The impact of an economic empowerment intervention on intimate partner violence among women engaged in sex work in southern Uganda: A cluster randomized control trial

Women engaged in sex work (WESW) are at heightened risk of experiencing intimate partner violence (IPV) compared to women in the general population. This study examines the impact of an economic empowerment intervention on IPV among WESW in Southern Uganda. We used data from 542 WESW in Southern Uganda recruited from 19 HIV hotspots between June 2019 and March 2020. Eligible participants were 18+ years old, engaged in sex work-defined as vaginal or anal sexual intercourse in exchange for money, alcohol, or other goods, reported at least one episode of unprotected sexual intercourse in the past 30 days with a paying, casual, or regular sexual partner (spouse, main partner). We analyzed data collected at baseline, 6, and 12months of follow up. To examine the impact of the intervention on IPV, separate mixed-effects logistic regression models were run for each type of IPV (physical, emotional, and sexual) as experienced by participants in the last 90 days. Results show that the intervention was efficacious in reducing emotional and physical IPV as evidenced by a statistically significant intervention main effect for emotional IPV, χ2(1) = 5.96, p = 0.015, and a significant intervention-by-time interaction effect for physical IPV, χ2(2) = 13.19, p < 0.001. To qualify the intervention impact on physical IPV, pairwise comparisons showed that participants who received the intervention had significantly lower levels of physical IPV compared to those in the control group at six months (contrasts = -0.12 (95% CI: -0.22, -0.02), p = 0.011). The intervention, time, and intervention-by-time main effects for sexual IPV were not statistically significant. Our findings suggest economic empowerment interventions as viable strategies for reducing emotional IPV among WESW. However, it is also essential to understand the role of interventions in addressing other forms of IPV especially for key populations at high risk of violence, HIV, and STI. The study was registered at ClinicalTrials.gov, ID: NCT03583541.

HIV pre-exposure prophylaxis uptake, retention and adherence among female sex workers in sub-Saharan Africa: a systematic review

OBJECTIVE

To evaluate oral pre-exposure prophylaxis (PrEP) uptake, retention and adherence among female sex workers (FSWs) receiving care through community and facility delivery models in sub-Saharan Africa (SSA).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched online databases (PubMed, MEDLINE, SCOPUS, EMBASE, Google Scholar, Cochrane Database of Systematic Reviews and Web of Science) between January 2012 and 3 April 2022.

ELIGIBILITY CRITERIA FOR STUDIES

Randomised controlled trials, cohort studies, cross-sectional studies and quasi-experimental studies with PrEP uptake, adherence and retention outcomes among FSWs in SSA.

DATA EXTRACTION AND SYNTHESIS

Seven coders extracted data. The framework of the Cochrane Consumers and Communication Review Group guided data synthesis. The Risk of Bias In Non-Randomized Studies of Interventions tool was used to evaluate the risk of bias. Meta-analysis was conducted using a random-effects model. A narrative synthesis was performed to analyse the primary outcomes of PrEP uptake, adherence and retention.

RESULTS

Of 8538 records evaluated, 23 studies with 40 669 FSWs were included in this analysis. The pooled proportion of FSWs initiating PrEP was 70% (95% CI: 56% to 85%) in studies that reported on facility-based models and 49% (95% CI: 10% to 87%) in community-based models. At 6 months, the pooled proportion of FSWs retained was 66% (95% CI: 15% to 100%) for facility-based models and 83% (95% CI: 75% to 91%) for community-based models. Factors associated with increased PrEP uptake were visiting a sex worker programme (adjusted OR (aOR) 2.92; 95% CI: 1.91 to 4.46), having ≥10 clients per day (aOR 1.71; 95% CI: 1.06 to 2.76) and lack of access to free healthcare in government-run health clinics (relative risk: 1.16; 95% CI: 1.06 to 1.26).

CONCLUSIONS

A hybrid approach incorporating both facility-based strategies for increasing uptake and community-based strategies for improving retention and adherence may effectively improve PrEP coverage among FSWs.

PROSPERO REGISTRATION NUMBER

CRD42020219363.

