.3), Trichomonas vaginalis (3.0%, IQR 0.0-15.4), syphilis (1.1%, IQR 0.0-1.3) and HIV (0.2%, IQR 0.0-0.4). The proportion of positive tests varied between 0 and 13.9% between LPHD, with a higher variation of proportion of positive tests in LPHD with a smaller number of reported STI tests.

CONCLUSIONS

Participating LPHD varied in terms of performed STI tests and FSW visits. The proportion of positive STI tests was low, but varied between LPHD. This variation likely reflects different testing strategies. Existing testing guidelines should be used by all LPHD to ensure high quality care for FSW.

Policy responses to HIV/AIDS in Central Asia

The countries of Central Asia (Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan) are confronted with one of the fastest growing HIV/AIDS epidemics worldwide, largely driven through injecting drug use. This article, based on a review of academic and grey literature, explores how they have responded. We find major similarities and differences across the region. At one extreme is Turkmenistan, which denies that there is any problem, does not offer harm reduction services or HIV/AIDS treatment and does not report any meaningful data to the international community. Uzbekistan is also pretty closed to outside influences, has discontinued its opioid substitution project and shares with Turkmenistan the legal prohibition of male-to-male sex. Kyrgyzstan originally led many progressive approaches in the region and, like neighbouring Tajikistan, has received substantial assistance by international agencies, in particular the Global Fund. Kazakhstan, with a much higher gross domestic product per capita, has taken on the financing of harm reduction activities through its national budget and has liberalised its drug policies. Yet, across the region punitive approaches to injecting drug use and people living with HIV/AIDS persist as do stigma and discrimination, while coverage with harm reduction programmes and treatment services is still low although with substantial variation across countries.

UK guideline for the use of HIV Post-Exposure Prophylaxis Following Sexual Exposure, 2015

We present the updated British Association for Sexual Health and HIV guidelines for HIV post-exposure prophylaxis following sexual exposure (PEPSE). This document includes a review of the current data to support the use of PEPSE, considers how to calculate the risks of infection after a potential exposure, and provides recommendations on when PEPSE should and should not be considered. We also review which medications to use for PEPSE, provide a checklist for initial assessment, and make recommendations for monitoring individuals receiving PEPSE. Special scenarios, cost-effectiveness of PEPSE, and issues relating to service provision are also discussed. Throughout the document, the place of PEPSE within the broader context of other HIV prevention strategies is considered.

Victimization and HIV Risks Among Croatian Female Sex Workers: Exploring the Mediation Role of Depressiveness and the Moderation Role of Social Support

To assess the association between victimization and HIV vulnerability among Croatian female sex workers (FSWs), a survey involving 157 FSWs recruited from Croatia's two largest urban areas was conducted in 2014. A majority of participants reported direct and indirect victimization, which was found to be significantly associated with condom use at most recent noncommercial sexual intercourse and sexually transmitted infection (STI) diagnosis in the past 12 months. The association between victimization and STI diagnosis was partially mediated by depressiveness and moderated by social support. The buffering role of social support points to the importance of including counseling services in HIV prevention programs in Croatia.

Psychological health and HIV transmission among female sex workers: a systematic review and meta-analysis

Current HIV prevention interventions for female sex workers (FSWs) have tended to target the cognitive factors in changing their behaviors, yet little attention has been paid to the psychological factors that influence the behavior of women in sex work. This review aimed to explore the associations between the psychological health of FSWs and HIV risk. A total of eight studies published in English before July 2013 were identified and reviewed. FSWs had reported psychological issues, including depression, suicidal thoughts as well as lower quality of life, and the pooled prevalence of probable depression was as high as 62.4%. The majority of studies showed that higher scores in psychological health problems were associated with increased HIV risk behavior, in particular inconsistent condom use, or sexually transmitted infections. Among the five studies which measured symptoms of depression, four documented that higher depression scores were significantly associated with inconsistent condom use among FSWs with their clients and/or partners. Meta-analysis using a fixed-effects model was performed to examine the association between depression and inconsistent condom use and found that higher scores in depression were significantly associated with inconsistent condom use (odds ratio = 2.57, p < .001). This review contends that future HIV preventive interventions should take psychological health of FSWs into consideration.

Effect of self-care training program based on Orem's model on the behaviors leading to sexually transmitted disease in vulnerable women

Background:

Vulnerable women are prone to sexually transmitted diseases due to their high-risk behaviors. The present study aimed to investigate the effect of self-care training program based on Orem's model on the behaviors leading to sexually transmitted diseases in vulnerable women.

