High prevalence and partner correlates of physical and sexual violence by intimate partners among street and off-street sex workers

Strategies and Interventions Used to Prevent Violence Against Sex Workers in the United States: A Scoping Review Using the Social-Ecological Model

Structural factors in the United States, such as criminalization, contribute to disproportionate rates of violence against sex workers and subsequent risk of adverse health outcomes. There is a clear need for systemic interventions and risk reduction strategies to reduce violence in this population. To inform next steps in prevention, this scoping review provides an overview of the literature on violence prevention efforts targeting sex workers in the United States, mapped out according to the social-ecological model (SEM). A comprehensive search of peer-reviewed literature across five databases with no limit on publication date yielded 2,372 documents. Studies were eligible for inclusion if they focused on the U.S. population of sex workers and had a clearly defined aim or purpose of exploring, describing, or evaluating sex work violence prevention interventions or risk reduction strategies. Twelve studies met all eligibility criteria and were selected. Only two of the studies evaluated sexual violence prevention interventions, while the remaining 10 explored strategies sex workers use to minimize the risk of violence. Most research focused on female sex workers, violence from paying clients, and prevention at the individual level of the SEM. Our findings suggest a need for additional violence prevention interventions tailored for diverse groups of sex workers and cognizant of the overlapping forms of violence they face. This scoping review contributes to the limited body of research on the prevention of violence against sex workers in the United States by providing future directions for research and program development that span across the SEM.

The impact of exposure to physical and sexual violence on opioid consequences among trauma-exposed individuals recruited from the community who use opioids

Interpersonal violence and opioid use disorder are significant and intersecting public health concerns in the USA. The current study evaluated the consequences associated with opioid use (e.g., physical, social, interpersonal, intrapersonal, and impulse control) as a function of a history of exposure to interpersonal trauma, specifically physical and sexual violence. Participants were 84 trauma-exposed individuals recruited from the community who use opioids (M age = 43.5 50% men; 55% white). Whereas no significant differences emerged in the consequences of opioid use based on a history of physical violence, individuals with a history of sexual violence demonstrated higher levels of impulsive consequences of opioid use compared to individuals without a history of sexual violence. These data highlight the importance of considering the role of exposure to sexual violence in the context of opioid use disorder treatment.

Structural racism and violence: Routine healthcare access in a cohort of marginalized Indigenous women and Two-Spirit Peoples during the COVID-19 Pandemic

Objectives

Historical and ongoing colonial violence, racism, discrimination, criminalization, and intergenerational trauma continues to impact the health of Indigenous women (cisgender and transgender) and Two-Spirit Peoples. Previous and ongoing work clearly articulate the deeply harmful roles of colonialism and racism in continuing to systemically exclude Indigenous Peoples from accessing equitable and culturally safe healthcare. While the COVID-19 pandemic has amplified structural inequities, little attention has been paid to how the pandemic impacts healthcare access for Indigenous women and Two-Spirit Peoples living in urban settings. The aim of this study was to evaluate factors associated with experiencing difficulty accessing routine healthcare in a cohort of marginalized urban Indigenous women and Two-Spirit Peoples on the ancestral, occupied territories of the Musqueam, Squamish and Tsleil-Waututh Nations in what is now referred to as Metro Vancouver, Canada during the COVID-19 pandemic.

Methods

Data were drawn from AMPLIFY, a study of Indigenous cis and trans women and Two-Spirit Peoples in Metro Vancouver. Analyses drew on baseline and semi-annual questionnaire data collected with sex workers and women living with HIV from October 2020-August 2021. We used bivariate and multivariable logistic regression with generalized estimating equations (GEE) to model correlates of experiencing difficulty accessing a family doctor, nurse, or clinic for routine healthcare during the COVID-19 pandemic in the last 6-months.

Results

Amongst 142 marginalized Indigenous women and Two-Spirit Peoples (199 observations), 27.5% reported difficulty accessing routine healthcare. In multivariable GEE logistic regression, participants who had ever been pregnant (AOR:4.71, 95% CI:1.33-16.66) experienced negative changes in psychological and emotional well-being (AOR: 3.99, 95% CI: 1.33-11.98), lacked access to culturally safe health services (AOR:4.67, 95% CI:1.43-15.25), and had concerns regarding safety or violence in their community (AOR:2.72, 95% CI:1.06-6.94) had higher odds of experiencing recent difficulty accessing routine healthcare.

Discussion

Findings are in line with the BC Commissioned In Plain Sight report which recommends the need for accessible, culturally safe, anti-racist, and trauma-informed routine healthcare for marginalized Indigenous cisgender and transgender women and Two-Spirit Peoples during the current and future pandemics. More community-based research is needed to understand access needs for culturally safe routine healthcare amongst marginalized Indigenous cisgender and transgender women and Two-Spirit Peoples.

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

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

"Your Skin Crawled Every Time He Touched You": A Secondary Qualitative Analysis Exploring Bagwell-Gray's Taxonomy of Intimate Partner Sexual Violence

Bagwell-Gray et al. developed a taxonomy of intimate partner sexual violence (IPSV) focusing on type of force (physical or nonphysical) and type of sexual activity (penetration or no penetration). The current secondary descriptive qualitative analysis of interviews with 89 Canadian women IPV victims assessed IPSV that fit Bagwell-Gray's taxonomy. About half (46 or 51.7%) described sexual violence, most commonly sexual abuse (26 or 29.2%), sexual assaults (17 or 19%), and sexual coercion (16 or 17.9%), with overlap across categories. Forced sexual activity was seldom mentioned (3 or 3.4%). Implications for service providers and researchers are provided.

Housing Instability and Evictions Linked to Elevated Intimate Partner and Workplace Violence Among Women Sex Workers in Vancouver, Canada: Findings of a Prospective, Community-Based Cohort, 2010-2019

Objectives. To model the relationship of unstable housing and evictions with physical and sexual violence perpetrated against women sex workers in intimate and workplace settings. Methods. We used bivariate and multivariable logistic regression with generalized estimating equations to model the association of unstable housing exposure and evictions with intimate partner violence (IPV) and workplace violence among a community-based longitudinal cohort of cisgender and transgender women sex workers in Vancouver, Canada, from 2010 through 2019. Results. Of 946 women, 85.9% experienced unstable housing, 11.1% eviction, 26.2% IPV, and 31.8% workplace violence. In multivariable generalized estimating equation models, recent exposure to unstable housing (adjusted odds ratio [AOR] = 2.04; 95% confidence interval [CI] = 1.45, 2.87) and evictions (AOR = 2.45; 95% CI = 0.99, 6.07) were associated with IPV, and exposure to unstable housing was associated with workplace violence (AOR = 1.46; 95% CI = 1.06, 2.00). Conclusions. Women sex workers face a high burden of unstable housing and evictions, which are linked to increased odds of intimate partner and workplace violence. Increased access to safe, women-centered, and nondiscriminatory housing is urgently needed. (Am J Public Health. 2023;113(4):442-452. https://doi.org/10.2105/AJPH.2022.307207).