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

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

Prevalence of hepatitis B and C among female sex workers in Togo, West Africa

BACKGROUND

Hepatitis B and C are endemic in sub-Saharan Africa, with prevalence among the highest in the World. However, several challenges impede the progression towards the elimination of viral hepatitis by 2030 as suggested by the World Health Organization Global health sector strategy on viral hepatitis, including the lack of knowledge on the scale of this epidemic in the region. The aim of this study was to estimate the prevalence of hepatitis B and C among female sex workers (FSW) in Togo.

METHODS

This ancillary study from a national cross-sectional bio-behavioral study was conducted in 2017 using a respondent-driven sampling (RDS) method, in eight towns of Togo among FSW. Socio-demographic, behavioral and sexual characteristics were assessed using a standardized questionnaire. Blood samples were collected for HIV, hepatitis B and C serological testing. Data were analyzed using descriptive analysis and a logistic regression model.

RESULTS

Out of the 1,036 FSW recruited for this study, biological analyses for viral hepatitis were completed for 769 of them. The median age was 26 years [IQR: 22-33] and 49.8% (n = 383) had attained secondary school. The prevalence of hepatitis B was 9.9% [95% CI: (7.9-12.2)] and the prevalence of hepatitis C was 5.3% [95% CI: (3.9-7.2)]. Higher hepatitis B and C prevalence was associated with recruitment out of Lomé (aOR: 6.63; 95%CI: 3.51-13.40, p <0.001 and OR: 2.82; 95% CI: [1.37-5.99]; p<0.001, respectively) and, for hepatitis B, with never using condoms for vaginal intercourse (OR: 3.14; 95%CI: [1.02-8.71]; p<0.05).

CONCLUSIONS

Results from this study reveals high prevalence of hepatitis B and C among FSW in Togo and an opportunity for advocacy toward the introduction of immunizations and treatment in this population.

National and subnational size estimation of female sex workers in Ghana 2020: Comparing 3-source capture-recapture with other approaches

Background

Key Population size estimation (PSE) is instrumental for HIV/STI preventive, treatment and care services planning, implementation and delivery. The objective was to estimate the overall population of female sex workers (FSW) in all the 16 regions of Ghana using different PSE methods.

Method

Mapping of venues and complete enumeration of seaters was conducted at the formative stage prior to the bio-behavioral survey (BBS). Three PSE methods were used to derive the size estimates of FSW in the 16 regions. These include: Capture-recapture (CRC), service multiplier and three-source capture recapture (3SCRC) methods. The final choice of the estimation method used to estimate the roamer population was 3SCRC. This method was chosen because of its perfect record-linkage–hierarchic combination of three names that minimizes overmatching as well as the addition of an interaction term in the model which corrects for the dependencies in CRC.

Results

The total population size estimate of the female sex workers in the country obtained for roamers using capture re-capture was 41,746 (95% CI: 41,488–41,932). Using the service multiplier, the total population for both the roamers and seaters was 41,153 (95% CI: 37,242–45,984). The 3-source capture re-capture yielded 55,686 roamers FSW (95% CI: 47,686–63,686). The seater population was 4,363 FSW based on census/complete enumeration. The total population size estimate of FSW (seaters and roamers) in Ghana was 60,049 when 3SCRC and census were added. This represents about 0.76% of all estimated adult females aged 15-49yrs in Ghana.

Conclusion

We report population size estimates (PSE) for FSW in Ghana. These estimates are the results of 3SCRC. These findings provide a valid and reliable source of information that should be referenced by government officials and policymakers to plan, implement and provide HIV/STI preventive, treatment, and care services for FSW in Ghana.

