Economically motivated relationships and transactional sex among unmarried African American and white women: results from a U.S. national telephone survey

Unawareness of partner risk factors thwarts implementation of USPSTF recommendations for HIV pre-exposure prophylaxis in primary care

The United States Preventive Services Task Force recommends pre-exposure chemoprophylaxis for persons at high risk of HIV exposure. The optimal screening strategy for at-risk individuals in primary care is not known. We evaluated the strategy of universal screening and discussed challenges to the implementation of this recommendation in primary care. Around 430 of 500 (86%) screening surveys were completed. Mutual monogamy was common but monogamous partners with recent negative HIV testing were uncommon. Likewise, among heterosexually active men and women, inconsistent condom use was common. Such individuals would be on guideline for HIV pre-exposure prophylaxis (PrEP) if their partner was at risk for HIV exposure. None of these potentially at-risk individuals met the criteria for PrEP, but 13% lacked knowledge of their partners' sexual and behavioral risk factors, preventing a clear decision on whether PrEP should be used. Our screen identified no individuals who clearly met the guideline criteria for HIV PrEP. We conclude that universal screening for HIV PrEP in primary care is unlikely to be an efficient strategy; targeted screening is likely more appropriate. Moreover, the 2019 guidelines for heterosexually active men and women rely on information that is often unknown to the patient, which makes these guidelines difficult to implement. Future guidelines should address these problems.

Initial Validity Evidence for a Measure of Transactional Sex in a U.S. College Student Sample

The current study provides initial validity evidence for a measure of Transactional Sex (TS). Participants (N = 269) were recruited from a Northeastern University in the United States and consisted of undergraduate and graduate students. Participants completed an online survey through QuestionPro that contained the Transactional Sex Measure (TSM) as well as measures of depression, anxiety, and stress, condom use negotiation self-efficacy and sexual risk, alcohol and drug use, and materialism. Construct and criterion validity were examined. Findings revealed that the TSM provided good criterion validity evidence but the construct validity evidence was minimal. Further studies on the conceptualization of TS and distribution of the TSM across a variety of diverse samples can provide more validity evidence.

Transactional sex and risky sexual practices in Jamaica

BACKGROUND

Transactional sex relationships (TSRs) create financial and emotional support for men and women, as well as an increased sexual risk. Studies have reported high HIV and STI transmission rates among young women in transactional sex relationships. However, little is known about TSR prevalence in Jamaica and risky sexual practices among participants. This study investigates the sexual behaviour of Jamaicans in TSR.

METHODS

Secondary data analysis of a national survey revealed that 586 participants (38%) self-reported being in at least one TSR in the last 12 months. We also identified a third category called "Benefluids", who play both roles of benefactor and beneficiary in transactional sex relationships.

RESULTS

59 percent of male Benefluids had two to five transactional sex relationship partners in the last 12 months, compared to 40% of female Benefluids. Twenty-eight percent of female Benefluids reported sexually transmitted infection symptoms in the last 12 months compared to 13.5% of male Benefluids. While females reported more sexually transmitted infection symptoms, young men had the highest sexual risk precursors.

CONCLUSIONS

People in transactional sex relationships often play the role of beneficiaries and benefactors to meet material and sexual needs but this increases the risk of STI symptoms.

Correlates of Transactional Sex Among Black Men and Women Who Misuse Opioids

The rise in opioid misuse coincides with increased sexually transmitted infection (STI) and HIV incidence. Transactional sex is an under-researched phenomenon among Black Americans who misuse opioids, and may increase their risk of STI or HIV transmission. Given the disproportionate impact of the opioid epidemic on Black Americans and the risks associated with opioid misuse, the current study aims to investigate sociostructural factors, history of violence, and sexual risk factors associated with transactional sex among Black men and women. A sample of n = 375 Black adult Kentuckians reporting opioid misuse completed a survey including transactional sex, sociostructural, violence history, and sexual risk measures. Results of chi-squares and independent samples t-tests revealed that compared to men who did not report engaging in transactional sex, men who engaged in transactional sex were less educated, reported being sexually assaulted or having an unwanted sexual experience in their lifetime, and were more likely to use opioids or cocaine before or during sex in the last year. Women who engaged in transactional sex had a history of violence, more structural barriers, higher psychological distress, and engaged in more sexual risk behaviors compared to women who did not engage in transactional sex. Implications for future research and interventions with this population are discussed.

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

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

Exploring the Association Between Indicators of Socioeconomic Instability, Survival Sex, and Methamphetamine Use Among Young Adult Black Gay, Bisexual, and Other Men Who Have Sex With Men: A Cross-Sectional Study

ABSTRACT

Methamphetamine (Meth) use is a contributor to poor health outcomes among young Black American gay, bisexual, and other men who have sex with men (YB-GBMSM). Emerging research indicates that socioeconomic instability may be a salient antecedent of meth use as men may be encouraged to engage in health-eroding activities, such as survival sex, to care for themselves, and then cope with instability-related stress via use of substances. We examined the degree to which indicators of socioeconomic instability, including homelessness and food insecurity, would directly, and indirectly, predict increases in meth use, via survival sex engagement. Hypotheses were tested using mediated path analysis with data from 100 YB-GBMSM in Atlanta, Georgia. Preliminary analysis results demonstrated positive associations between engaging in survival sex, food insecurity, homelessness, and living with HIV. Findings demonstrated that homelessness and food insecurity were directly associated with increased survival sex engagement but were not directly associated with meth use. Homelessness and food insecurity were indirectly associated with increased severity of meth use, via increased engagement in survival sex. Socioeconomic instability and survival sex engagement may be important intervention targets for future meth use intervention/prevention programming. Integrating programmatic components that address homelessness and food insecurity may decrease YB-GBMSM's need to rely on survival sex to meet their needs and decrease their likelihood of using meth as a result.

Transactional sex among rural, justice-involved Appalachian women who use drugs

PURPOSE

Transactional sex is associated with an array of other health risk behaviors and adverse health outcomes, including HIV. However, despite concerns regarding a potential HIV outbreak, there is limited understanding of transactional sex among rural Appalachians who engage in high-risk behaviors. Thus, the current study describes the prevalence and correlates of transactional sex among a sample of rural, justice-involved Appalachian women who use drugs.

METHODS

Participants (N = 400) were randomly selected, screened, and interviewed face-to-face at 3 rural Appalachian jails in Kentucky. Bivariate analyses were used to examine differences between those who reported trading sex for drugs, money, goods, or services in the year prior to incarceration and those who had not, and multivariable logistic regression was used to examine independent correlates of transactional sex.

FINDINGS

On average, participants were 33 years old with 11 years of education. They were predominantly White (99.0%), about half (43.7%) reported lifetime transactional sex, and 25.9% reported past year transactional sex. Past year transactional sex was positively associated with experiencing money problems, substance use problem severity, injection drug use, unprotected sex with a casual partner, and number of sexual partners in the year prior to incarceration.

CONCLUSIONS

Results suggest that transactional sex is fairly common among rural Appalachian women who use drugs and are justice-involved and may signal other HIV-related risk behaviors. Given limited service availability throughout rural Appalachia, findings emphasize a need for increased access to risk-reduction interventions, including jail-based interventions, to educate vulnerable, hard-to-reach populations on the risks associated with HIV.

Transactional sex among women in Sub-Saharan Africa: A systematic review and meta-analysis

INTRODUCTION

Transactional sex is casual sex between two people to receive material incentives in exchange for sexual favors. Transactional sex is associated with negative consequences, which increase the risk of sexually transmitted diseases, including HIV/AIDS, unintended pregnancy, unsafe abortion, and physiological trauma. In Sub-Saharan Africa, several primary studies have been conducted in various countries to examine the prevalence and associated factors of transactional sex among women. These studies had great discrepancies and inconsistent results. Hence, this systematic review and meta-analysis aimed to synthesize the pooled prevalence of the practice of transactional sex among women and its associated factors in Sub-Saharan Africa.

METHOD

Data source: PubMed, Google Scholar, HINARI, the Cochrane Library, and grey literature were searched from March 6 to April 24, 2022, and included studies conducted from 2000 to 2022. The pooled prevalence of transactional sex and associated factors was estimated using Random Effect Model. Stata (version 16.0) was used to analyze the data. The I-squared statistic, a funnel plot, and Egger's test were used to check for heterogeneity and publication bias, respectively. A subgroup analysis was done based on the study years, source of data, sample sizes, and geographical location.