The Impact of Physical and Sexual Violence on Opioid Consequences among Trauma- exposed Individuals Recruited from the Community who Use Opioids

Interpersonal violence and opioid use disorder are significant and intersecting public health concerns in the United States. The current study evaluated the consequences associated with opioid use as a function of history of interpersonal trauma, specifically physical and sexual violence. Participants were 84 trauma-exposed individuals recruited from the community who use opioids (M age = 43.5 50% men; 55% white). Whereas no significant differences emerged in the consequences of opioid use based on a history of physical violence, individuals with a history of sexual violence demonstrated higher levels of impulsive consequences of opioid use compared to individuals without a history of sexual violence. These data highlight the importance of considering the role of sexual violence in the context of opioid use disorder treatment.

Effect of police enforcement and extreme social inequalities on violence and mental health among women who sell sex: findings from a cohort study in London, UK

OBJECTIVES

To examine legal and social determinants of violence, anxiety/depression among sex workers.

METHODS

A participatory prospective cohort study among women (inclusive of transgender) ≥18 years, selling sex in the last 3 months in London between 2018 and 2019. We used logistic generalised estimating equation models to measure associations between structural factors on recent (6 months) violence from clients or others (local residents, strangers), depression/anxiety (Patient Health Questionnaire-4).

RESULTS

197 sex workers were recruited (96% cisgender-women; 46% street-based; 54% off-street) and 60% completed a follow-up questionnaire. Street-based sex workers experienced greater inequalities compared with off-street in relation to recent violence from clients (73% vs 36%); police (42% vs 7%); intimate partner violence (IPV) (56% vs 18%) and others (67% vs 17%), as well as homelessness (65% vs 7%) and recent law enforcement (87% vs 9%). Prevalence of any STI was 17.5% (17/97). For street-based sex workers, recent arrest was associated with violence from others (adjusted OR (aOR) 2.77; 95% CI 1.11 to 6.94) and displacement by police was associated with client violence (aOR 4.35; 95% CI 1.36 to 13.90). Financial difficulties were also associated with client violence (aOR 4.66; 95% CI 1.64 to 13.24). Disability (aOR 3.85; 95% CI 1.49 to 9.95) and client violence (aOR 2.55; 95% CI 1.10 to 5.91) were associated with anxiety/depression. For off-street sex workers, financial difficulties (aOR 3.66; 95% CI 1.64 to 8.18), unstable residency (aOR 3.19; 95% CI 1.36 to 7.49), IPV (aOR 3.77; 95% CI 1.30 to 11.00) and alcohol/drug use were associated with client violence (aOR 3.16; 95% CI 1.26 to 7.92), while always screening and refusing clients was protective (aOR 0.36; 95% CI 0.15 to 0.87). Disability (aOR 5.83; 95% CI 2.34 to 14.51), unmet mental health needs (aOR 3.08; 95% CI 1.15 to 8.23) and past eviction (aOR 3.99; 95% CI 1.23 to 12.92) were associated with anxiety/depression.

CONCLUSIONS

Violence, anxiety/depression are linked to poverty, unstable housing and police enforcement. We need to modify laws to allow sex workers to work safely and increase availability of housing and mental health services.

Correlates of Suicidality Among A Community-Based Cohort of Women Sex Workers: The Protective Effect of Social Cohesion

Suicide is a critical public health concern globally. Sex workers experience a disproportionate burden of social and health inequities driven by forms of violence, stigma, and criminalization, yet empirical research on suicidality is limited. This study longitudinally investigated the burden and socio-structural correlates of recent suicidality among women sex workers in Vancouver, Canada. Data (2010-2017) were drawn from a community-based, prospective cohort of cis and trans women sex workers across Metro Vancouver. Women completed biannual interviewer-administered questionnaires, and correlates of suicidality in the last 6 months were analyzed using bivariate and multivariable logistic regression with generalized estimating equations (GEE). Of 867 women at baseline, 48% (n = 413) reported lifetime suicidality, 16% (n = 141) reported suicidality in the last 6 months, and 29% reported suicidality at some point during the study. In multivariable analysis, factors independently associated with suicidality included physical/sexual childhood abuse (adjusted odds ratio [AOR]: 2.99; 95% confidence interval [CI] = [1.75, 5.10]), mental health issues (depression/anxiety/posttraumatic stress disorder; AOR = 2.19; 95% CI = [1.63, 2.95]), intimate partner violence (AOR: 2.11; 95% CI = [1.60, 2.80]), physical/sexual client violence (AOR: 1.82; 95% CI = [1.33, 2.50]), and homelessness (AOR: 1.44; 95% CI = [1.10, 1.89]). Older age (AOR: 0.97; 95% CI = [0.95, 0.99]) and higher social cohesion (AOR: 0.88; 95% CI = [0.78, 0.99]) were significantly associated with reduced odds of suicidality. Findings reveal key socio-structural correlates of suicidality among sex workers including experiences of historical and interpersonal violence, trauma/mental health issues, and homelessness. Strengthening social cohesion may have a protective effect on suicidality. Trauma-informed community-led structural interventions tailored to sex workers are urgently needed alongside a legal framework that enables collectivization and connectedness.

Client-Initiated Violence Against Zambian Female Sex Workers: Prevalence and Associations With Behavior, Environment, and Sexual History

Violence against women is a known risk factor for HIV and affects female sex workers (FSW) in sub-Saharan Africa. Little is known about the magnitude and determinants of violence against FSW in Zambia, where HIV and gender-based violence prevalence are high. We conducted a cross-sectional study, using multivariable logistic regression, to determine the prevalence and correlates of client-initiated physical violence among 419 FSW in Lusaka and Ndola. The prevalence of client-initiated physical violence was 39%. The odds of violence were higher for FSW who: lived in Lusaka, recruited clients from the street, serviced clients in the clients' homes, had a physically forced sexual debut, and had a higher client volume. Our results call for safer working spaces for FSW and violence prevention interventions for their male clients.

Individual, Environmental, and Early Life Factors Associated With Client-Perpetrated Violence Among Women Who Exchange Sex in New York City, 2016

Women who exchange sex are at an increased risk of violence from both clients and nonpaying intimate partners. This study utilizes data from the 2016 New York City National HIV Behavioral Surveillance Study cycle focused on high-risk women to examine factors associated with experiencing client-perpetrated violence (CPV). Women who exchanged sex for money or drugs (n = 330) were recruited via respondent-driven sampling. Adjusted log-linked Poisson regression was used to analyze individual, environmental, and early-life factors associated with experiencing CPV in the past 12 months. Compared with women who did not experience CPV, women who experienced CPV were more likely to have a household income of <$10,000 (adjusted prevalence ratio [aPR]: 2.15; 95% confidence interval [CI]: [1.29, 3.57]), have a same-sex partnership (aPR: 2.31; 95% CI: [1.23, 4.33]), have > 2 male exchange sex partners (aPR: 2.76; 95% CI: [1.28, 5.99]), find clients on the street (aPR: 2.10; 95% CI: [1.05, 3.99]), have been refused help from or avoided the police due to exchange sex (aPR: 1.88; 95% CI: [1.06, 3.32]) and to have experienced sexual violence as a minor (aPR: 2.16; 95% CI: [1.29, 3.30]). Multilevel approaches to violence prevention among women who exchange sex, particularly those who find clients on the street, should be considered.