Work-Related Human T-lymphotropic Virus 1 and 2 (HTLV-1/2) Infection: A Systematic Review

Human T-lymphotropic virus 1 and 2 (HTLV-1/2) belong to the delta group of retroviruses which may cause a life-long infection in humans, HTLV-1 leading to adult T-cell leukemia/lymphoma and other diseases. Different transmission modes have been described, such as breastfeeding, and, as for other blood-borne pathogens, unsafe sexual activity, intravenous drug usage, and blood transfusion and transplantation. The present systematic review was conducted to identify all peer-reviewed studies concerning the work-related infection by HTLV-1/2. A literature search was conducted from January to May 2021, according to the PRISMA methodology, selecting 29 studies: seven related to health care workers (HCWs), five to non-HCWs, and 17 to sex workers (SWs). The findings showed no clear evidence as to the possibility of HTLV-1/2 occupational transmission in HCWs, according to the limited number and quality of the papers. Moreover, non-HCWs showed a higher prevalence in jobs consistent with a lower socioeconomic status or that could represent a familial cluster, and an increased risk of zoonotic transmission from STLV-1-infected non-human primates has been observed in African hunters. Finally, a general increase of HTLV-1 infection was observed in SWs, whereas only one paper described an increased prevalence for HTLV-2, supporting the urgent need for prevention and control measures, including screening, diagnosis, and treatment of HTLV-1/2, to be offered routinely as part of a comprehensive approach to decrease the impact of sexually transmitted diseases in SWs.

How Can We Support the Use of Oral PrEP Among Young Women who Sell Sex? A PrEP Cascade Analysis

BACKGROUND

We constructed self-reported pre-exposure prophylaxis (PrEP) cascades and explored factors associated with and barriers to PrEP use to inform efforts to support PrEP use among young women who sell sex.

METHODS

Using self-reported data from HIV-negative young women who sell sex enrolled into a cohort study using respondent-driven sampling in Zimbabwe, we constructed PrEP cascades assessing knowledge of, ever offered, ever used, and current PrEP use in 2017 and 2019. We used logistic regression to examine factors associated with PrEP use by 2019. Through qualitative interviews with 43 women enrolled in the cohort, we investigated barriers to PrEP use.

RESULTS

At enrollment, 50% of women had heard of PrEP, 12% had ever been offered PrEP, and 7% ever used PrEP. Over time, all cascade domains: 96% of women had heard of and 55% reported an active offer of PrEP. Among women retained in the study in 2019 (56%; n = 538), 34% ever took PrEP by 2019. PrEP use was associated with, at enrollment, reporting more clients in the past month (10+: 45% vs 1-3: 27% adjOR = 1.71 95% CI: 1.06 to 2.76), duration of selling sex (24% <2 years vs 38% 2-3 years; adjOR = 0.51 95% CI: 0.32 to 0.83), and having visited a female sex worker program in the past 12 months (55% vs 27%; adjOR = 2.92 95% CI: 1.91 to 4.46). Qualitative interviews revealed fear of disclosing sex work, HIV-related/ART-related stigma, and (opportunity) costs of accessing PrEP as barriers to use.

CONCLUSION

PrEP use was associated with factors known to increase HIV risk. Fear of stigma, disclosure, and supply-side barriers need to be addressed to increase women's ability to use PrEP.

Sex Workers and Syndemics: A Population Vulnerable to HIV and COVID-19

COVID-19 has disproportionately affected vulnerable populations across the U.S. Street-based sex workers are one vulnerable population whose health and impact of COVID-19 have been understudied to date. The goal of this study was to evaluate findings from a community needs assessment with street-based sex workers on impact of COVID-19 on health behaviors and social circumstances. A brief survey was developed at a community-based harm reduction and recovery services organization. Surveys were administered by peer specialists to street-based sex workers during street outreach in April and May 2020. A total of 46 surveys were analyzed. Many individuals reported continuing to do sex work and use substances during the COVID pandemic. Slightly more than a quarter of individuals (n = 13; 28.3%) indicated using personal protective equipment while doing sex work and described challenges to using precautions when working with clients. Individuals had used marijuana (n = 32, 71.1%), cocaine (n = 17, 39.5%), prescription stimulants (n = 9, 21.4%), methamphetamines (n = 5, 11.9%), prescription opioids (n = 12, 27.3%), street opioids (n = 12, 27.3%), sedatives (n = 11, 25.0%), hallucinogens (n = 3, 6.8%), inhalants (n = 3, 7.0%), or some other substance (n = 4, 8.7%) in the past 30 days. About half (48.8%) reported that COVID-19 had a major impact on their lives. This study is among the first to characterize the impact of COVID-19 on street-based sex workers. From a public health standpoint, this group also represents a high-priority population given their vulnerability and close contact with others, which increases the potential for community spread.