RESULTS

The pooled prevalence of transactional sex among women in Sub-Saharan Africa was 12.55% (9.59%-15.52%). Early sexual debut (OR = 2.58, 95% CI: 1.56, 4.27), substance abuse (OR = 4.62, 95% CI: 2.62, 8.08), history of sexual experience (OR = 4.87, 95% CI: 2.37, 10.02), physical violence abuse (OR = 6.70, 95% CI: 3.32, 13.53), orphanhood (OR = 2.10, 95% CI: 1.27, 3.47), and sexual violence abuse (OR = 3.76, 95% CI: 1.08, 13.05) were significantly associated with transactional sex.

CONCLUSION

The prevalence of transactional sex among women in sub-Saharan Africa was high. Alcohol consumption, substance abuse, early sex debuts, having a history of sexual experiences, physical violence, and sexual violence increased the practice of transactional sex.

The feasibility and acceptability of Project POWER: a mindfulness-infused, cognitive-behavioral group intervention to address mental and sexual health needs of young pregnant women in Liberia

BACKGROUND

Following 14 years of civil war in Liberia, war exposure, gender-based violence, and extreme poverty have been identified as key challenges affecting the mental and sexual health of young pregnant women and the health of their unborn children. Despite ongoing efforts to rebuild the country's healthcare infrastructure, empirical and culturally tailored interventions to address the consequences of war are severely limited. To address these concerns, we developed Project POWER (Progressing Our Well-being, Emotions, and Relationships), a mindfulness-infused, cognitive-behavioral intervention for young adult pregnant women. This study sought to 1) assess the feasibility and acceptability of POWER and 2) determine the preliminary efficacy of POWER for improving mental and sexual health outcomes among Liberian war-exposed young adult pregnant women.

METHODS

Eighty-seven women aged 18-25 were recruited from three catchment areas in Monrovia, Liberia to participate in a two-condition, pre-post design quasi-experimental pilot trial. Participants were allocated to the intervention (POWER) or the control condition (a health education program) based on where they resided relative to the catchment areas. Each condition completed a ten-session program delivered over 5-weeks. Feasibility and acceptability of POWER were examined using program logs (e.g., the number of participants screened and enrolled, facilitator satisfaction, etc.) and data from an end-of-program exit interview. The preliminary efficacy of POWER on mental and sexual health outcomes was assessed using repeated measures ANOVA with time and condition as factors.

RESULTS

Analyses provided preliminary support for the feasibility and acceptability of POWER. Participants attended an average of 8.99 sessions out of 10 and practiced material outside the sessions at least 2.77 times per week. Women in both conditions showed significant reductions in the level of prenatal distress (baseline, M = 16.84, 3-month assessment, M = 12.24), severity of post-traumatic stress disorder (PTSD) symptoms (baseline, M = 11.97, 3-month assessment, M = 9.79),), and the number of transactional sexual behaviors (baseline, M = 1.37, 3-month assessment, M = .94) over time. Participants who received POWER showed significant reductions in the frequency of depressive symptoms (baseline, M = 5.09, 3-month assessment, M = 2.63) over women in the control condition.

CONCLUSIONS

Findings suggest that POWER may be a feasible and acceptable intervention to promote mental and sexual health for young adult pregnant women in Liberia. However, fully powered clinical trials are still needed to determine the efficacy and effectiveness of POWER before recommending its use on a larger scale in Liberia.

Unwanted sexual activity among United States women early in the COVID-19 pandemic

BACKGROUND

Female sexual activity and, accordingly, birth rates tend to decline in times of stress, such as a pandemic. In addition, when resources are scarce or exogenous conditions are threatening, some women may engage in sexual activity primarily to maintain socioeconomic security. Having unwanted sex may indicate sexual activity in exchange for economic security.

OBJECTIVE

This study aimed to describe patterns and correlates of unwanted sex, defined as having sex more frequently than desired, among US women early in the COVID-19 pandemic.

STUDY DESIGN

The National US Women's Health COVID-19 Study was conducted in April 2020, using a nested quota sample design to enroll 3200 English-speaking women (88% cooperation rate) aged 18 to 90 years recruited from a research panel. The quota strata ensured sufficient sample sizes in sociodemographic groups of interest, namely, racial and ethnic subgroups. Patterns of sexual activity, including unwanted sex early in the pandemic, were described. To further elucidate the experiences of women reporting unwanted sex, open-ended responses to an item querying "how the coronavirus pandemic is affecting your sex life" were assessed using conventional content analysis. Logistic regression analyses-adjusting for sociodemographic characteristics, self-reported health, and prepandemic health-related socioeconomic risk factors, including food insecurity, housing instability, utilities and transportation difficulties, and interpersonal violence-were used to model the odds of unwanted sex by a pandemic-related change in health-related socioeconomic risk factors.

RESULTS

The proportion of women who were sexually active early in the pandemic (51%) was about the same as in the 12 months before the pandemic (52%), although 7% of women became active, and 7% of women became inactive. Overall, 11% of sexually active women were having unwanted sex in the early pandemic. The rates of anxiety, depression, traumatic stress symptoms, and each of the 5 health-related socioeconomic risk factors assessed were about 2 times higher among women having unwanted sex than other women (P<.001). Women having unwanted sex were also 5 times more likely than other women to report an increased frequency of sex since the pandemic (65% vs 13%; P<.001) and 6 times more likely to be using emergency contraception (18% vs 3%; P<.001). Women reporting unwanted sex commonly described decreased libido or interest in sex related to mood changes since the pandemic, having "more sex," fear or worry about the transmission of the virus because of sex, and having sex to meet the partner's needs. Among sexually active women, the odds of unwanted sex (adjusting for demographic, reproductive, and health factors) were higher among women with 1 prepandemic health-related socioeconomic risk factor (adjusted odds ratio, 2.0; 95% confidence interval, 1.1-3.8) and 2 or more prepandemic health-related socioeconomic risk factors (adjusted odds ratio, 6.0; 95% confidence interval, 3.4-10.6). Among sexually active women with any prepandemic health-related socioeconomic risk factor, those with new or worsening transportation difficulties early in the pandemic were particularly vulnerable to unwanted sex (adjusted odds ratio, 2.7; 95% confidence interval, 1.7-4.3).

CONCLUSION

More than 1 in 10 sexually active US women was having unwanted sex early in the COVID-19 pandemic. Socioeconomically vulnerable women, especially those with new or worsening transportation problems because of the pandemic, were more likely than others to engage in unwanted sex. Pandemic response and recovery efforts should seek to mitigate unwanted sexual activity and related health and social risks among women.

Associations of Transactional Sex and Sexually Transmitted Infections Among Treatment-Seeking Individuals With Opioid Use Disorder

INTRODUCTION

Coinciding with the rise in opioid use across the U.S., the rates of sexually transmitted infections have reached historically high levels, underscoring the need to understand multiple pathways of disease spread. Although prevention is often focused on injection-related behaviors, this study sought to identify the prevalence and associations of a little understood pathway, transactional sex, among individuals with opioid use disorder, including associations of transactional sex with the prevalence of sexually transmitted infection diagnoses.

METHODS

Data were sourced from a nationwide opioid surveillance program of treatment-seeking individuals with opioid use disorder utilizing a serial, cross-sectional survey of 4,366 new entrants to 1 of 99 substance use treatment programs for opioid use disorder in 37 states from October 2018 to June 2021.

RESULTS

A quarter of the sample (24.9%) self-reported a lifetime history of transactional sex for drugs, with rates highest for sexual (56.6%) and gender (53.8%) minority, female (33.4%), Latinx (30.4%), and Black (29.6%) subgroupings. Lifetime diagnoses of all specific sexually transmitted infections analyzed were significantly higher (p<0.001) among those reporting transactional sex, particularly syphilis (14.3% vs 4.4%) and HIV (4.0 vs 0.9%). Financial hardship, trauma, and psychiatric disorder were significantly associated with transactional sex engagement.

CONCLUSIONS

Transactional sex is relatively common among patients with opioid use disorder, particularly among sexual/gender minorities, which was associated with a greater lifetime prevalence of all sexually transmitted infections assessed. Sexually transmitted infection testing remains at low levels within substance use treatment programs, occurring in just 26.3% of programs; sexual health screenings and sexually transmitted infection prevention/testing need to be prioritized and integrated into opioid use disorder patient care.