Sex differences in the effects of physical and sexual abuse on the odds of past 30-day opioid misuse among Florida justice-involved children

AIM

Opioid misuse is a severe threat to justice-involved children and adolescents. Identifying risk factors and sex differences is critical to design accurate risk assessments and person-centered interventions. Stress theory and research posit that abuse may be linked to opioid misuse, and the consequences may be harsher for females. The study tests the hypothesis that physical and sexual abuse will individually and cumulatively increase the risk for opioid misuse, and females will have a higher risk than males.

METHODS

A statewide sample of 79,960 justice-involved children in Florida were examined. Opioid misuse, illicit and non-medical use, was measured by urine analysis or self-disclosure within the past-30 days. Bivariate and multivariate logistic regression analyses were employed. Marginal effects were estimated to investigate the interaction between abuse and sex.

RESULTS

Over 2000 youth met the criteria for opioid misuse. One-third of female opioid users experienced both physical and sexual abuse. Compared to those with no history of physical or sexual abuse, those who were physically abused had 43% higher odds of opioid misuse, those who were sexually abuse had 78% higher odds, and those who experienced both had twice as high odds of opioid misuse. The individual and combined effects of these abuse types were higher for females. For example, female youth who were sexually abused had 2.7-times higher odds of opioid misuse than males who were sexually abused.

CONCLUSION

Intervention efforts can be improved by integrating physical and sexual abuse into risk assessments and tailoring assessments by sex.

Violence Against Male Sex Workers: A Systematic Scoping Review of Quantitative Data

Sex workers are recognized to be potentially vulnerable to violence and abuse. However, the extent and nature of violence committed against male sex workers remains under reported. The aim of this evidence scoping review was to identify the prevalence of violence against male sex workers globally. A systematic search was conducted of 8 databases from 1990 to the end of December 2016. In total, quantitative data from 27 studies conducted in 18 countries were included in the review. Evidence indicates that some male sex workers, especially those in non-Western countries, do experience high levels of violence. The largest proportion of studies reported data on sexual violence, whilst the most common type of violence experienced overall by male sex workers was that of 'verbal or emotional abuse or threats'. The views and experiences of male sex workers should be integrated fully into sex work debates, policy and service provision.

Experiences and challenges of Prostitute Women in Iran: A phenomenological qualitative study

Background

Prostitutes in Iran are faced with many challenges and problems that pose risks to their health.

Objective

The present study is an attempt to identify and narrate the challenges and experiences of Iranian prostitutes based on a qualitative approach.

Methods

This qualitative study was conducted with a phenomenological approach in (2018) in Tehran, Iran. The data were collected through semi-structured interviews with 22 prostitutes who were selected using a snowball sampling method and analyzed with Colaizzi's method. In order to examine the quality of findings, Guba and Lincoln's measures were used.

Results

Data analysis results were classified into five main categories and 14 subcategories. The main issues are: The experience of violence, Heath risk, social ostracism, objectifying, and lack of social and legal supporting structures.

Conclusion

Prostitutes in Iran experience numerous problems at personal and social levels. By providing social, economic, and legal supports for them such as social services (e.g. educations on how to use contraceptives, how to have safe sexual intercourse, and free counseling services for mental support), we can improve their health and welfare.

Effects of traumatic events on sex workers' mental health and suicide intentions in Burkina Faso: a trauma-informed approach

Background Data from other settings suggest that female sex workers (FSWs) are regularly exposed to violence and risks of psychological and physical trauma, although less is known about the effects of this violence. The objective of this study was to understand the experiences of violence and relationships with mental health symptomatology among FSWs.

METHODS

A mixed-methods design was used to explore the contexts and social perceptions of violence and mental health effects among FSW in Burkina Faso in 2013.

RESULTS

In all, 696 FSWs were recruited via respondent-driven sampling and enrolled in the study in Ouagadougou and Bobo-Dioulasso, Burkina Faso. Seventy participants were also recruited into qualitative research. Nearly two-thirds of quantitative respondents (61.7%) reported experiencing lifetime physical violence, of whom 77.4% reported experiencing violence after initiating sex work. Further, 40.9% of participants reported forced non-consensual sex, most of which occurred after they had started sex work (73.0%). In some cases, the male perpetrator used physical force to force non-consensual sex. Forced non-consensual sex was often without condoms. Among quantitative participants, 41.8% reported ever having feelings of depression; there was also a high prevalence of suicide ideation in this group. Qualitative participants also described feelings of depression, alienation, and suicide ideation. Some qualitative participants described using protective methods to avoid violence and to promote social protection among FSWs.

CONCLUSIONS

The findings suggest that stigma and physical and sexual abuse are prevalent among FSWs. Within this context of sex work, lifetime experiences of physical and sexual violence were highly correlated with self-reported mental health symptoms.

Police-related barriers to harm reduction linked to non-fatal overdose amongst sex workers who use drugs: Results of a community-based cohort in Metro Vancouver, Canada

BACKGROUND

High rates of overdose and overdose-related mortality in North America represent a pressing health and social concern. Women sex workers face severe health and social inequities, which have been linked to structural factors including negative police interactions; however, little is known regarding the burden of overdose or how policing impacts overdose risk amongst sex workers who use drugs. Given this, we aimed to explore the independent effects of experiencing police-related barriers to harm reduction on non-fatal overdose amongst women sex workers who use drugs in Metro Vancouver, Canada over a 7.5-year period.

METHODS

Data were drawn from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women sex workers in Metro Vancouver, from 2010 to 2017. Using multivariate logistic regression with generalized estimating equations (GEE), we used a confounder modeling approach to identify the independent effect of experiencing police-related barriers to harm reduction strategies on non-fatal overdose amongst sex workers using drugs within the last six months at each study visit.

RESULTS

Amongst 624 participants, 7.7% overdosed within the last six months at baseline and 27.6% overdosed during the study period, contributing 287 non-fatal overdose events over the 7.5-year period. 68.6% reported police-related barriers to harm reduction strategies during the study. In a multivariate confounder model, exposure to police-related barriers to harm reduction strategies [AOR: 2.15, CI: 1.60-2.90] was independently associated with higher odds of non-fatal overdose after adjustment for key confounders.

CONCLUSIONS

Our findings suggest that in the context of the current overdose crisis, adversarial policing practices may undermine access to lifesaving overdose prevention services and exacerbate overdose risks for marginalized women. Findings underscore the urgent need to scale-up access and remove barriers to progressive harm reduction strategies for women sex workers.

Effectiveness of a multilevel intervention to reduce violence and increase condom use in intimate partnerships among female sex workers: cluster randomised controlled trial in Karnataka, India

Introduction

Samvedana Plus is a multilevel intervention working with sex workers, their intimate partners (IPs) and communities to reduce intimate partner violence (IPV) and to increase condom use within intimate relationships of sex workers in Northern Karnataka, India.

Methods

A cluster randomised controlled trial in 47 villages. Female sex workers with IPs in the last 6 months were eligible for baseline (2014), midline (2016) and endline (2017) surveys. 24 villages were randomised to Samvedana Plus and 23 to a wait-list control. Primary outcomes among sex workers included experience of physical and/or sexual IPV or severe physical/sexual IPV in the last 6 months and consistent condom use with their IP in past 30 days. Analyses adjusted for clustering and baseline cluster-level means of outcomes.