Seroprevalence of HBV and HCV in female sex workers from four cities in the state of Pará, northern Brazil

Female sex workers (FSWs) represent a high vulnerability group for the acquisition of sexual and parenteral infections such as hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. The present study aimed to determine the prevalence of serological markers and risk factors associated with exposure to HBV and HCV among FSWs in the state of Pará, Brazil. A cross-sectional study using principles of the time location sampling (TLS) method was conducted in four cities (Belém, Bragança, Barcarena, and Augusto Corrêa) of the state of Pará, from 2005 to 2006. In total, 365 FSWs were interviewed using a standardized questionnaire. Blood samples were collected and tested for serological markers of exposure to HBV and HCV using an enzyme immunoassay. The overall prevalence of exposure to HBV and HCV was 36.7% and 7.7%, respectively. The prevalence of surface antigen of HBV was 3.0%. The prevalence of anti-HBc and anti-HBc+ anti-HBs antibodies were 6.3% and 27.4%. Very few (4.7%) FSWs had vaccine immunity against HBV (anti-HBs antibodies only). The prevalence of anti-HCV antibodies was 7.7%. Low monthly income, drug usage, and unprotected sex were some of the social characteristics associated with exposure to the viruses using different analysis. The seroprevalence of HBV and HCV infections among FSWs in four cities of the state of Pará is high when compared to the general population of Brazil, but similar to those found in FSWs in other nondeveloped countries. The prevalence of HBV was higher in Belém, while the prevalence of HCV was higher in the other three cities, highlighting the importance of establishing control and prevention programs to reduce the risk of acquiring these viruses in Pará.

The Epidemiological Impact of STIs among General and Vulnerable Populations of the Amazon Region of Brazil: 30 years of Surveillance

Sexually transmitted infections (STIs) represent a worldwide public health problem and, although many of them are curable, they continue to be neglected, especially in areas with a low human development index, such as in the northern region of Brazil. This review describes the results of 30 years of studies at the Virus Laboratory at the Federal University of Pará, including the prevalence and molecular epidemiology of HIV-1, HTLV-1/2, HPV, HBV, Treponema pallidum and Chlamydia trachomatis among urban and non-urban populations, and also in vulnerable groups in the Brazilian Amazon. Control strategies and challenges in preventing STIs are discussed considering this immense geographic region, where essential health services are unable to reach the entire population, especially the most vulnerable, such as female sex workers, people who use illicit drugs, remnants of quilombolos and indigenous communities.

Sexually transmitted infections and factors associated with risky sexual practices among female sex workers: A cross sectional study in a large Andean city

Background

There are limited published data on factors related to risky sexual practices (RSP) affecting sexually transmitted infections (STIs) among female sex workers (FSWs) in Ecuador.

Methods

Cross-sectional study of FSWs presenting for a consultation in a primary health care centre during 2017. A questionnaire was administered to collect information on RSP and potential risk factors including age, membership of an FSW association, self-report of previous STI diagnosis, previous treatment for suspected STI and temporary migration for sex work. Associations between RSP and potential risk factors were estimated by logistic regression. The proportion of STI was estimated from vaginal swabs by real-time PCR for four sexually transmitted pathogens (Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, and Mycoplasma genitalium).

Results

Of 249 FSWs recruited, 22.5% had reported RSPs at least once during sex work. Among FSWs reporting unprotected vaginal sex in the previous three months, 25.5% had at least one other RSP type. 17.6% (95%CI 13.3–22.8) had at least one active STI. Prevalence of co-infections was 2.4% (95%CI 1.1–5.2). In multivariable analysis, RSP was associated with age (adjusted OR 1.06; 95%CI 1.02–1.10), membership of an FSWs association (aOR 3.51; 95%CI 1.60–7.72) and self-reported previous STI (aOR 3.43; 95%CI 1.28–9.17).