Materials and Methods:

This field trial was initially conducted on 100 women covered under health services and welfare organization in Isfahan city, who were selected by rationing ssampling. For needs assessment, they filled the self-care needs assessment questionnaire in three domains of knowledge, attitude, and practice. Then, at the stage of intervention (self-care training), 64 subjects were selected through convenient sampling and were assigned to experimental and control groups by random allocation. Data were analyzed by descriptive and analytical statistical tests through SPSS 18.

Results:

Results showed that mean scores of knowledge (P < 0.001), attitude (P < 0.001), practice (P = 0.04), and behavior change (P = 0.01) were significantly higher immediately after and 3 months after intervention, compared to before intervention, but there was no significant difference in mean scores between immediately after and 3 months after intervention.

Conclusions:

With regard to these results, it can be concluded that if the educational programs are planned based on clients’ real needs assessment, the learners follow the educational materials, related to their problems, more seriously and it results in a notable behavior change in them.

Prevalence and Correlates of Client-Perpetrated Violence against Female Sex Workers in 13 Mexican Cities

BACKGROUND

Globally, client-perpetrated violence against female sex workers (FSWs) has been associated with multiple health-related harms, including high-risk sexual behavior and increased exposure to HIV/STIs. This study examined correlates of client-perpetrated sexual, physical, and economic violence (e.g., robbery) against FSWs in 13 cities throughout Mexico.

METHODS

FSWs (N = 1,089) who were enrolled in a brief, evidence-based, sexual risk reduction intervention for FSWs (Mujer Segura) were interviewed about their work context, including experiences of violence perpetrated by clients, sexual risk and substance use practices, financial need, and social supports. Three broad categories of factors (sociodemographic, work context, behavioral and social characteristics of FSWs) were examined as correlates of sexual, physical, and economic violence.

RESULTS

The prevalence of different types of client-perpetrated violence against FSWs in the past 6 months was: sexual (11.7%), physical (11.8%), economic (16.9%), and any violence (22.6%). Greater financial need, self-identification as a street worker, and lower perceived emotional support were independently associated with all three types of violence. Alcohol use before or during sex with clients in the past month was associated with physical and sexual violence. Using drugs before or during sex with clients, injection drug use in the past month, and population size of city were associated with sexual violence only, and FSWs' alcohol use score (AUDIT-C) was associated with economic violence only.

CONCLUSIONS

Correlates of client-perpetrated violence encompassed sociodemographic, work context, and behavioral and social factors, suggesting that approaches to violence prevention for FSWs must be multi-dimensional. Prevention could involve teaching FSWs strategies for risk avoidance in the workplace (e.g., avoiding use of alcohol with clients), enhancement of FSWs' community-based supports, development of interventions that deliver an anti-violence curriculum to clients, and programs to address FSWs' financial need by increasing their economic opportunities outside of the sex trade.

HIV, HCV, HBV, HSV, and syphilis prevalence among female sex workers in Tehran, Iran, by using respondent-driven sampling

To find out the prevalence of HIV, HCV, HBV, HSV, and syphilis infections among female sex workers (FSWs) in Tehran, a cross-sectional study by using respondent-driven sampling (RDS) method was conducted. From December 2012 to April 2013 FSWs in Tehran were recruited. Inclusion criteria consisted of trading sex during the 12 months prior to this study and selling sex for at least 6 months in participants' lifetime. Among 161 consenting participants, 5% were infected with HIV. Moreover, 8.1% of FSWs were HCV positive, 37.9% were of HSV type1/type2, 1.2% of participants were infected with HBV, and none of the participants were infected with syphilis. HIV-positive participants were significantly more likely to be co-infected with HSV type1/type2, be younger, have more sexual partners and especially more clients during seven days prior to this study and report more history of having at least one of sexually transmitted infections symptoms in 12 months prior the study. In the multiple logistic regression analysis, being infected with HSV and also being under 25 years of age were found to be independently associated with HIV infection. Compared with the prevalence of HIV among general population of Tehran, relatively high prevalence of HIV and other viral infections among FSWs should be considered. All in all, it is critical to commence effective counter-measures for this high-risk group if the aim is to prevent spreading of these viruses to general population.

Social and Structural Factors Shaping High Rates of Incarceration among Sex Workers in a Canadian Setting