Evidence for the Role of State-Level Economic Policy in HIV Risk Reduction: State Earned Income Tax Credit Generosity and HIV Risk Behavior Among Single Mothers

We investigated the impact of State-level Earned Income Tax Credit (SEITC) generosity on HIV risk behavior among single mothers with low education. We merged individual-level data from the Behavioral Risk Factor Surveillance System (2002-2018) with state-level data from the University of Kentucky Center for Poverty Research and conducted a multi-state, multi-year difference-in-differences (DID) analysis. We found that a refundable SEITC ≥ 10% of the Federal Earned Income Tax Credit was associated with 21% relative risk reduction in reporting any high-risk behavior for HIV in the last year, relative to no SEITC. We also found that a 10-percentage point increase in SEITC generosity was associated with 38% relative risk reduction in reporting any high-risk HIV behavior in the last year. SEITC policy may be an important strategy to reduce the burden of HIV infections among women with low socioeconomic status, particularly single mothers.

Mechanisms Linking High Residential Mobility to Decreased Contraceptive Use: The Importance of Method Availability

While research has demonstrated that high residential mobility has negative consequences for an array of outcomes, particularly among women and young adults, the mechanisms underlying these associations are unclear. The consequences of high residential mobility may be comprised solely of a series of short-term disruptions surrounding individual moves, or there may also be long-term, cumulative effects from repeated moves. High residential mobility may diminish access to resources as individuals move to different neighborhoods, impose a cognitive burden that impairs their ability to plan ahead, or decrease the relative power they have in their relationships to limit exposure to risk behaviors. We adjudicate between these possibilities by predicting the effects of high residential mobility on sexual intercourse and contraceptive use, the proximate determinants of pregnancy, during women's transition to adulthood. Using 2.5 years of monthly address data for 882 respondents in the Relationship Dynamics and Social Life study-a random sample of young women in Genesee County, Michigan-we find that high residential mobility is associated with long-term decreases in contraceptive use. These long-term consequences are independent of the short-term effects of individual moves and attributable to diminished contraceptive access. We disentangle the effects of home-leaving, which is distinct from subsequent moves.

Analysis of Heavy Rainfall in Sub-Saharan Africa and HIV Transmission Risk, HIV Prevalence, and Sexually Transmitted Infections, 2005-2017

IMPORTANCE

Extreme precipitation, including heavy rains and flooding, is associated with poor health outcomes mediated in part by decreases in income and food production. However, the association between heavy rains and HIV burden is unknown.

OBJECTIVE

To investigate the association between heavy rainfall, HIV prevalence, and HIV transmission risk over a 12-year span in sub-Saharan Africa.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional population-based study, using data collected from the 2005-2017 Demographic and Health Surveys, was conducted in 21 countries in sub-Saharan Africa and analyzed from July 29, 2021, to June 14, 2022.

EXPOSURES

Heavy rainfall was defined based on the extent to which annual rainfall deviated from the historical average (standardized precipitation index ≥1.5) at the enumeration area level.

MAIN OUTCOMES AND MEASURES

HIV, self-reported sexually transmitted infections (STIs), and number of sexual partners.

RESULTS

The study included 288 333 participants aged 15 to 59 years; 172 344 were women (59.8%), and 183 378 were married (63.6%). Mean (SD) age was 31.9 (10.0) years. Overall, 42.4% of participants were exposed to at least 1 year of heavy rainfall in the past 10 years. Each year of heavy rainfall was associated with 1.14 (95% CI, 1.11-1.18) times the odds of HIV infection and 1.11 (95% CI, 1.07-1.15) times the odds of an STI in the past 12 months. There was also an association between heavy rainfall and the reported number of sexual partners (incident rate ratio, 1.12; 95% CI, 1.10-1.15). The odds were greater for the association between heavy rainfall and HIV prevalence and STIs among participants aged older than 20 years and participants in rural areas.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that heavy rainfall was associated with a higher HIV burden in sub-Saharan Africa. The association between heavy rainfall and STIs and number of sexual partners suggests that an increase in the risk of sexual transmission is a plausible mechanism for the observed findings around HIV prevalence. Heavy rainfall could also worsen food insecurity, increasing the risk of transactional sex, or cause damage to public health infrastructure, reducing access to STI education, HIV testing, and treatment.

Serological Confirmed Syphilis Among Transgender Women in Dominican Republic

Purpose

Transgender women (TW) in the Dominican Republic (DR) are at high risk for syphillis infection. Although treatable, infection rates remain at epidemic proportions.

Methods

In 2016, we conducted a national survey, with serological sampling of TW in the DR (n=255).

Results

In our sample, syphillis seropositivity was 47.45%. There was a statistically significant association between age (t=-2.93, df, p<0.01), arrest history (χ ²=8.15, p<0.01), exposure to violence (χ ²=3.73, p<0.05), and syphilis seropositivity. Multivariate analyses show TW arrested in the past 6 months have higher odds of seropositivity (odds ratio=2.05, confidence interval: 1.04-4.06, p<0.05).

Conclusions

There is a need for education and public health campaigns focused on TW specifically.

HIV and Herpes Simplex Virus Type 2 Incidence Among Adolescent Mothers in South Africa: A Longitudinal Analysis of HIV Prevention Trials Network 068 Data

BACKGROUND

Adolescent motherhood is common in South Africa and occurs against a backdrop of high HIV risk. While childbearing during adolescence may result in social and economic strain that may negatively impact health, there has been limited study of whether adolescent motherhood increases the risk of HIV or herpes simplex virus type 2 (HSV-2) acquisition or engagement in high-risk sexual partnerships.

SETTING

Data are from HIV Prevention Trials Network 068, a longitudinal conditional cash transfer study of adolescent girls and young women (age, 13-23) in rural South Africa.

METHODS

We used survival analysis to estimate hazard ratios to determine if adolescent motherhood (live birth before 20 years) predicted incident HIV and incident HSV-2 and generalized estimating equations for behavioral risk ratios to determine if adolescent motherhood was associated with transactional sex and age-disparate partnerships.

RESULTS

Of 2452 adolescent girls and young women who were HIV negative at baseline, 5% were adolescent mothers; 16% were adolescent mothers by the end of the study period. After controlling for covariates, adolescent motherhood predicted incident HSV-2 acquisition [ adjusted hazard ratios, 1.30; 95% confidence interval (CI): 1.01 to 1.95] but not HIV acquisition ( adjusted hazard ratios, 1.19; 95% CI, 0.76 to 1.86). Adolescent motherhood was also associated with being in an age-disparate partnership (adjusted risk ratio, 1.30; 95% CI: 1.07 to 1.58) but not transactional sex.

CONCLUSION

Adolescent motherhood increased the risk of HSV-2 and engagement in age-disparate partnerships, both known risk factors for HIV infection. Sexually transmitted infection screening and/or tailored combination HIV prevention interventions that account for the context of adolescent motherhood are critical to maximize adolescent mothers' long-term health and to meet UNAIDS 95-95-95 targets by 2030.

Considerations for the Design of Pre-exposure Prophylaxis (PrEP) Interventions for Women: Lessons Learned from the Implementation of a Novel PrEP Intervention

Pre-exposure prophylaxis (PrEP) uptake among women in the United States has been low. To increase uptake, we developed a peer outreach and navigation PrEP intervention. Semi-structured qualitative interviews with 32 cisgender women and 3 transgender women were conducted to assess the intervention. We used a thematic approach to identify barriers to, and facilitators of the intervention. Facilitators included interest in PrEP, offer of health and social services, the intervention’s women-focused approach, and peer outreach and navigation. Barriers were perceived HIV risk, concerns about medication side effects or interactions, housing insecurity and travel, co-occurring health-related conditions, and caregiving responsibilities. We recommend that future interventions consider packaging PrEP in local community settings, such as syringe exchange programs; include services such as food and housing assistance; use peers to recruit and educate women; integrate a culturally appropriate women’s focus; and consider providing same-day PrEP.