Conclusions

Among a population of female sex workers with high proportion of STIs, increasing age and belonging to an FSWs association was associated with a higher likelihood of engaging in RSP with clients. Engaging with FSWs organisations may reduce the burden of STI among sex workers.

Characterising HIV and STIs among transgender female sex workers: a longitudinal analysis

OBJECTIVES

Though highly vulnerable to HIV and STIs, transgender female sex workers (TFSWs) are understudied in the US HIV and STI response. This study examined the correlates of laboratory-confirmed STIs among a cohort of 62 TFSWs followed over the course of 1 year and explored associations between specimen site and self-reported engagement in insertive and receptive anal intercourse.

METHODS

Participants completed an interviewer-administered computer-assisted personal interview at baseline, 3-, 6-, 9- and 12-month visits where self-administered anal swabs and urine samples for gonorrhea, chlamydia and trichomoniasis were also collected. HIV testing was conducted at baseline, 6-month and 12-month visits.

RESULTS

Baseline HIV prevalence was 40.3% with no HIV seroconversions over follow-up. Baseline prevalence of gonorrhea, chlamydia and trichomoniasis was 9.7%, 17.7% and 14.5%, respectively. In the multivariable regression modelling, recent arrest was significantly associated with testing positive for any STI (adjusted risk ratio (RR) 1.77; 95% CI: 1.10 to 2.84). Insertive anal sex with clients was associated with increased risk of testing positive for an STI via urine specimen (RR 3.48; 95% CI: 1.14 to 10.62), while receptive anal sex was not significantly associated with specimen site.

CONCLUSION

Our findings confirm a high prevalence of STIs among TFSWs and highlight the importance of addressing structural drivers such as criminal justice involvement as well as the need to ensure screening for STIs at all anatomical sites regardless of self-reported sites of potential exposure. More research is needed to better understand HIV and STI vulnerabilities and appropriate interventions for TFSWs in the USA.

Intimate partner violence is a barrier to antiretroviral therapy adherence among HIV-positive women: Evidence from government facilities in Kenya

INTRODUCTION

Intimate Partner Violence (IPV) is linked to low engagement with HIV management services and adverse clinical outcomes, including poor ART adherence. In sub-Saharan Africa, studies on pregnant/postpartum women and transactional sex workers have produced divergent evidence regarding IPV's association with poor ART adherence. We investigate this association among a broad group of women.

METHODS

We sampled 408 HIV-positive women receiving free ART from different types of HIV clinics at government health facilities, assessing for IPV exposure by a current partner, ART adherence rate, and other factors that affect ART adherence (e.g. education, disclosure). ART adherence rates were measured using the Visual Analogue Scale (VAS); responses were dichotomised at a ≥95% cut-off. Multiple logistic regression models assessed the association between the independent variables and ART adherence.

RESULTS

The participants' mean age was 38.6 (range: 18-69 years). The majority had ever attended school (94%, n = 382), were in monogamous marriages (70%, n = 282), and had disclosed status to partners (94%, n = 380). Overall, 60% (n = 242) reported optimal ART adherence (≥ 95%) in the previous 30 days. The prevalence of IPV by the current partner was 76% (CI95 = 72-80%). Experiencing physical IPV (AOR 0.57, CI95: 0.34-0.94, p = .028), sexual IPV (AOR 0.50, CI95: 0.31-0.82, p = .005), or controlling behaviour (AOR 0.56, CI95: 0.34-0.94, p = .027) reduced the odds of achieving optimal adherence, while a higher education level and having an HIV-positive partner increased the odds.

CONCLUSION

IPV is common and is associated with suboptimal ART adherence rates among a broad group of HIV-positive women. ART programs could consider incorporating basic IPV interventions into regular clinic services to identify, monitor and support exposed women, as they might be at risk of poor ART adherence. Still, there is need for more research on how IPV affects ART adherence.