Result

Baseline (n=620) imbalance was observed with respect to age (33.9 vs 35.2) and IPV (31.4% vs 45.0%). No differences in physical/sexual IPV (8.1% vs 9.0%), severe physical/sexual IPV (6.9% vs 8.7%) or consistent condom use with IPs (62.5% vs 57.3%) were observed by trial arm at end line (n=547). Samvedana Plus was associated with decreased acceptance of IPV (adjusted OR (AOR)=0.62, 95% CI 0.40 to 0.94, p=0.025), increased awareness of self-protection strategies (AOR=1.73, 95% CI=1.04-2.89, p=0.035) and solidarity of sex workers around issues of IPV (AOR=1.69, 95% CI=1.02-2.82, p=0.042). We observed an increase in IPV between baseline (25.9%) and midline (63.5%) among women in Samvedana Plus villages but lower in comparison villages (41.8%-44.3%) and a sharp decrease at end line in both arms (~8%).

Conclusion

We found no evidence that Samvedana Plus reduced IPV or increased condom use, but it may impact acceptance of IPV, increase knowledge of self-protection strategies and increase sex worker solidarity. Inconsistencies in reported IPV undermined the ability of the trial to assess effectiveness.

Trial registration number

NCT02807259.

Media, nationalism, and the body: Exploring masculinities, male partner violence, and HIV vulnerability among female sex workers in northern Karnataka, India

Public health and media discourses on men and HIV prevention in India have largely focused on changing knowledge, attitudes and risk behaviour pertaining to condom use and safe sex. Little attempt has been made towards intervening in areas such as masculinity, dominant gender norms and intimate partner violence (IPV) that have been shown to have a direct link to HIV prevalence. In this paper, drawing on findings from an ethnographic study in northern Karnataka (India), we show how socio-political and communicative contexts influence and perpetuate violent behaviours by men in intimate relationships with female sex workers (FSW). We argue that constructions of masculinity, the stereotypes of which are reinforced through contemporary media, and movies, are intricately linked with processes of nationalism and play out in forms of chauvinism among working-class men. Violence, celebrated through various patriarchal discourses, legitimises and reinforces gender ideals that govern the private lives of men and their female intimate partners. This study provides a complex and nuanced understanding of structural factors that lead to IPV against FSWs and offers implications for HIV intervention planning in the region and beyond.

The Effect of Violence and Intersecting Structural Inequities on High Rates of Food Insecurity among Marginalized Sex Workers in a Canadian Setting

Food security is both a basic human right and a public health necessity. Despite known gendered contexts of food insecurity, there is a dearth of research on prevalence and factors driving increased food insecurity for sex workers in a criminalized setting. The current study longitudinally examines the prevalence and structural and individual factors associated with increased odds of food insecurity among street and off-street sex workers in a Canadian urban setting. Prospective analyses drew on data from a community-based longitudinal cohort of cis and trans women in street and off-street sex work in An Evaluation of Sex Workers Health Access (2010-2014). The primary outcome was a time-updated measure of food insecurity, using the Radimer-Cornell scale. We used bivariable and multivariable logistic regression using generalized estimating equations to prospectively model correlates of food insecurity over a five-year period. Of 761 cis and trans women sex workers, 72.4% (n = 551) were food insecure over the study period. Over a third (35.2%, n = 268) identified as Indigenous and a quarter, 25.6% (n = 195) were of a gender/sexual minority. Within the 11.0% (n = 84) of women living with HIV, 96.4% (n = 81) were food insecure over the follow-up period. In multivariable analysis, Indigenous ancestry (AOR = 1.58 [95% CI 1.18, 2.10]), unstable housing (AOR = 1.27 [95% CI 1.03, 1.57]), stimulant use (AOR = 1.97 [95% CI 1.57, 2.45]), heroin use (AOR = 1.72 [95% CI 1.36, 2.19]), mental health diagnosis (AOR = 2.38 [95% CI 1.85, 3.05]), recent violence (AOR = 1.54 [95% CI 1.24, 1.91]), means of food access: reliant on food services only vs. self-sufficient (AOR = 1.78 [95% CI 1.38, 2.29]), and means of food access: both vs. self-sufficient (AOR = 2.29 [95% CI 1.84, 2.86]) were associated with food insecurity. In separate multivariable models, both recent and lifetime physical and/or sexual violence remained independently associated with food insecurity (AOR 1.54 [95% CI 1.24, 1.91]; AOR 4.62 [95% CI 2.99, 7.14], respectively). Almost all study participants living with HIV reported being food insecure. These intersecting risks demonstrate the negative impacts associated with living with HIV, experiencing food insecurity and/or physical or sexual violence. This study also highlights the potential for interventions that address structural inequities (e.g., decriminalizing sex work) to have crosscutting impacts to reduce barriers to accessing necessities (including food) or health and social services (e.g., methadone; primary care).

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.

Longitudinal analysis of HIV risk behaviour patterns and their predictors among public primary care patients with tuberculosis in South Africa

The goal of this study was to identify various HIV risk behaviours among tuberculosis (TB) patients in a longitudinal study design in South Africa. In 42 public primary healthcare facilities in three districts in three provinces, adult new TB and TB retreatment patients with hazardous or harmful alcohol use were interviewed within 1 month of initiation of anti-TB treatment and were followed up at 6 months. The total sample with a complete 6-month follow-up assessment was 853. At the follow-up assessment, several HIV risk behaviours significantly reduced from baseline to follow-up. In multivariate Generalized Estimating Equations logistic regression analyses, high poverty (odds ratio (OR): 2.68, 95% confidence interval (CI): 1.56–4.62), Posttraumatic Stress Disorder (PTSD) symptoms (OR = 1.55, 95% CI = 1.03–2.36), and sexual partner on antiretroviral therapy (ART) (OR = 1.84, 95% CI = 1.09–3.10) were associated with a higher odds, and excellent/very good perceived health status (OR: 0.61, 95% CI: 0.37–0.98), severe psychological stress (OR = 0.51, 95% CI = 0.34–0.77), and HIV non-disclosure to most recent sexual partner (OR = 0.40, 95% CI = 0.25–0.65) were associated with a lower odds of inconsistent condom use. Being HIV positive (OR = 4.18, 95% CI = 2.68–6.53) and excellent/very subjective health status (OR = 2.98, 95% CI = 1.73–5.13) were associated with a higher odds, and having PTSD symptoms (OR = 0.60, 95% CI = 0.36–0.99), being on ART (OR = 0.48, 95% CI = 0.25–0.95), having a sexual partner on ART (OR = 0.41, 95% CI = 0.18–0.96), and HIV status non-disclosure (OR = 0.25, 95% CI = 0.15–0.41) were associated with a lower odds of having sex with an HIV-positive or HIV status unknown person. High poverty index (OR = 1.97, 95% CI = 1.19–3.25) and having a sexual partner on ART (OR = 4.37, 95% CI = 1.82–10.48) were associated with a higher odds, and having a partner with HIV-negative status (OR = 0.29, 95% CI = 0.16–0.51) and inconsistent condom use (OR = 0.39, 95% CI = 0.24–0.64) were associated with a lower odds of HIV status non-disclosure at last sex. The study found that among TB patients with problem drinking over a 6-month TB treatment period, the frequency of some HIV risk behaviours (inconsistent condom use) declined (OR = 0.64, 95% CI = 0.41–0.98), but also persisted at a high-level calling for a strengthening and integration of HIV prevention into TB management.