Reframing Sexual Health for Black Girls and Women in HIV/STI Prevention Work: Highlighting the Role of Identity and Interpersonal Relationships

While Black girls and women are disproportionately impacted by sexual health disparities, there continues to be an overwhelming focus on individual risk behaviors within prevention initiatives, which offers a fragmented narrative of the multidimensional nature of risk and plausibly limits effectiveness of prevention programs and attenuates reductions in disparities. Because sexual health is experienced within an individual's beliefs/values, interpersonal relationships, and behaviors and reflects larger social and cultural systems, it is important to critically examine common theories used to inform HIV/STI prevention interventions for Black women and girls. To fill this gap in the literature, we critique two commonly used theories in HIV/STI prevention interventions, namely the social cognitive theory and the theory of gender and power, by highlighting theoretical and practical strengths and weaknesses. We propose research implications that incorporate key strengths of the two theories while adding new concepts grounded in the intersectionality theory. The overall goal is to introduce a more comprehensive conceptual model that is reflective of and applicable to the multidimensional sexual experiences of Black girls and women within the evolving definition of sexual health and behavior.

From Survival to Glamour: Motivations for Engaging in Transactional Sex and Relationships Among Adolescent Girls and Young Women in South Africa

We explored transactional sex and relationships (TSR) among South African adolescent girls and young women (AGYW) using (1) survey data from 4,399 AGYW aged 15–24 years, and (2) qualitative data from 237 AGYW and 38 male peers. Ten percent of sexually active AGYW reported having ever had transactional sex; 14% reported having stayed in a relationship for money or material items. Factors associated with higher reporting of TSR included HIV positivity, higher food insecurity, and alcohol use. Those AGYW who were between the ages of 20–24 years (OR: 1.0; 95% CI: 0.81–1.24), had a sexual partner older than her by 5 years or more (OR: 1.89; 95% CI: 1.58–2.26), and had a transactional relationship in the past (OR: 61.1; 95% CI: 47.37–78.76) were more likely to report having transactional sex. AGYW qualitative narratives included both assertions of agency in choosing to engage in TSR, and power inequities resulting in condomless sex. Our findings can inform interventions to addressing transactional sex and relationships, critical to South Africa’s HIV response.

(De)criminalization of Survivors of Domestic Minor Sex Trafficking: A Social Work Call to Action

Survivors of domestic minor sex trafficking (DMST) are failing to be identified and are frequently criminalized. Examining the linkages between DMST and the juvenile legal system is important, as many trafficked youths are only identified after entry into the child welfare or juvenile court system as a result of being arrested or detained on related delinquency charges. Due to legacies of structural violence, marginalized youths are reluctant to approach police officers for help. Therefore, social workers have an opportunity to identify, intervene, and advocate for trafficked youths. In this article, the author provides an overview of existing research related to the demographic profile of DMST, homelessness and survival sex, recruitment and entry, barriers to effective community response, and prevention and intervention strategies. This article represents a call to broaden our view of young people in the sex trade and supports the decriminalization of trafficked youths. Interventions and policies must be designed to fit their complex needs and experiences, resulting in empowerment, opportunity, and new beginnings.

Structural and syndemic barriers to PrEP adoption among Black women at high risk for HIV: a qualitative exploration

In the USA, Black women are at disproportionately higher risk for HIV compared to women of other races/ethnicities, which can be explained by the Substance Abuse, Violence and AIDS (SAVA) syndemic. Disparities in HIV, substance use and violence are driven by multiple influences, including structural factors (e.g. housing and poverty), which exacerbate social- and individual-level factors leading to more sex partners, engaging in unprotected sex, having sex for money, experiencing forced sex from an intimate partner or increased substance use, all of which increase HIV risk. Pre-exposure prophylaxis (PrEP), a pill that can prevent HIV, is a discreet and underutilised method that Black women experiencing syndemics can use to decrease their risk. This study explored Black women's interest in, and barriers to adopting PrEP over 6 months. Thirty Black women (age M = 32.2) who experienced multiple substance use, violence and HIV-related syndemic factors were interviewed four times over a 6-month period. Results demonstrated that experiencing intimate partner violence, substance use, community violence and other structural factors (poor access to social services, transport and childcare) all acted as barriers to PrEP adoption. Future research should consider multi-level interventions that include methods such as media campaigns, providing PrEP or referrals where women who experience syndemic and structural factors seek help, and implement a PrEP adherence programmes and interventions in support group settings.

Longitudinal predictors of male sexual partner risk among Black and Latina women in their late thirties: ethnic/racial identity commitment as a protective factor

This study aimed to investigate predictors of male sexual partner risk among Latinas and Black women in their late thirties. We used multiple regression analysis to examine factors associated with male sexual partner risk among 296 women who participated in two waves of the Harlem Longitudinal Development Study (New York, 2011-2013 and 2014-2016). Women who experienced childhood sexual abuse had higher risk partners than those who did not [b = 0.16, 95% confidence interval (CI) = 0.06, 0.28]. Earlier marijuana use was a risk factor for partner risk in the late thirties (b = 0.12, 95% CI = 0.04, 0.27). Higher levels of ethnic/racial identity commitment mitigated this risk (b = - 0.15, 95% CI = - 0.26, - 0.04). Ethnic/racial identity commitment can be protective against male sexual partner risk among Latina and Black women who use marijuana. Further research should explore the protective role of different dimensions of ethnic/racial identity against sexually transmitted infections, including HIV.

Birth Control Sabotage as a Correlate of Women's Sexual Health Risk: An Exploratory Study

INTRODUCTION

To explore associations between birth control sabotage, a form of reproductive coercion, and women's sexual risk among women attending family planning health centers. Data were collected from a 2017 cross-sectional online survey of 675 women who attended Connecticut Planned Parenthood centers. Participants reported birth control sabotage; sexual risk (i.e., inconsistent condom use during vaginal and anal sex in the past 6 months, lifetime sexually transmitted infection diagnosis, lifetime exchange sex [trading sex for money, drugs, or other goods], and multiple sexual partners in the past 6 months); and sociodemographics. Bivariate and multivariable logistic regression models were used to examine associations between birth control sabotage and women's sexual risk.

RESULTS

One in six women (16.4%; n = 111) reported experiencing birth control sabotage. Women who reported birth control sabotage had a greater odds of ever having an sexually transmitted infection (adjusted odds ratio, 2.18; 95% confidence interval, 1.31-3.60; p = .003), ever engaging in exchange sex (adjusted odds ratio, 2.77; 95% confidence interval, 1.17-6.53; p = .020), and having multiple sexual partners in the past 6 months (adjusted odds ratio, 1.96; 95% confidence interval, 1.21-3.18; p = .006).

CONCLUSIONS

Our findings demonstrate increased engagement in sexual risk taking among women who reported birth control sabotage compared with women did not.

HIV Prevalence Among Women Who Exchange Sex for Money or Drugs-4 U.S. Cities

BACKGROUND

Limited data exist in the United States on the prevalence of HIV among women who exchange sex.

SETTING

We estimate HIV prevalence of women who exchange sex from a 2016 survey in Chicago, Detroit, Houston, and Seattle and compare it with the prevalence of HIV among women of low socioeconomic status (SES), who did not exchange sex, and women in the general population.

METHODS

Women who exchange sex were recruited via respondent-driven sampling among some cities participating in National HIV Behavioral Surveillance, interviewed, and offered HIV testing. We estimate HIV prevalence and, using prevalence ratios, compare it with the prevalence among women of low SES who did not exchange sex in the 2013 National HIV Behavioral Surveillance cycle, and to women in the general population estimated using 2015 National HIV Surveillance data.

RESULTS

One thousand four hundred forty women reported exchange sex in 2016. Aggregated HIV prevalence was 4.9% [95% confidence interval (CI): 2.7 to 7.1] among women who exchanged sex, 1.6% (95% CI: 0.3 to 2.8) among women of low SES who did not exchange sex, and 0.6% (95% CI: 0.5% to 0.6%) among women in the general population. HIV prevalence among women who exchanged sex was 3.1 times (95% CI: 1.6 to 5.9) as high as among women of low SES who did not exchange sex, and 8.8 times (95% CI: 7.0 to 11.1) as high as among women in the general population.

CONCLUSION

HIV prevalence was significantly higher among women who exchanged sex compared with women in the general population and women of low SES who did not exchange sex.

Exchange Sex Among High School Students-Washington, DC, 2017

PURPOSE

Exchange sex, the exchange of money or nonmonetary items for sex, is associated with sexually transmitted diseases and HIV. We sought to identify prevalence and characteristics associated with exchange sex among District of Columbia (DC) high school students.