Access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: Coverage, barriers and facilitators

The provision of comprehensive prevention services is vital for reducing the high burden of HIV amongst Ukrainian female sex workers (FSWs). To identify barriers and facilitators that influence access to HIV prevention amongst this population between 2009 and 2017, we developed a literature-informed conceptual framework and conducted a document analysis to identify the components of the Ukrainian prevention package (PP). Using the Integrated Bio Behavioural Surveillance Surveys, we then conducted descriptive analyses to explore PP coverage from 2009 to 2017 and the influence of factors, identified by our conceptual framework. After increasing over four years, a drop in PP coverage was observed from 2013 onwards. Being a client of a non-governmental organisation, street and highway solicitation, non-condom use, and knowledge of HIV may influence access to HIV prevention in the Ukrainian context. Future interventions should consider barriers and facilitators to HIV prevention and the multiple structural levels on which they operate.

Access to sexual and reproductive health care among young adult sex workers in Toronto, Ontario: a mixed-methods study

BACKGROUND

Young adult sex workers may benefit from sexual and reproductive health care services; however, little research has examined their access experiences. This study aimed to assess barriers to and facilitators of access to sexual and reproductive health care among young adult sex workers, and identify practices suggested by participants to improve services.

METHODS

This was a community-based mixed-methods study of adults aged 18-29 years who were currently or had previously been engaged in sex work, conducted in Toronto in 2017-2018. The study was guided by a Youth Advisory Committee of 4 youth with lived experience of sex work. Participants completed an online survey, or participated in a focus group or a one-on-one interview; all 3 modalities included parallel questions about barriers to and facilitators of access to sexual and reproductive health care. We summarized quantitative data using descriptive statistics and identified qualitative themes using thematic analysis, followed by triangulation of the 2 strands.

RESULTS

There were 54 survey respondents (response rate 48%) and 17 participants in the qualitative phase (14 in focus groups and 3 in interviews), for a total sample size of 71. Survey respondents reported suboptimal access to sexual and reproductive health care, with 8 (15%) reporting no regular source of care, and only 6 (11%) reporting that they disclose their sex work experience to providers. Actual or expected stigma regarding sex work on the part of providers was the dominant barrier to care, whereas nonjudgmental providers, particularly those who themselves have sex work experience, was a key facilitator. Participants suggested 7 practices to improve access to sexual and reproductive health care.

INTERPRETATION

Young adult sex workers face many barriers to accessing sexual and reproductive health care. Including people with sex work experience in the development of solutions will maximize the capacity to address the needs of this underserved population.

Investigating the effects of COVID-19 on global male sex work populations: a longitudinal study of digital data

OBJECTIVES

Recommendations of 'social distancing' and home quarantines to combat the global COVID-19 pandemic have implications for sex and intimacy, including sex work. This study examined the effects of COVID-19 on male sex work globally and investigated how men who sold sex responded to and engaged with the virus in the context of work.

METHODS

This study made use of an existing database of deidentified data extracted from the online profiles maintained by male sex workers on a large, international website. Website engagement metrics were calculated for the periods before (September to December 2019) and during COVID-19 (January to May 2020); Poisson regression analyses were used to assess changes over time before and after, while a content analysis was undertaken to identify modes of engagement with the virus.

RESULTS

Data were collected from 78 399 profiles representing 19 388 individuals. In the 'before' period, the number of active profiles was stable (inter-rate ratio (IRR)=1.01, 95% CI 0.99 to 1.01, p=0.339) but during COVID-19 decreased by 26.3% (IRR=0.90, 95% CI 0.89 to 0.91, p<0.001). Newly created profiles also decreased during COVID-19 (59.4%; IRR=0.71, 95% CI 0.69 to 0.74, p<0.001) after a period of stability. In total, 211 unique profiles explicitly referenced COVID-19; 185 (85.8%) evoked risk reduction strategies, including discontinuation of in-person services (41.2%), pivoting to virtual services (38.9%), COVID-19 status disclosure (20.9%), enhanced sanitary and screening requirements (12.3%) and restricted travel (5.2%). Some profiles, however, seemed to downplay the seriousness of COVID-19 or resist protective measures (14.7%).