The Prevalence and Correlates of Physical and Sexual Violence Affecting Female Sex Workers in Swaziland

Female sex workers (FSW) have a heightened vulnerability to violence and negative sexual/reproductive health outcomes. Limited research has examined how experiencing physical and sexual violence (PSV) mediates risk for poor health outcomes among FSW in Swaziland. The present analyses aim to contribute to literature linking violence with poor health outcomes, high-risk behaviors, and reduced health service-seeking among FSW. Data were analyzed from a cross-sectional study conducted in Swaziland between July and September 2011 with 325 adult women who reported exchanging sex for money, goods, or favors in the last 12 months, recruited through respondent-driven sampling (RDS). Logistic regression was used to assess the relationship between PSV and ancillary violence/abuse exposures, risk behaviors, and sexual/reproductive and mental health outcomes. PSV was conceptualized as either ever having been beaten up as a result of selling sex or ever being forced to have sex since the age of 18, or both. Prevalence of PSV in this sample was 59.0% in crude estimation, and 48.4% (95% confidence interval [CI]:[39.2,57.6]) with RDS weighting. Separate RDS-weighted estimates of being beaten up as a result of sex work and ever being forced to have sex were 32.4% (95%CI=[24.4,40.4]) and 33.1% (95%CI =[25.0,41.2%]), respectively. Experiencing PSV was associated with being blackmailed (adjusted odds ratio [aOR]= 1.93, 95%CI= [1.07,3.52]), non-injection drug use in the last 12 months (aOR= 1.84, 95%CI= [1.02,3.33]), and feeling afraid to seek health services as a result of selling sex (aOR = 1.74, 95%CI= [1.01,2.99]). Given these findings, violence prevention strategies should be prioritized in programs that address Swazi FSW health, empowerment, and safety.

Informal recycling, income generation and risk: Health and social harms among people who use drugs

BACKGROUND

Informal recycling refers to the street-based collection of discarded materials for reuse, resale, or return to a recycling facility for money. While qualitative research has explored experiences and perceptions of informal recycling, little is known about the scope and exposures associated with informal recycling among people who use drugs (PWUD).

METHODS

Using data from two prospective longitudinal cohorts of PWUD, we examined the prevalence of informal recycling and its association with social, structural and health risks, including criminal justice system involvement.

RESULTS

Between June 2010 and May 2015, of 1664 participants, 557 (33.5%) reported engaging in informal recycling during the study period. In multivariable generalised estimating equations (GEE) analyses, informal recycling was positively associated with injection drug use (Adjusted Odds Ratio (AOR) = 1.43, 95% Confidence Interval (CI) 1.21-1.68), public injection (AOR = 1.27, 95% CI 1.09-1.49), methamphetamine use (AOR = 1.35, 95% CI 1.05-1.72), difficulty finding harm reduction equipment (AOR = 1.16, 95% CI 1.02-1.32), and police interactions (AOR = 1.35, 95% CI 1.18-1.55). Sub-analyses revealed PWUD engaged in informal recycling were more likely to be told to move on, ticketed, stopped for jaywalking, and directed to services by police.

CONCLUSIONS

These findings suggest informal recycling as a situated practice for PWUD, with potential indications for higher-risk drug use, experiencing greater surveillance, and difficulty accessing health and addiction treatment services. This research highlights the significance of the broader risk environment and the need for health-promoting policies for socioeconomically marginalised PWUD engaged in informal recycling.

Violence Exposure and Mental Health of College Students in the United States

Background: Despite the well-established link between exposure to violence and mental health problems, less is known about this association among college students. The current study aimed to investigate the association between history of exposure to violence and mental health of American college students. Methods: Healthy Mind Study (HMS, 2016⁻2017) is a national online survey of 41,898 adult college students. The independent variable was lifetime history of exposure to violence (psychological, physical, and sexual). The dependent variables were anxiety, depression, and suicidality. Race, age, gender, sexual orientation, parental education, financial stress, transfer status, enrollment status, and graduate status were covariates. Linear and logistic regression models were used for data analysis. Results: History of exposure to violence was associated with all three aspects of poor mental health, namely general anxiety, depression, and suicidality. These associations were independent of covariates and type of abuse. Conclusions: There is a need to address various mental health needs of college students who have experienced various forms of violence. College students who screen positive for history of violence exposure should be evaluated for anxiety, depression, and suicidal behaviors.

Third-world realities in a first-world setting: A study of the HIV/AIDS-related conditions and risk behaviors of sex trade workers in Saskatoon, Saskatchewan, Canada

The transmission and prevalence of Human Immunodeficiency Virus (HIV) among those employed as sex trade workers (STW) is a major public health concern. The present study describes the self-reported responses of 340 STW, at-risk for contracting HIV. The participants were recruited by selective targeting between 2009 and 2010 from within the Saskatoon Health Region (SHR), Saskatchewan, Canada. As of 2012, the SHR has the highest incidence rate of positive test reports for HIV in Canada, at more than three times the national average (17.0 vs. 5.9 per 100,000 people). Additionally, the epidemiology of HIV/AIDS in the SHR is different from that seen elsewhere in Canada (still mostly men having sex with men and Caucasians), with its new HIV cases predominantly associated with injection drug use and Aboriginal cultural status. The purpose of this study was to (a) describe the demographic and socio-economic characteristics of the STW in the SHR, (b) identify their significant life events, self-reported problems, knowledge, attitudes, behaviors, self-efficacy, and barriers regarding HIV, and (c) determine the significant independent risk indicators for STW self-reporting a chance of greater than 50% of becoming infected with HIV/AIDS. The majority of the study participants were females, who were never married, of Aboriginal descent, without a high school diploma, and had an annual income of less than $10,000. Using multivariate regression analysis, four significant independent risk indicators were associated with STW reporting a greater that 50% chance of acquiring HIV/AIDS, including experiencing sexual assault as a child, injecting drugs in the past four weeks, being homeless, and a previous Chlamydia diagnosis. These findings provide important evidence of the essential sexual and drug-related vulnerabilities associated with the risk of HIV infection among STW and offer insight into the design and implementation of effective and culturally sensitive public health intervention and prevention efforts. To be most effective, it is recommended that such intervention and prevention initiatives: (1) use specifically tailored community-based outreach to high risk STW who are drug users and link them with appropriate drug treatment and HIV/AIDS prevention and treatment services, (2) provide free and confidential, routine HIV counseling and testing in substance abuse programs, and (3) build capacity among the local, Aboriginal NGOs so as to address with cultural sensitivity both the drug and HIV-related risk factors prevalent among this vulnerable population.