METHODS

We used the 2017 DC Youth Risk Behavior Survey, a cross-sectional survey of students in grades 9-12 (n = 8,578). We performed multivariable logistic regression to examine associations between exchange sex and demographic, home environment, and substance use measures.

RESULTS

In 2017, a total of 7.4% (95% confidence interval [CI]: 6.6-8.2) of students reported ever having engaged in exchange sex. Odds of exchange sex were higher among males (adjusted odds ratio [AOR]: 2.5; 95% CI: 1.6-4.0) and students who had sexual contact with partners of both sexes (AOR: 2.4; 95% CI: 1.2-4.9), compared with students having sexual contact with partners of opposite sex only. Exchange sex was also associated with having been kicked out, run away, or abandoned during the past 30 days (AOR: 10.7; 95% CI: 7.0-16.3]); going hungry during the past 30 days (AOR: 2.2; 95% CI: 1.1-4.5); and ever using synthetic marijuana (AOR: 2.6; 95% CI: 1.3-5.0) or cocaine, heroin, methamphetamines, or ecstasy (AOR: 2.9; 95% CI: 1.6-5.3]), compared with those who had not.

CONCLUSIONS

Approximately one in 14 DC high school students engaged in exchange sex. Programs providing services to youth with unstable housing, food insecurity, or who use drugs should incorporate sexual health services to address exchange sex practices.

Incidence and predictors of violence from clients, intimate partners and police in a prospective US-based cohort of women in sex work

OBJECTIVE

Gender-based violence threatens women's health and safety. Female sex workers (FSWs) experience violence disproportionately, yet prospective data on violence predictors is lacking. In the first US-based prospective FSW cohort study, we examine incidence rates (IRs) and predictors of violence from distinct perpetrators: paying clients, non-paying intimate partners and police.

METHODS

The parent cohort (Sex Workers and Police Promoting Health In Risky Environments) recruited street-based cisgender FSWs in urban Baltimore, MD (n=250) with 5 assessments at 3-month intervals through 12-month follow-up. Stratifying by violence perpetrator, we characterise violence at baseline, IR over the study period and time-varying predictors using Poisson models.

RESULTS

The violence IR per person year was highest for client-perpetrated violence (0.78), followed by intimate partner violence (IPV; IR 0.39), and police violence (IR 0.25). Prevalence over the 12-month follow-up period among participants with complete visit data (n=103), was 42% for client violence, 22% for IPV and 16% for police violence. In adjusted analyses, risk factors for incident violence varied across perpetrators and included entry to sex work through force or coercion (adjusted IR ratio (aIRR)IPV 2.0; 95% CI 1.2 to 3.6), homelessness (aIRRIPV 2.0; 95% CI 1.3 to 2.9; aIRRpolice 2.7; 95% CI 1.3 to 5.8) and daily injection drug use (aIRRclient 1.9; 95% CI 1.2 to 3.0). Risk of incident client violence and IPV was elevated by past abuse from each respective perpetrator. Help-seeking following abuse was limited.

CONCLUSIONS

FSWs face profound, enduring risk for violence from a range of perpetrators, likely enabled by criminalisation-related barriers to justice and perpetrator impunity. FSWs represent a priority population for access to justice, trauma-informed healthcare and violence-related support services. Structural vulnerabilities including homelessness and addiction represent actionable priorities for improving safety and health.

Exploring patterns of substance use among highly vulnerable Black women at-risk for HIV through a syndemics framework: A qualitative study

Black women who use alcohol, marijuana, and other drugs are disproportionately affected by health disparities. Black women's HIV diagnosis rates are 15 times higher than White women, and is among the leading causes of death among Black women in the US. Previous studies support the association between substance use and HIV risk, yet it is essential to better understand the specific factors experienced within the context of substance misuse and recovery among vulnerable Black women at-risk for substance misuse, HIV, and adverse life experiences. We conducted qualitative interviews with 31 black women (age M = 32.13, range 18-57) four times over six months. Eligible participants were 18+ years, identified as a Black/African-American woman, had unprotected vaginal or anal sex with a man in the past 30 days, and spoke fluent English. All transcripts were transcribed verbatim and were analyzed used thematic content analysis. Two groups of participants emerged: 1) those in recovery from their drug of choice (n = 11, 7 of whom misused alcohol or marijuana during the study), and 2) those who misused their drug of choice during the study (active use group; n = 20). Four themes emerged in the context of substance use: cultural factors, structural factors (i.e., housing and employment), past and present adverse life experiences, and individual factors (i.e., substance use to cope with stress, self-medicating with substances for mental health symptoms, intimate partner violence, and sex exchange). While participants in both groups used substances to cope with regard to these factors, the recovery group tended to use substances at lower frequencies and did not relapse with their drug of choice during the study. The active use group reported more substance use with regard to structural factors and recent adverse life events, had more difficulty regarding employment, and less instances of intimate partner violence (IPV) but were more likely to cope using substances. Substance use interventions tailored to vulnerable Black women should consider including trauma-informed interventions and support groups that address the structural, social, and individual factors to better serve their needs.

Inconsistent Condom Use Among Female Sex Workers: Partner-specific Influences of Substance Use, Violence, and Condom Coercion

Female sex workers (FSWs) are disproportionately affected by HIV. Inconsistent condom use (ICU) represents the most proximal risk for acquisition and transmission. We evaluate associations of partner-specific factors including physical and sexual violence, coercion, and substance use with ICU with clients and regular non-paying partners, respectively, among FSWs. Baseline survey data from a prospective cohort of 250 street-based FSW in Baltimore, Maryland, USA included partner-level drug and alcohol use, violence, condom coercion and ICU, in addition to individual and structural exposures. Logistic regression analyses were stratified by partner type, followed by path analysis where indicated. Within client and regular non-paying partnerships, FSWs reported prevalent recent violence (34.8%, 16%, respectively), condom coercion (42.4%, 9.9%, respectively) and ICU (39.2%, 44.4%, respectively). Recent physical or sexual violence enabled coercive condom negotiation (AOR_client 8.22, 95% CI 4.30, 15.73; AOR_{nonpayingpartner} 3.01 95% CI 1.05, 8.63). ICU with clients was associated with client condom coercion (AOR 1.76, 95% CI 1.03, 3.02), and client intoxication during sex (AOR 2.25, 95% CI 1.13, 4.45). In path analysis of client-FSW partnerships, condom coercion fully mediated the influences of both sex worker intoxication and recent violence on ICU. ICU with non-paying partners was associated with FSW intoxication during sex (AOR 8.66, 95% CI 3.73, 20.10), and past-year police violence (AOR 2.92, 1.30, 6.57). Partner-level substance use and gendered power differentials influenced FSWs' ICU patterns differently by partner type. ICU with clients was rooted solely in partner factors, and coercive condom negotiation mediated the roles of violence and partner-level substance use on ICU. By contrast, ICU with non-paying partners was rooted in partner-level substance use and police violence as a structural determinant. Addressing HIV risk behavior for FSWs requires condom promotion efforts tailored to partner type that addresses power differentials.

Implementing Respondent-Driven Sampling to Recruit Women Who Exchange Sex in New York City: Factors Associated with Recruitment and Lessons Learned

Respondent-driven sampling (RDS) relies on productive peer recruitment to capture hidden populations. Domestic studies have identified characteristics of productive recruitment among RDS samples of men who have sex with men and persons who use drugs, but not of women who exchange sex, a group vulnerable to HIV infection. We examined sociodemographic-, behavioral-, exchange-sex-, and protocol-related factors associated with recruitment among seeds (n = 25) and peers (n = 297) in the 2016 New York City National HIV Behavioral Surveillance Study cycle focused on women who exchange sex. Recruiter productivity was significantly associated with not having been recently incarcerated, lower rate of HIV testing, and larger exchange sex networks among seeds, and with HIV-prevention services usage among peers. We describe challenges and lessons learned from implementing RDS in this population. Our study identifies seed characteristics and protocol improvements researchers can utilize when implementing future RDS studies among women who exchange sex.