In light of the emphasis on enforcement-based approaches towards sex work, and the well-known negative impacts of these approaches on women's health, safety and well-being, we conducted a study to investigate the prevalence and correlates of recent incarceration among a cohort of women sex workers in Vancouver, Canada. Data were obtained from an open prospective community cohort of female and transgender women sex workers, known as An Evaluation of Sex Workers' Health Access (AESHA). Bivariate and multivariable logistic regression analyses, using generalized estimating equations (GEE), were used to model the effect of social and structural factors on the likelihood of incarceration over the 44-month follow-up period (January 2010-August 2013). Among 720 sex workers, 62.5 % (n = 450) reported being incarcerated in their lifetime and 23.9 % (n = 172) being incarcerated at least once during the study period. Of the 172 participants, about one third (36.6 %) reported multiple episodes of incarceration. In multivariable GEE analyses, younger age (adjusted odds ratio [AOR] = 1.04 per year younger, 95 % confidence interval [CI] 1.02-1.06), being of a sexual/gender minority (AOR = 1.62, 95 % CI 1.13-2.34), heavy drinking (AOR = 1.99, 95 % CI 1.20-3.29), being born in Canada (AOR = 3.28, 95 % CI 1.26-8.53), living in unstable housing conditions (AOR = 4.32, 95 % CI 2.17-8.62), servicing clients in public spaces (versus formal sex work establishments) (AOR = 2.33, 95 % CI 1.05-5.17) and experiencing police harassment without arrest (AOR = 1.82, 95 % CI 1.35-2.45) remain independently correlated with incarceration. This prospective study found a very high prevalence and frequency of incarceration among women sex workers in Vancouver, Canada, with the most vulnerable and marginalized women at increased risk of incarceration. Given the well-known social and health harms associated with incarceration, and associations between police harassment and incarceration in this study, our findings further add to growing calls to move away from criminalized and enforcement-based approaches to sex work in Canada and globally.

Correlates of HIV infection among street-based and venue-based sex workers in Vietnam

Commercial sex work is one of the driving forces of the HIV epidemic across the world. In Vietnam, although female sex workers (FSWs) carry a disproportionate burden of HIV, little is known about the risk profile and associated factors for HIV infection among this population. There is a need for large-scale research to obtain reliable and representative estimates of the measures of association. This study involved secondary data analysis of the 'HIV/STI Integrated Biological and Behavioral Surveillance' study in Vietnam in 2009-2010 to examine the correlates of HIV among FSWs. Data collected from 5298 FSWs, including 2530 street-based sex workers and 2768 venue-based sex workers from 10 provinces in Vietnam, were analyzed using descriptive statistics and bivariate and multivariate logistic regression analyses. HIV prevalence among the overall FSW population was 8.6% (n = 453). However, when stratified by FSW subpopulations, HIV prevalence was 10.6% (n = 267) for street-based sex workers and 6.7% (n = 186) for venue-based sex workers. Factors independently associated with HIV infection in the multivariate analysis, regardless of sex work types, were injecting drug use, high self-perceived HIV risk, and age ≥ 25 years. Additional factors independently associated with HIV risk within each FSW subpopulation included having ever been married among street-based sex workers and inconsistent condom use with clients and having sex partners who injected drugs among venue-based sex workers. Apart from strategies addressing modifiable risk behaviours among all FSWs, targeted strategies to address specific risk behaviours within each FSW subpopulation should be adopted.

Sexually transmitted infections among female sex workers tested at STI clinics in the Netherlands, 2006-2013

Background

Specialised sexually transmitted infection (STI) clinics in the Netherlands provide STI care for high-risk groups, including female sex workers (FSW), at the clinic and by outreach visiting commercial sex workplaces with a permit. The objective was to investigate the STI positivity rate and determinants of an STI diagnosis among FSW tested by STI clinics in the Netherlands.

Methods

Sexually transmitted infection clinics report demographic, behavioural and diagnostic information of every consultation to the National Institute for Public Health and the Environment. We analysed all consultations of FSW between 2006 and 2013. Trends in STI positivity rate (chlamydia, gonorrhoea, infectious syphilis, HIV and hepatitis B) were analysed using χ² for trend and logistic regression was used to analyse determinants associated with an STI diagnosis. Differences between consultations at the STI clinic and consultations during outreach were analysed using χ² tests.

Results

The positivity rate for any STI (overall 9.5 %) was stable from 2006 to 2013. Chlamydia positivity rate (overall 7.1 %) decreased (p < 0.001) and gonorrhoea positivity rate (overall 2.6 %) increased (p < 0.001). For gonorrhoea, the highest positivity rate was found oropharyngeal (2.0 %). Characteristics associated with STI were a younger age [adjusted odds ratio (aOR) 0.96, 95 % confidence interval (CI) 0.95–0.97 per year], a previous STI diagnosis (aOR 1.63, 95 % CI 1.38–1.92) and being notified for an STI by partner notification (aOR 2.61, 95 % CI 2.0–3.40). The STI positivity rate was significantly lower among FSW tested at outreach locations (8.6 %) compared to FSW tested at the STI clinic (11.7 %, p < 0.001).

Conclusions

The STI positivity rate among FSW remained stable, but underlying this was a decreasing chlamydia trend and an increasing gonorrhoea trend, suggesting a shift in STI risks among FSW over time. Condom use during oral sex should be promoted since oropharyngeal gonorrhoea was frequently diagnosed and because of the potential spread of antimicrobial resistant gonococci.