Sexual Violence in the Context of Drug Use Among Young Adult Opioid Users in New York City

Drug and alcohol use have been associated with increased risk for sexual violence, but there is little research on sexual violence within the context of drug use among young adult opioid users. The current mixed-methods study explores young adult opioid users' sexual experiences in the context of their drug use. Forty-six New York City young adults (ages 18-32) who reported lifetime nonmedical use of prescription opioids (POs) completed in-depth, semistructured interviews, and 164 (ages 18-29) who reported heroin and/or nonmedical PO use in the past 30 days completed structured assessments that inquired about their drug use and sexual behavior and included questions specific to sexual violence. Participants reported frequent incidents of sexual violence experienced both personally and by their opioid using peers. Participants described sexual violence, including sexual assault, as occurring within a context characterized by victimization of users who were unconscious as a result of substance use, implicit and explicit exchanges of sex for drugs and/or money that increased risk for sexual violence, negative sexual perceptions ascribed to drug users, and participants' own internalized stigma. Recommendations to reduce sexual violence among young adult opioid users include education for users and service providers on the risk of involvement in sexual violence within drug using contexts and efforts to challenge perceptions of acceptability regarding sexual violence.

Does psychedelic drug use reduce risk of suicidality? Evidence from a longitudinal community-based cohort of marginalised women in a Canadian setting

OBJECTIVE

This study aimed to longitudinally investigate whether ever having used a psychedelic drug can have a protective effect on incidence of suicidality among marginalised women.

DESIGN

Longitudinal community-based cohort study.

SETTING

Data were drawn from a prospective, community-based cohort of marginalised women in Metro Vancouver, Canada.

PARTICIPANTS

766 women completed the baseline questionnaire between January 2010 and August 2014. Participants who did not report suicidality at baseline and who completed at least one follow-up visit were included.

MAIN OUTCOME MEASURE

Extended Cox regression was used to model predictors of new suicidality (suicide ideation or attempts) over 54-month follow-up.

RESULTS

Nearly half (46%; n=355) of participants reported prior suicidality and were thus excluded from the present analyses. Of 290 women eligible at baseline, 11% (n=31) reported recent suicidality during follow-up, with an incidence density of 4.42 per 100 person-years (95% CI 3.10 to 6.30). In multivariable analysis, reported lifetime psychedelic drug use was associated with a 60% reduced hazard for suicidality (adjusted HR (AHR) 0.40; 95% CI 0.17 to 0.94). Crystal methamphetamine use (AHR 3.25; 95% CI 1.47 to 7.21) and childhood abuse (AHR 3.54; 95% CI 1.49 to 8.40) remained independent predictors of suicidality.

CONCLUSION

The high rate of suicidality identified in this study is of major concern. Alongside emerging evidence on the potential of psychedelic-assisted therapy to treat some mental illness and addiction issues, our findings demonstrate that naturalistic psychedelic drug use is independently associated with reduced suicidality, while other illicit drug use and childhood trauma predispose women to suicidality. While observational, this study supports calls for further investigation of the therapeutic utility of psychedelic drugs in treating poor mental health and promoting mental wellness.

Interpersonal and structural contexts of intimate partner violence among female sex workers in conflict-affected northern Uganda

Intimate partner violence (IPV) is the most prevalent form of violence against women, yet remains under-researched among sex workers in sub-Saharan Africa. We explored the interpersonal and structural determinants of recent IPV among female sex workers in northern Uganda. This analysis drew on data from a community-based cross-sectional study (conducted May 2011-January 2012), involving 379 female sex workers in Gulu, northern Uganda. Using logistic regression and multivariable modeling, we examined the correlates of recent male-perpetrated physical or sexual IPV. Of 379 women with noncommercial partners, 59 percent reported having experienced recent moderate/severe physical or sexual IPV. Reporting recent client violence (adjusted odds ratio (AOR): 3.67; 95 percent confidence interval [CI]: 2.31-5.83), doing what their partner wanted (AOR: 2.46; 95 percent CI: 1.46-4.13), and forced sexual debut (AOR: 1.92; 95 percent CI: 1.20-3.05) were independently associated with moderate/severe IPV; recent police arrest and/or incarceration were/was marginally significantly associated with IPV (AOR: 2.25; 95 percent CI: 0.86-5.88, p = 0.097). Greater odds of IPV among sex workers were associated with recent workplace violence, forced sexual debut, and gendered power dynamics favoring male partner control. Programs and policies promoting the safety and health of marginalized women and addressing gender dynamics and violence are needed.

Violence, trauma and living with HIV: Longitudinal predictors of initiating crystal methamphetamine injection among sex workers

BACKGROUND

Despite rapid increases in crystal methamphetamine (CM) use worldwide and established gendered patterns of use, empirical research on CM injection initiation among sex workers is limited. Given the wide range of harms associated with CM, alongside stimulant effects including sexual dis-inhibition and prolonged awake-ness, this study aimed to longitudinally investigate socio-structural predictors of initiating CM injection among sex workers in Vancouver, Canada.

METHODS

Data (2010-2014) were drawn from a community-based cohort of women sex workers: AESHA (An Evaluation of Sex Workers Health Access). Participants completed bi-annual interviewer-administered questionnaires and HIV/STI testing. Kaplan Meier methods and Cox proportional hazards regression were used to model predictors of CM injection initiation among CM injection-naïve participants.

RESULTS

Of 455 participants eligible at baseline, 14.3% (n=65) injected CM for the first time over follow-up, with an incidence density of 6.79 per 100 person-years (95% Confidence Interval [CI] 5.30-8.69). In multivariable analysis, injection heroin use (Adjusted Hazard Ratio [AHR] 6.11; 95%CI 3.24-11.52), having an intimate partner who injects drugs (AHR 2.93; 95%CI 1.57-5.46), workplace violence (AHR 2.85; 95%CI 1.74-4.67), HIV seropositivity (AHR 2.69; 95%CI 1.45-5.00), and childhood abuse (AHR 1.86; 95%CI 0.99-3.49) were independently associated with initiating CM injection.

CONCLUSIONS

Findings underscore the gendered and social risk environment of CM injection initiation among sex workers. The strong influences of historical/workplace violence, coupled with heroin injection (known to be self-medicating for post-traumatic stress) as a primary risk pathway, emphasize the urgency of increasing access to integrated, trauma-informed addiction treatment and HIV care for marginalized women.

Multi-level risk factors associated with sex trading among women living with HIV in Kazakhstan: A neglected key population

Little is known about the prevalence and risk factors associated with sex trading among HIV-positive women. A total of 242 HIV-positive women were recruited in five regions in Kazakhstan. These women completed a survey containing items on socio-demographics, HIV stigma, intimate partner violence, and partner risk behaviors. Multivariate regression was used to examine associations between risk factors and sex trading after controlling for socio-demographic factors. Fifty-six (23.1%) women reported trading sex in the past 90 days. Women who reported recent sex trading were more likely than women who did not trade sex in the past 90 days to experience intimate partner violence (adjusted odds ratio [AOR]: 2.25; 95% confidence interval [CI]: 1.08-4.73), to have been homeless in the past 90 days (AOR: 4.12; 95% CI: 1.19-14.29), and to know or suspect a male partner had a sexually transmitted infection (AOR: 2.20; 95% CI: 1.07-4.53), had sex with another partner (AOR: 4.53; 95% CI: 2.25-9.14), or injected drugs in the past year (AOR: 3.31; 95% CI: 1.64-6.65). These findings underscore the need for comprehensive HIV prevention and intervention programs that address the multi-level risk factors associated with sex trading for women infected with HIV.