The Relationship Between Economic Deprivation, Housing Instability and Transactional Sex Among Women in North Carolina (HPTN 064)

Transactional sex is associated with socioeconomic disadvantage and HIV risk but few studies in the United States (US) have examined both individual and area-level predictors of transactional sex or distinguished transactional sex from sex work. We combined data from HIV Prevention Trials Network 064 study and the US Census to estimate prevalence ratios (PR) for the relationship between census-level and individual measures of economic deprivation and housing instability on transactional sex in 417 women in North Carolina. Increased transactional sex was associated with food insecurity (PR 1.86; 95%; CI 1.57, 2.19), housing instability (PR 1.33; 95% CI 1.11, 1.59), substance abuse (PR 1.90; 95% CI 1.64, 2.19) and partner incarceration (PR 1.32; 95% CI 1.09, 1.61). Census-level indicators were not associated with transactional sex, adjusted for individual-level covariates. Interventions should support housing stability and financial opportunities among southern African American women to reduce HIV risk, particularly among women with incarcerated partners.

States with higher minimum wages have lower STI rates among women: Results of an ecological study of 66 US metropolitan areas, 2003-2015

Prior research has found that places and people that are more economically disadvantaged have higher rates and risks, respectively, of sexually transmitted infections (STIs). Economic disadvantages at the level of places and people, however, are themselves influenced by economic policies. To enhance the policy relevance of STI research, we explore, for the first time, the relationship between state-level minimum wage policies and STI rates among women in a cohort of 66 large metropolitan statistical areas (MSAs) in the US spanning 2003-2015. Our annual state-level minimum wage measure was adjusted for inflation and cost of living. STI outcomes (rates of primary and secondary syphilis, gonorrhea and chlamydia per 100,000 women) were obtained from the CDC. We used multivariable hierarchical linear models to test the hypothesis that higher minimum wages would be associated with lower STI rates. We preliminarily explored possible socioeconomic mediators of the minimum wage/STI relationship (e.g., MSA-level rates of poverty, employment, and incarceration). We found that a $1 increase in the price-adjusted minimum wage over time was associated with a 19.7% decrease in syphilis rates among women and with an 8.5% drop in gonorrhea rates among women. The association between minimum wage and chlamydia rates did not meet our cutpoint for substantive significance. Preliminary mediation analyses suggest that MSA-level employment among women may mediate the relationship between minimum wage and gonorrhea. Consistent with an emerging body of research on minimum wage and health, our findings suggest that increasing the minimum wage may have a protective effect on STI rates among women. If other studies support this finding, public health strategies to reduce STIs among women should include advocating for a higher minimum wage.

A syndemic of psychosocial and mental health problems in Liberia: Examining the link to transactional sex among young pregnant women

Transactional sex may be a driver of the rising HIV epidemic in Liberia, especially among young women. The goal of this study was to explore the independent and additive effects of psychosocial conditions on engagement in transactional sex among 191 pregnant women in Monrovia, Liberia. Between March and August 2016, women receiving prenatal services completed a cross-sectional structured questionnaire. These data were used to examine the independent and additive effects of exposure to trauma, depression, post-traumatic stress disorder symptoms, and intimate partner violence on transactional sex. Overall, the results are in support of our hypothesis that these psychosocial conditions cluster together and are independently associated with transactional sex. Multivariate logistic regression analysis demonstrated an additive effect of the number of psychosocial conditions experienced on transactional sex. Women experiencing 2 psychosocial conditions had 5.96 greater odds of engaging in transactional sex compared to women reporting 0 conditions (AOR: 5.96, 95% CI: 2.22-15.99), and women experiencing 3 or 4 psychosocial conditions had 11.91 greater odds of engaging in transactional sex compared to women report 0 conditions (AOR: 11.91, 95% CI: 4.12-34.45). Our results demonstrate the need for comprehensive HIV prevention programming inclusive of mental health support and IPV prevention for Liberian women.

Transactional Sex and HIV Risk among Adolescent School Girls in Ethiopia: Mixed Method Study

Background

Young people in Sub-Saharan Africa are affected by HIV pandemic to a greater extent than elsewhere. Transactional sex among adolescent school girls with older men commonly called "sugar daddies" is one of the major factors fueling the spread of the infection due to the extended sexual network. Thus, this study aimed to assess the magnitude and factors associated with transactional sex among adolescent girls and "sugar daddies" in relation to HIV/AIDS.

Methods

Mixed method cross-sectional study was done among 620 female students in Hawassa town, South Ethiopia, from September 2010 to May 2011. A structured questionnaire and in-depth interview check list were used to collect the quantitative and qualitative data, respectively. Survey participants were selected randomly from five preparatory schools whereas ten in-depth interview participants were recruited by a snowball sampling technique from the same schools. Data were entered using Epi-Info and analyzed by SPSS. A descriptive statistics followed by multivariable logistic regression analyses were conducted to identify factors associated with transactional sex with "sugar daddy". Both crude and adjusted odds ratios with 95% confidence interval were reported. We used OpenCode software for coding and categorizing the in-depth interviews and quotes that represent the informants opinion were used to support the quantitative findings.

Results

A substantial number of female students, 71(11.5%), reported to have had transactional sex with older men. Most of the respondents who dated "sugar daddies" (93%) had multiple sexual partners concurrently and sequentially, and among them, only 22.7% had consistent condom use. Girls who were in older age group [OR (CI) 6.87 (3.48-13.58)], who had lost both parents [OR (CI) 2.99 (1.14-7.84)], had perceived less economic status [OR: 25.41; 95% CI: 7.80-82.76] and engaged in substance abuse [OR (CO) 5.8 (2.1-15.77)] had higher odds of practicing transactional sex with "sugar daddies". In-depth interviewed participants also revealed that they were involved in transactional sex for monetary while having concurrent and subsequent sexual network with their schoolmates and other young partners.

Conclusion

Transactional sex among female students was high, and the sexual network they had with the young men put young people in the network at risk of HIV and other sexually transmitted infections. Therefore, HIV prevention programs shall focus on transactional sex among adolescent school girls to halt transmission of HIV among the generation.

A review of transactional sex for natural resources: Under-researched, overstated, or unique to fishing economies?

Environmental change is projected to decrease the availability of key natural resources. Decreasing availability of resources that support food security and livelihoods for vulnerable populations is hypothesised to increase engagement in transactional sex. Therefore, we systematically examined the peer-reviewed literature to characterise what is known about transactional sex for natural resources, document the natural resources that are exchanged for sex, and identify qualitative trends. Of the 1063 articles, 33 were retained for full abstraction. A majority of articles were published after 2005 (93%) and focused on Africa (90%). Two-thirds of articles focused on sex-for-fish exchanges. Reports of transactional sex were also found for other resources, including agricultural land (12%) as well as food, water, and fuel in emergency contexts (12%). Migration and altered resource availability were described as underlying causes of transactional sex. Some studies described an increased risk of sexually transmitted infection, including HIV, as a health consequence of transactional sex. We offer three possible explanations for why the preponderance of previous studies have focused on sex-for-fish rather than other natural resources, and suggest directions for future research.

Transactional sex among Nigerian university students: The role of family structure and family support

BACKGROUND

The reasons for the persistence of risky sexual behaviours among adolescents and young adults in sub-Saharan Africa despite the increasing knowledge about the associated risks continue to attract scholarly debates. Drawing from a cross-sectional study conducted among male and female Nigerian university students, we examined the relationship between family structure, family support and transactional sex.

METHODS

A pre-validated questionnaire was administered to 800 male and female students selected using stratified sampling; however, we performed the analysis on 630 participants who had ever engaged in sex. Transactional sex was operationalised as self-reporting of giving or receiving money, gifts or favour in exchange for sex. We fitted a list-wise logistic regression model to examine the relationship between family structure, family support and transactional sex while controlling for essential covariates.

RESULTS

Of the 630 participants included in the analysis, 17.9% had given and 23.8% had received money, gift or favour in exchange for sex. Our bivariate analysis shows that individuals from polygamous families had higher odds of reporting that they have ever given (AOR: 1.89; CI: 1.05-3.39) or received (AOR: 1.85; CI: 1.85-3.19) money, gift or favour in exchange for sex; however, the relationship was not statistically significant after controlling for relevant covariates. After controlling for essential covariates, the odds of giving or receiving money, gift or favour in exchange for sex was 56% lower in individuals who received adequate family support compared to those who received no or insufficient family support.

CONCLUSION

In conclusion, this paper lends support to the assertion that family structure and family support are protective factors against transactional sex among adolescents and young adults. Future surveys need to include a larger sample in order to explore the effect of single-parent and polygamous family on transactional sex in Nigeria where family formation is changing rapidly.