CONCLUSIONS

These findings support the contention that COVID-19 has dramatically impacted the sex industry; globally, male sex workers may be facing considerable economic strain. Targeted education and outreach are needed to support male sex workers grappling with COVID-19, including around the most effective risk reduction strategies. Those involved with the sex industry must have access to state-sponsored COVID-19 financial and other aid programmes to support individual and public health.

The Effects of Methamphetamine Use on the Sexual Lives of Gender and Sexually Diverse People in Dhaka, Bangladesh: A Qualitative Study

Methamphetamine use has increased among gender and sexually diverse people in several countries, including Bangladesh. This study aimed to explore the effects of methamphetamine on the sexual lives of these people in Dhaka, Bangladesh. An exploratory qualitative study was conducted, comprising 30 in-depth interviews with gender and sexually diverse people including males having sex with males, male sex workers, and transgender women (hijra) under HIV intervention coverage. Ten key informant interviews were also conducted with individuals who have expertise in relevant disciplines such as drug use, harm reduction, and HIV and AIDS. Digitally recorded data were manually analyzed under the thematic analysis framework. Findings indicated that many participants reported that methamphetamine brought changes in their sexual lives such as increased sexual drive, engagement in group sex, the increased ability to perform serial sex, transactional sex, impulsive and coercive sex, initiation and switching of male-to-male sexual practices, and limited condom use. Key informants noted that there is a dearth of methamphetamine-related services in Bangladesh. Methamphetamine use was found to lead to diverse effects on the sexual lives of gender and sexually diverse people, thus making it a driving force for shaping sexual practices and, hence, sexual risks. Therefore, it is essential for policy-level stakeholders and program managers to consider the risks of methamphetamine use due to their negative ramifications on sexual health, including HIV risks.

The PEARL study: a prospective two-group pilot PrEP promotion intervention for cisgender female sex workers living in Baltimore, MD, U.S

HIV remains elevated among female sex workers (FSW) globally, with a number of structural (e.g., poverty, access to care) factors driving these persistently high rates. Pre-exposure prophylaxis (PrEP), a user-controlled prevention method, is a promising means of empowering vulnerable populations to protect themselves and enhance agency. Yet there is a dearth of PrEP research and interventions targeting cisgender women in the United States, and even fewer aimed to reach FSW. We developed and implemented a multifaceted PrEP pilot intervention, the Promoting Empowerment And Risk Reduction (PEARL) study, to meet this gap. This paper describes the development process and nature of a community-informed intervention for tenofovir/emticitrabine (TDF/FTC) pre-exposure prophylaxis engagement among street-based cisgender FSW in Baltimore, Maryland, U.S. In the course of the study's implementation, structural, programmatic, and medical barriers have already posed significant barriers to full engagement. PEARL implemented a number of strategies in an effort to counter barriers and facilitate increased success of PrEP uptake and maintenance. The study will provide critical insights into the nature of intervention components that could help FSW to initiate PrEP and reduce PrEP care cascade gaps.

Risk factors of HIV infection among female entertainment workers in Cambodia: Findings of a national survey

Background

Cambodia has been well recognized for its success in the fight against the HIV epidemic. However, challenges remain in eliminating HIV infections in key populations, including women working in entertainment establishments, such as massage parlors, karaoke bars, or beer gardens. This study explored the prevalence of HIV and identified factors associated with HIV infection among female entertainment workers (FEWs) in Cambodia.

Methods

This national biological and behavioral survey was conducted in 2016 in Phnom Penh and 17 provinces. We used a two-stage cluster sampling method to recruit FEWs for HIV testing performed on-site and face-to-face interviews using a structured questionnaire. We investigated factors associated with HIV infection using multiple logistic regression.