Factors associated with violence against female sex workers in ten Brazilian cities

Few studies in Brazil have focused on violence against female sex workers, a theme that has attracted researchers' attention worldwide, especially due to possible associations with HIV. The current study aims to estimate the prevalence of violence against female sex workers according to type and perpetrator and to identify associated factors. A cross-sectional study was conducted with data on 2,523 female sex workers from ten Brazilian cities, and with the respondent-driven sampling (RDS). Prevalence of verbal violence was 59.5%, physical violence 38.1%, sexual violence 37.8%, intimate partner physical violence 25.2%, and violence by clients 11.7%. Factors associated with physical violence were age < 30 years (aOR = 2.27; 95%CI: 1.56-3.29), drug use (aOR = 2.02; 95%CI: 1.54-2.65), and price of trick ≤ BRL 29.00 or USD 9.00 (aOR = 1.51; 95%CI: 1.07-2.13). In conclusion, Brazilian female sex workers suffer a disproportional burden of violence. The identification of vulnerability factors is essential for interventions to safeguard human rights and control HIV.

Is Intimate Partner and Client Violence Associated with Condomless Anal Intercourse and HIV Among Male Sex Workers in Lima, Peru?

Violence experience can increase HIV risk behaviors; however, literature is scarce on violence among male sex workers (MSWs) globally. In 2014, 210 Peruvian MSWs (median age 24.9) were interviewed about their experience of physical, emotional, and sexual violence and condom use with non-paying intimate partners and clients and were tested for HIV. Multivariable models examined relationships between violence in the past 6 months, condomless anal intercourse (CLAI) in the past 3 months and HIV infection. HIV infection (24 %), CLAI (43 %), being a violence victim (42 %) and perpetrator (39 %) were common. In separate multivariable models, being a violence victim [adjusted prevalence ratio aPR = 1.49 (95 % CI 1.09-2.03)] and perpetrator [aPR = 1.39 (1.03-1.87)] were associated with CLAI. Further, being a victim [aPR = 1.65 (1.04-2.62)] was associated with HIV infection. Violence, which was significantly associated with CLAI and HIV infection, is common among Peruvian MSWs, reinforcing the importance of violence awareness and prevention as HIV risk-reduction strategies.

Structural determinants of inconsistent condom use with clients among migrant sex workers: findings of longitudinal research in an urban canadian setting

BACKGROUND

Migrant women in sex work experience unique risks and protective factors related to their sexual health. Given the dearth of knowledge in high-income countries, we explored factors associated with inconsistent condom use by clients among migrant female sex workers over time in Vancouver, BC.

METHODS

Questionnaire and HIV/sexually transmitted infection testing data from a longitudinal cohort, An Evaluation of Sex Workers Health Access, were collected from 2010 to 2013. Logistic regression using generalized estimating equations was used to model correlates of inconsistent condom use by clients among international migrant sex workers over a 3-year study period.

RESULTS

Of 685 participants, analyses were restricted to 182 (27%) international migrants who primarily originated from China. In multivariate generalized estimating equations analyses, difficulty accessing condoms (adjusted odds ratio [AOR], 3.76; 95% confidence interval [CI], 1.13-12.47) independently correlated with increased odds of inconsistent condom use by clients. Servicing clients in indoor sex work establishments (e.g., massage parlors) (AOR, 0.34; 95% CI, 0.15-0.77), and high school attainment (AOR, 0.22; 95% CI, 0.09-0.50) had independent protective effects on the odds of inconsistent condom use by clients.

CONCLUSIONS

Findings of this longitudinal study highlight the persistent challenges faced by migrant sex workers in terms of accessing and using condoms. Migrant sex workers who experienced difficulty in accessing condoms were more than 3 times as likely to report inconsistent condom use by clients. Laws, policies, and programs promoting access to safer, decriminalized indoor work environments remain urgently needed to promote health, safety, and human rights for migrant workers in the sex industry.

Universal Coverage without Universal Access: Institutional Barriers to Health Care among Women Sex Workers in Vancouver, Canada

Background

Access to health care is a crucial determinant of health. Yet, even within settings that purport to provide universal health coverage (UHC), sex workers’ experiences reveal systematic, institutionally ingrained barriers to appropriate quality health care. The aim of this study was to assess prevalence and correlates of institutional barriers to care among sex workers in a setting with UHC.

Methods

Data was drawn from an ongoing community-based, prospective cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers’ Health Access). Multivariable logistic regression analyses, using generalized estimating equations (GEE), were employed to longitudinally investigate correlates of institutional barriers to care over a 44-month follow-up period (January 2010-August 2013).

Results

In total, 723 sex workers were included, contributing to 2506 observations. Over the study period, 509 (70.4%) women reported one or more institutional barriers to care. The most commonly reported institutional barriers to care were long wait times (54.6%), limited hours of operation (36.5%), and perceived disrespect by health care providers (26.1%). In multivariable GEE analyses, recent partner- (adjusted odds ratio [AOR] = 1.46, % 95% Confidence Interval [CI] 1.10–1.94), workplace- (AOR = 1.31, 95% CI 1.05–1.63), and community-level violence (AOR = 1.41, 95% CI 1.04–1.92), as well as other markers of vulnerability, such as self-identification as a gender/sexual minority (AOR = 1.32, 95% CI 1.03–1.69), a mental illness diagnosis (AOR = 1.66, 95% CI 1.34–2.06), and lack of provincial health insurance card (AOR = 3.47, 95% CI 1.59–7.57) emerged as independent correlates of institutional barriers to health services.

Discussion

Despite Canada’s UHC, women sex workers in Vancouver face high prevalence of institutional barriers to care, with highest burden among most marginalized women. These findings underscore the need to explore new models of care, alongside broader policy changes to fulfill sex workers’ health and human rights.

Women Exiting Street-Based Sex Work: Correlations between Ethno-Racial Identity, Number of Children, and Violent Experiences

Through this article the authors examine data collected from 126 women seeking services at a transitional housing facility, primarily for women leaving street-based prostitution. Descriptive statistics on the women's ethno-racial identity, numbers of children, and experiences with violence are presented and analyzed to determine correlations and implications for social service providers working with this unique population of women. Nearly half of respondents are women of color, a majority have given birth to at least one child, and more than half are in a non-commercial intimate partnership, with a significant number reporting extensive experiences with violent trauma and abuse. Results indicate statistically significant differences in women's ethno-racial self-identification and their experiences of sex work and violence, as well as their marital status. Most notably, African-American and Hispanic women face the greatest and most diverse forms of intimate partner violence and negative sex industry experiences, with African-Americans more likely to engage in sex work as minors, be sexually abused as children, work for a pimp, and face physical assault and instances of sex trafficking. Results also support existing research showing correlations between traumatic childhood events and adult substance abuse, sexual assault, and other negative outcomes.