Societal determinants of HIV vulnerability among clients of female commercial sex workers in Indonesia

This study aimed to explore societal determinants of HIV vulnerability among the clients of female commercial sex workers (FCSWs) in Belu and Malaka districts, Indonesia. A qualitative inquiry using in-depth interviews was employed to collect data from participants (n = 42) recruited using a purposive and snowball sampling technique. Data analysis was guided by a qualitative data analysis framework. The study results revealed several societal determinants that supported vulnerability to HIV infection among the participants. They included low education level and sexual health literacy including the lack of knowledge and information about HIV transmission and prevention. Additional determinants identified were limited source of HIV/AIDS-related information, availability of and ease of accessibility of brothels and FCSWs, peer influence, and high mobility of the study participants. Findings of this study indicate the needs and call for interventions that aim to protect both FCSWs and their clients, through provision of HIV/AIDS and sexual health education and information and improvement in the availability and accessibility of condoms.

Exchange Sex Among Persons Who Inject Drugs in the New York Metropolitan Area: The Importance of Local Context, Gender and Sexual Identity

Exchanging sex for money or drugs is known to increase risk for HIV among persons who inject drugs (PWID). To better understand determinants of exchange sex among PWID we examined factors associated with exchange sex in the New York metropolitan area-defined as New York City (NYC), NY; Newark, NJ; and Long Island, NY-using data from the 2012 National HIV Behavioral Surveillance system cycle on injection drug use. Of the 1160 PWID in this analysis, 24% reported exchange sex, with differences in gender and sexual identity by location. In multivariable analysis gay/bisexual men, heterosexual women, and lesbian, gay, or bisexual (LGB) women were more likely to exchange sex compared to heterosexual men. Exchange sex was also associated with race/ethnicity, homelessness, incarceration, location, and non-injection crack and cocaine use. We find that heterosexual women and LGB women who injected drugs residing in Newark were more likely to report exchange sex compared to NYC. This study highlights how local conditions impact exchange sex.

Usage of the Terms Prostitution, Sex Work, Transactional Sex, and Survival Sex: Their Utility in HIV Prevention Research

This article considers the terms prostitution, sex work, transactional sex, and survival sex, the logic of their deployment and utility to research concerned with people who are paid for sex, and HIV. The various names for paid sex in HIV research are invested in strategically differentiated positionings of people who receive payment and emphasize varying degrees of choice. The terminologies that seek to distinguish a range of economically motivated paid sex practices from sex work are characterized by an emphasis on the local and the particular, efforts to evade the stigma attached to the labels sex worker and prostitute, and an analytic prioritizing of culture. This works to bestow cultural legitimacy on some locally specific forms of paid sex and positions those practices as artifacts of culture rather than economy. This article contends that, in HIV research in particular, it is necessary to be cognizant of ways the deployment of alternative paid sex categories relocates and reinscribes stigma elsewhere. While local identity categories may be appropriate for program implementation, a global category is necessary for planning and funding purposes and offers a purview beyond that of isolated local phenomena. We argue that "sex work" is the most useful global term for use in research into economically motivated paid sex and HIV, primarily because it positions paid sex as a matter of labor, not culture or morality.

Examining relationships of intimate partner violence and food insecurity with HIV-related risk factors among young pregnant Liberian women

Gender inequities place women at an increased risk for HIV acquisition, and this association may particularly disenfranchize young pregnant women. Intimate partner violence (IPV) and food insecurity may contribute to gender differences in power, thereby influencing HIV disparities between women and men. Factors influencing gender disparities in HIV are unique and country-specific within sub-Saharan Africa, yet these factors are understudied among women in Liberia. This paper sought to examine the unique contributions and intersections of intimate partner violence (IPV) and food insecurity with HIV-related risk factors among young pregnant women in Liberia. Between March 2016 and August 2016, cross-sectional data collected from 195 women aged 18-30, residing in Monrovia, Liberia who were receiving prenatal services were used to examine the independent and interaction effects of IPV and food insecurity on HIV-related risk factors (i.e., sexual partner concurrency, economically-motivated relationships). IPV (31.3%) and food insecurity (47.7%) were prevalent. Young women who experience IPV are more likely to report food insecurity (p < 0.05). Young women who experienced IPV and food insecurity were more likely to start a new relationship for economic support (ps < 0.05). Young women who experience IPV and food insecurity were more likely to report engaging in transactional sex (ps < 0.05). There were no significant interaction effects between IPV and food insecurity (ps > 0.05). IPV and food insecurity each uniquely heighten young Liberian women's vulnerability to HIV. Intervention and policy efforts are need to promote and empower women's sexual health through integrated sexual and reproductive health services, and reduce IPV and food insecurity among pregnant Liberian women.

Exchange sex among people receiving medical care for HIV in the United States - medical monitoring project 2009-2013

Many studies of persons who exchange sex for money or drugs have focused on their HIV acquisition risk, and are often limited to select populations and/or geographical locations. National estimates of exchange sex among people living with HIV (PLWH) who are in medical care, and its correlates, are lacking. To address these gaps, we analyzed data from the Medical Monitoring Project, a surveillance system that produces nationally representative estimates of behavioral and clinical characteristics of PLWH receiving medical care in the United States, to estimate the weighted prevalence of exchange sex overall, and by selected socio-demographic, behavioral and clinical characteristics. We found 3.6% of sexually active adults reported exchange sex in the past 12 months. We found a higher prevalence of exchange sex among transgender persons, those who experienced homelessness, and those with unmet needs for social and medical services. Persons who exchanged sex were more likely to report depression and substance use than those who did not exchange sex. We found a higher prevalence of sexual behaviors that increase the risk of HIV transmission and lower viral suppression among persons who exchanged sex. PLWH who exchanged sex had a higher prevalence of not being prescribed ART, and not being ART adherent than those who did not exchange sex. We identify several areas for intervention, including: provision of or referral to services for unmet needs (such as housing or shelter), enhanced delivery of mental health and substance abuse screening and treatment, risk-reduction counseling, and ART prescription and adherence support services.

History of Sex Exchange in Women with a History of Incarceration

Sex exchange among incarcerated women is not well-described in the literature. Sex exchange can lead to numerous adverse health outcomes, especially when combined with individual factors (e.g., depression and homelessness) and larger systemic inequalities. The purpose of this study was to explore factors associated with having a history of sex exchange among a sample of incarcerated women. Of 257 women surveyed in this study, 68 women (26.5%) reported a history of sex exchange. In multivariate logistic regression analysis, physical abuse history (p=.05, OR 2.20), history of two or more sexually transmitted infections (p=.01, OR 2.90), injection drug use (p=.04, OR 2.46) and crack-cocaine use (p&lt;.01, OR 3.42) were associated with prior sex exchange. This is one of only two studies to examine factors associated with prior sex exchange among incarcerated women. Our study has important implications for corrections providers to provide more comprehensive care, directly addressing the unique needs of this population.

Correlates of exchange sex among a population-based sample of low-income women who have heterosexual sex in Baltimore

Sex exchange is associated with HIV and other morbidities yet has received little research, surveillance, and programmatic attention in the U.S. This study identified correlates of exchange sex and among low-income women in Baltimore, Maryland. Participants were recruited into the National HIV Behavioral Surveillance (NHBS) system in 2013 using respondent driven sampling (RDS) and completed a survey and HIV testing. The analytic sample (n = 253) consisted of women aged ≥18 years who had recent (past year) heterosexual sex. Multivariable logistic regression identified correlates of recent exchange sex. Independently associated with recent exchange sex were history of injection drug use (adjusted odds ratio (AOR) = 3.4, 95% CI: 1.1-10.3), recent prescription painkiller use (AOR = 3.7, 95% CI: 1.4-9.9), recent crack/cocaine use (AOR = 6.6, 95% CI: 2.1-20.9), recent arrest (AOR = 4.1, 95% CI: 1.2-14.8), and recent consistent condom use (AOR 1.1; 95% CI: 1.0-1.3). Women who exchanged sex exhibited heightened social and structural vulnerability and substance use. These data demonstrate the need for further research examining the context of exchange sex among low-income women and synergies between substance use and HIV risk.