Electronic supplementary material

The online version of this article (doi:10.1186/s12982-015-0034-7) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Condom use among female sex workers in Catalonia: why do they use a condom, why don't they use it?

The present study, based on social representation theory (Moscovici, 1961), aimed to identify the social representation of condom use (CU) in a collective of female sex workers (FSW) in Catalonia, considering both their work and private life. It involved 124 FSW and combined both qualitative and quantitative methodologies. Results suggest that both CU and non-CU represent strategies that FSW use mainly when confronted by threats to things they consider important. In work life, where CU is widespread, the most important thing is health protection, and the threat is represented by sexually transmitted infections. In private life, where non-CU is widespread, the most important thing is that their relationships adhere to an idealized relationship model, based on love, trust, and sexual gratification; this model lies in contrast to the status of the women as FSW. The threats are represented by both partner infidelity and their FSW status (symbolic threats).

The HIV epidemic in Eastern Europe and Central Asia

Eastern Europe and Central Asia represent one of the few regions globally where there is a continued increase in the incidence of HIV infection. For example, in Eastern Europe the rate of diagnosed cases of HIV infection per 100 000 population has increased from 11.7 in 2004 to 22.5 in 2011. Initially propelled by injection drug use, heterosexual transmission has now become a major driver of new infections in the region. Nonetheless substance use remains an important factor, with its control limited by challenges in scaling up harm reduction efforts. While most countries have implemented opioid substitution therapy programs, their scale remains very limited. Similarly, coverage of needles syringe programs across the region is variable. Complicating the control of HIV has been the emergence of non-injection drugs and inadequate access to antiretroviral therapy. In addition, structural barriers and stigma toward HIV infected people may contribute to the high proportion of late presentations for HIV care. Finally in the wake of the HIV epidemic, high rates of hepatitis C infection and tuberculosis have been noted.

Risk-taking behaviours and HIV infection among sex workers in Portugal: results from a cross-sectional survey

OBJECTIVES

Sex workers (SW) are key populations at an increased risk of HIV infection. This study aimed to characterise risk-taking behaviours and assess HIV prevalence among SW in Portugal.

METHODS

A cross-sectional survey was conducted with 1040 SW using a participatory research approach. SW were recruited in sex-work locations and community-based organisation offices. Data were collected through a questionnaire with trained interviewers. An HIV rapid test was performed in 213 respondents.

RESULTS

Reported HIV prevalence was 8%: 17.6% of man-to-woman transgenders, 7.4% of women and 5% of men. Of SW reportedly living with HIV, 52.2% reported ever injecting drug use. Inconsistent condom use with clients in the last month was higher among male SW (26.5%) and with non-paying partners in the last year was higher among women (71.3%). Among reported HIV-positive SW, the proportions of inconsistent condom use were high. In multivariate regression analysis, reported HIV infection remained significantly higher among transgenders (OR 6.4; 95% CI 1.7 to 24.3), those older (OR 5.1; 95% CI 1.3 to 21.1), working outdoors (OR 5.4; 95% CI 1.9 to 15.6), having ever used psychoactive substances (OR 4.1; 95% CI 2.2 to 7.7) and earning ≤€1000 per month (OR 2.6; 95% CI 1.2 to 5.9). Of those who had an HIV rapid test, 8.9% were reactive; 73.7% were unaware of their seropositivity.

CONCLUSIONS

The HIV infection burden in SW is high. Efforts to promote HIV testing must be sustained in order to reduce undiagnosed infection. The diverse risk profiles of SW must be addressed in targeted HIV interventions. Prevention interventions should be systematically implemented within most-at-risk subgroups of SW.

Drug use as a driver of HIV risks: re-emerging and emerging issues

PURPOSE OF REVIEW

We reviewed the studies published in 2012-2013 that focused on re-emerging and emerging injection and noninjection drug use trends driving HIV risk behaviors and transmission in some parts of the world.

RECENT FINDINGS

Although HIV incidence has declined in many countries, HIV epidemics remain at troubling levels among key drug-using populations, including females who inject drugs (FWIDs), FWIDs who trade sex, sex partners of people who inject drugs, young people who inject drugs, and people who use noninjection drugs in a number of low-income and middle-income countries such as in Central Asia, Eastern Europe, Southeast Asia, and parts of Africa.

SUMMARY

HIV epidemics occur within the contexts of global economic and political forces, including poverty, human rights violations, discrimination, drug policies, trafficking, and other multilevel risk environments. Trends of injection and noninjection drug use and risk environments driving HIV epidemics in Central Asia, Eastern Europe, Southeast Asia, and parts of Africa call for political will to improve HIV and substance use service delivery, access to combination HIV prevention, and harm reduction programs.