The impact of violence on sex risk and drug use behaviors among women engaged in sex work in Phnom Penh, Cambodia

BACKGROUND

Violence, substance use, and HIV disproportionately impact female entertainment and sex workers (FESW), but causal pathways remain unclear.

METHODS

We examined data from an observational cohort of FESW age 15-29 in Phnom Penh, Cambodia for associations between violence exposure and sexual risk and drug use. Validated measures of physical and sexual violence were assessed at baseline. Self-reported outcomes measured quarterly over the next 12-months included past month sexual partners, consistent condom use by partner type, sex while high, and amphetamine type stimulant (ATS) use. Biomarkers measured quarterly included prostate specific antigen (PSA) and urine toxicology. Generalized estimating equations were fit adjusting for age, education, marital status and sex work venue.

RESULTS

Of 220 women, 48% reported physical or sexual violence in the preceding 12-months. Physical violence was associated with increased number of sex partners (adjusted incidence rate ratio [aIRR] 1.33; 95% CI: 1.04-1.71), greater odds of sex while high (adjusted odds ratio [aOR] 2.42; 95% CI: 1.10-5.33), increased days of ATS use (aIRR 2.74; 95% CI: 1.29-5.84) and increased odds of an ATS+ urine screen (aOR 2.80, 95%CI: 1.38-5.66). Sexual violence predicted decreased odds of consistent condom use with non-paying partners (aOR 0.24; 95% CI: 0.10-0.59) and greater odds of a PSA+ vaginal swab (aOR 1.83; 95% CI: 1.13-2.93).

CONCLUSIONS

Physical and sexual violence are prevalent among Cambodian FESW and associated with subsequent sexual risk and drug use behaviors. Clinical research examining interventions targeting structural and interpersonal factors impacting violence is needed to optimize HIV/AIDS prevention among FESW.

The role of dyad-level factors in shaping sexual and drug-related HIV/STI risks among sex workers with intimate partners

BACKGROUND

Despite high HIV burden among sex workers (SWs) globally, and relatively high prevalence of client condom use, research on potential HIV/STI risk pathways of intimate partnerships is limited. This study investigated partner/dyad-level factors associated with inconsistent condom use among SWs with intimate partners in Vancouver, Canada.

METHODS

Baseline data (2010-2013) were drawn from a community-based prospective cohort of women SWs. Multivariable generalized estimating equations logistic regression examined dyad-level factors associated with inconsistent condom use (<100% in last six months) with up to three male intimate partners per SW. Adjusted odds ratios and 95% confidence intervals were reported (AOR[95%CI]).

RESULTS

Overall, 369 SWs reported having at least one intimate partner, with 70.1% reporting inconsistent condom use. Median length of partnerships was 1.8 years, with longer duration linked to inconsistent condom use. In multivariable analysis, dyad factors significantly associated with increased odds of inconsistent condom use included: having a cohabiting (5.43[2.53-11.66]) or non-cohabiting intimate partner (2.15[1.11-4.19]) (versus casual partner), providing drugs (3.04[1.47-6.30]) or financial support to an intimate partner (2.46[1.05-5.74]), physical intimate partner violence (2.20[1.17-4.12]), and an intimate partner providing physical safety (2.08[1.11-3.91]); non-injection drug use was associated with a 68% reduced odds (0.32[0.17-0.60]).

CONCLUSIONS

Our study highlights the complex role of dyad-level factors in shaping sexual and drug-related HIV/STI risk pathways for SWs from intimate partners. Couple and gender-focused interventions efforts are needed to reduce HIV/STI risks to SWs through intimate partnerships. This research supports further calls for integrated violence and HIV prevention within broader sexual/reproductive health efforts for SWs.

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

Background

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

Methods

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

Results

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

Conclusion

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

Sexual relationship power and intimate partner violence among sex workers with non-commercial intimate partners in a Canadian setting

There is little information on the private lives of women engaged in sex work, particularly how power dynamics within intimate relationships may affect intimate partner violence (IPV). Using baseline data of sex workers enrolled in a longitudinal cohort, "An Evaluation of Sex Workers' Health Access" (AESHA), the present study examined the association between sexual relationship power and IPV among sex workers in non-commercial partnerships in Vancouver, Canada. Pulweritz's Sexual Relationship Power Scale (SRPS) and The World Health Organization (WHO) Intimate Partner Violence against Women Scale (Version9.9) were used. Bivariable and multivariable logistic regression techniques were used to investigate the potential confounding effect of sexual relationship power on IPV among sex workers. Adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were reported. Of 510 sex workers, 257 (50.4%) reported having an non-commercial intimate partner and were included in this analysis. In the past 6 months, 84 (32.7%) sex workers reported IPV (physical, sexual or emotional). The median age was 32 years, 39.3% were of Aboriginal ancestry, and 27.6% were migrants. After controlling for known confounders (e.g., age, Aboriginal ancestry, migrant status, childhood trauma, non-injection drug use), low relationship power was independently associated with 4.19 increased odds (95% CI: 1.93-9.10) and medium relationship power was associated 1.95 increased odds (95% CI: 0.89-4.25) of IPV. This analysis highlights how reduced control over sexual-decision making is plays a critical role in IPV among sex workers, and calls for innovation and inclusive programming tailored to sex workers and their non-commercial intimate partnerships.

Prevalence and correlates of nonmedical prescription opioid use among a cohort of sex workers in Vancouver, Canada

BACKGROUND

The nonmedical use of prescription opioids (POs) is a major public health concern, causing extensive morbidity and mortality in North America. Canada has the second highest consumption rate of POs globally and data indicate nonmedical PO use (NPOU) is growing among key populations and increasingly available in street-level drug markets. Despite accumulating evidence documenting the rise of NPOU, few studies have systematically examined NPOU in Canada among key vulnerable populations, such as sex workers. This study prospectively evaluated the prevalence and correlates of NPOU within a Vancouver cohort of sex workers over three-years follow-up.

METHODS

Data were drawn from an open prospective cohort, AESHA (An Evaluation of Sex Workers Health Access) in Metro Vancouver, Canada (2010-2013). Women were recruited through outreach from outdoor street locations and indoor venues. Bivariate and multivariable logistic regression using Generalized Estimating Equations (GEE) were used to examine social and structural correlates of NPOU over 36 months.

RESULTS

Of the 692 sex workers at baseline, close to one-fifth (n=130, 18.8%) reported NPOU (injection or non-injection) in the last six months. In multivariable GEE analyses, factors independently correlated with recent NPOU were: exchanging sex while high (AOR 3.26, 95%CI 2.29-4.64), police harassment/arrest (AOR 1.83, 95%CI 1.43-2.35), intimate partner injects drugs (AOR 1.66, 95%CI 1.11-2.49), and recent physical/sexual intimate partner violence (AOR 1.65, 95%CI 1.21-2.24).

CONCLUSION

Our results demonstrate that nearly one-fifth of sex workers in Metro Vancouver report NPOU. Factors independently statistically associated with NPOU included exchanging sex while high, police harassment/arrest, a drug injecting intimate partner and recent physical/sexual intimate partner violence. The high prevalence of NPOU use among sex workers underscores the need for further prevention and management strategies tailored to this key population. The correlates of NPOU uncovered here suggest that structural interventions may be further implemented to ameliorate this growing concern.