Constrained relationship agency as the risk factor for intimate partner violence in different models of transactional sex

Women who engage in transactional sex are more likely to experience intimate partner violence (IPV) and are at higher risk of HIV. However, women engage in transactional sex for a variety of reasons and the precise mechanism linking transactional sex and IPV is not fully understood. We conducted a behavioural survey with a cross-sectional sample of 401 women attending 1 rural and 1 urban public antenatal clinic in Swaziland between February and June 2014. We used structural equation modelling to identify and measure constrained relationship agency (CRA) as a latent variable, and then tested the hypothesis that CRA plays a significant role in the pathway between IPV and transactional sex. After controlling for CRA, receiving more material goods from a sexual partner was not associated with higher levels of physical or sexual IPV and was protective against emotional IPV. CRA was the single largest predictor of IPV, and more education was associated with decreased levels of constrained relationship agency. Policies and interventions that target transactional sex as a driver of IPV and HIV may be more successful if they instead target the broader social landscape that constrains women’s agency and drives the harmful aspects of transactional sex.

Gender and race as correlates of high risk sex behaviors among injection drug users at risk for HIV enrolled in the HPTN 037 study

BACKGROUND

Sexual contact has been shown to be a major mode of HIV transmission among people who inject drugs (PWID). This study examined gender and racial differences among PWID' sexual risk behaviors from the perspective of sexual scripts.

METHODS

696 PWID enrolled from Philadelphia on HPTN 037 were classified as engaging in high-risk sex behaviors if they reported having sex in the past 30 days and condomless sex with a non-primary partner, giving/receiving sex for money, or multiple partners. A multivariable logistic regression model was used to assess associations between demographic factors and high risk sex.

RESULTS

Findings of the multivariable regression analysis demonstrated that being White (OR = 0.52, p < 0.001) and male (OR = 0.59, p = 0.002) were protective of high risk sex, while homelessness (OR = 1.7, p = 0.005), and being single (OR = 1.83, p = 0.006) were positively associated with high risk sex. African American (AA) women were 1.7 times more likely to report high-risk sex than AA men (p = 0.002), 3.28 times more likely than White men (p < 0.001), and 1.93 times more likely than White women (p < 0.001).

CONCLUSIONS

Since AA women report high-risk sex behaviors more than other demographic groups, behavioral interventions for HIV risk reduction among PWID may benefit from focusing on sex-risk reduction among AA women.

Agency as a mediator in the pathway from transactional sex to HIV among pregnant women in Swaziland: a multigroup path analysis

Introduction: Transactional sex is a structural driver of HIV for women and girls in sub-Saharan Africa. In transactional relationships, sexual and economic obligations intertwine and may have positive and negative effects on women’s financial standing and social status. We conducted a clinic-based survey with pregnant women in Swaziland using a locally validated transactional sex scale to measure the association between subjective social status, transactional sex, and HIV status, and to assess whether this association differed according to a woman’s agency within her relationship.

Methods: We recruited a convenience sample of 406 pregnant women at one rural and one urban public antenatal clinic in Swaziland and administered a behavioural survey that was linked to participant HIV status using clinic records. We then conducted a multigroup path analysis to test three hypotheses: (1) that more engagement in transactional sex is associated with decreased condom use and increased subjective social status; (2) that subjective social status mediates the relationship between transactional sex and HIV status; and (3) that these relationships are different across groups according to whether or not a woman reported any indicator of constrained agency within her relationship.

Results: The amount and value of material goods received from a sexual partner was significantly and positively associated with higher subjective social status among all participants. As the amount of material goods received from a partner increased, women who reported no indicators of constrained agency were less likely to use condoms. Conversely, there was no relationship between transactional sex and condom use among women who reported any indicator of constrained relationship agency. Among women who reported any indicator of constrained agency, HIV was significantly associated with lower subjective social status.

Conclusions: Relationship agency likely plays a key role in determining which mechanisms create HIV risk for women in transactional relationships. Interventions to mitigate these risks must address social forces that penalize women who engage in sexual relationships as well as structural drivers of gendered economic disparity that reduce women’s agency within their sexual and romantic relationships.

Exchange Sex and HIV Infection Among Women Who Inject Drugs-20 US Cities, 2009

BACKGROUND

Women who inject drugs and who also exchange sex are at increased risk for HIV infection, but data on this population in the United States remain sparse.

METHODS

This study assessed the prevalence of exchanging sex for money or drugs among women who inject drugs using data from the 2009 US National HIV Behavioral Surveillance (NHBS) system. Prevalence of being HIV-positive (testing positive in NHBS), HIV-positive-unaware (reporting being HIV-negative or unknown status but testing positive in NHBS), and risk behaviors and use of services were compared between women who did and did not exchange sex. The association between exchange sex and being HIV-positive-unaware of the infection was examined using multivariate Poisson models with robust standard errors.

RESULTS

Among 2305 women who inject drugs, 39% reported receiving things like money or drugs from ≥1 male partners in exchange for oral, vaginal, or anal sex in the previous 12 months. Women who exchanged sex were more likely to be unemployed, homeless, lack health insurance, have multiple condomless vaginal or anal sex partners, and receptively share syringes. In multivariate analysis, exchange sex was associated with being HIV-positive-unaware (adjusted prevalence ratio 1.97, 95% confidence intervals: 1.31 to 2.97).

CONCLUSIONS

Prevalence of exchange sex was high in this population. Women who exchange sex were more likely to be socially disadvantaged, report sexual and injection risk, and be HIV-positive-unaware. They represent an important group to reach with HIV prevention, testing, and care services.

Ecological correlates of multiple sexual partnerships among adolescents and young adults in urban Cape Town: a cumulative risk factor approach

Studies in South Africa have reported unsafe levels of risky sexual behvaiours among adolescents and young adults, with the country reporting the highest burden of HIV/AIDS globally, as well as a high rate of teenage pregnancy. While determinants of risky sexual behaviours have been investigated for factors occurring at the individual and household levels, not fully explored in the literature is the effect of community level factors. Furthermore, it is unclear whether risk factors occurring within the ecology of adolescents and young adults act cumulatively to influence their sexual practices. This article aims to address this knowledge gap using a case study of the Cape Area Panel Study of adolescents and young adults in urban Cape Town, South Africa. The ecological framework was adopted to guide the selection of risk factors at the individual, household, and community levels. Multivariate linear discriminant function analyses were used to select significant risk factors for multiple sexual partnerships and used to produce risk indices for the respondents. The cumulative risk approach was applied to test whether significant risk factors acted cumulatively. Findings point to the importance of ecological factors in influencing outcomes of multiple sexual partnerships among respondents and further demonstrate that ecological risk factors may act cumulatively. These findings are important for South Africa that is grappling with teenage pregnancy and disproportionate HIV epidemic among the youth.

Economic Resources and HIV Preventive Behaviors Among School-Enrolled Young Women in Rural South Africa (HPTN 068)

Individual economic resources may have greater influence on school-enrolled young women's sexual decision-making than household wealth measures. However, few studies have investigated the effects of personal income, employment, and other financial assets on young women's sexual behaviors. Using baseline data from the HIV Prevention Trials Network (HPTN) 068 study, we examined the association of ever having sex and adopting sexually-protective practices with individual-level economic resources among school-enrolled women, aged 13-20 years (n = 2533). Age-adjusted results showed that among all women employment was associated with ever having sex (OR 1.56, 95 % CI 1.28-1.90). Among sexually-experienced women, paid work was associated with changes in partner selection practices (OR 2.38, 95 % CI 1.58-3.58) and periodic sexual abstinence to avoid HIV (OR 1.71, 95 % CI 1.07-2.75). Having money to spend on oneself was associated with reducing the number of sexual partners (OR 1.94, 95 % CI 1.08-3.46), discussing HIV testing (OR 2.15, 95 % CI 1.13-4.06), and discussing condom use (OR 1.99, 95 % CI 1.04-3.80). Having a bank account was associated with condom use (OR 1.49, 95 % CI 1.01-2.19). Economic hardship was positively associated with ever having sex, but not with sexually-protective behaviors. Maximizing women's individual economic resources may complement future prevention initiatives.

Medical Care of the Homeless: An American and International Issue

Homeless persons die significantly younger than their housed counterparts. In many cases, relatively straightforward primary care issues escalate into life-threatening, expensive emergencies. Poor health outcomes driven by negative interactions between comorbid symptoms meet the definition of a health syndemic in this population. Successful primary care of patients struggling with homelessness may result in long-term lifesaving measures along with decreased expenditure to hospital systems. This primary prevention requires patience, creativity, and acknowledgment that the source of many confounders may lay outside the control of these patients.