Results

This study included 3149 FEWs with a mean age of 26.2 years (SD 5.7). The adjusted prevalence of HIV was 3.2% (95% CI 1.76–5.75). In the multiple logistic regression model, the odds of HIV infection were significantly higher among FEWs in the age group of 31 to 35 (AOR 2.72, 95% CI 1.36–8.25) and 36 or older (AOR 3.62, 95% CI 1.89–10.55); FEWs who were not married but living with a sexual partner (AOR 3.00, 95% CI 1.16–7.79); FEWs who had at least ten years of formal education (AOR 0.32, 95% CI 0.17–0.83); FEWs who reported having abnormal vaginal discharge (AOR 3.51, 95% CI 1.12–9.01), genital ulcers or sores (AOR 2.06, 95% CI 1.09–3.17), and genital warts (AOR 2.89, 95% CI 1.44–6.33) in the past three months; and FEWs who reported using illicit drugs (AOR 3.28, 95% CI 1.20–4.27) than their respective reference group. The odds of HIV infection were significantly lower among FEWs working in karaoke bars (AOR 0.26, 95% CI 0.14–0.50) and beer gardens (AOR 0.17, 95% CI 0.09–0.54) than among freelance FEWs.

Conclusions

The prevalence of HIV among FEWs in Cambodia remains much higher than that in the general population. These findings indicate that differentiated strategies to address HIV and other sexually transmitted infections should be geared towards FEWs working as freelancers or in veiled entertainment venues such as massage parlors and freelance sex workers. Prevention efforts among venue-based FEWs should be sustained.

Using factor analyses to estimate the number of female sex workers across Malawi from multiple regional sources

PURPOSE

Human immunodeficiency virus (HIV) risks are heterogeneous in nature even in generalized epidemics. However, data are often missing for those at highest risk of HIV, including female sex workers. Statistical models may be used to address data gaps where direct, empiric estimates do not exist.

METHODS

We proposed a new size estimation method that combines multiple data sources (the Malawi Biological and Behavioral Surveillance Survey, the Priorities for Local AIDS Control Efforts study, and the Malawi Demographic Household Survey). We used factor analysis to extract information from auxiliary variables and constructed a linear mixed effects model for predicting population size for all districts of Malawi.

RESULTS

On average, the predicted proportion of female sex workers among women of reproductive age across all districts was about 0.58%. The estimated proportions seemed reasonable in comparing with a recent study Priorities for Local AIDS Control Efforts II (PLACE II). Compared with using a single data source, we observed increased precision and better geographic coverage.

CONCLUSIONS

We illustrate how size estimates from different data sources may be combined for prediction. Applying this approach to other subpopulations in Malawi and to countries where size estimate data are lacking can ultimately inform national modeling processes and estimate the distribution of risks and priorities for HIV prevention and treatment programs.

Effect of a mobile phone intervention for female sex workers on unintended pregnancy in Kenya (WHISPER or SHOUT): a cluster-randomised controlled trial

BACKGROUND

Female sex workers in low-income and middle-income countries face high risks of unintended pregnancy. We developed a 12-month, multifaceted short messaging service intervention (WHISPER) for female sex workers in Kenya who had the potential to become pregnant, to improve their contraceptive knowledge and behaviours. The aim of this study was to assess the effectiveness of the intervention to reduce the incidence of unintended pregnancy among sex workers in Kenya compared with an equal-attention control group receiving nutrition-focused messages (SHOUT).

METHODS

Our two-arm, cluster-randomised controlled trial was done in sex-work venues in two subcounties of Mombasa, Kenya (Kisauni and Changamwe). Participants, aged 16-34 years, not pregnant or planning pregnancy, able to read text messages in English, residing in the study area, and who had a personal mobile phone with one of two phone networks, were recruited from 93 randomly selected sex-work venues (clusters). Random cluster allocation (1:1) to the intervention or control group was concealed from participants and researchers until the intervention started. Both groups received text messages in English delivered two to three times per week for 12 months (137 messages in total), as well as additional on-demand messages. Message content in the intervention group focused on promotion of contraception, particularly long-acting reversible contraception and dual method contraceptive use; message content in the control group focused on promotion of nutritional knowledge and practices, including food safety, preparation, and purchasing. The primary endpoint, analysed in all participants who were randomly assigned and attended at least one follow-up visit, compared unintended pregnancy incidence between groups using discrete-time survival analysis at 6 and 12 months. This trial is registered with Australian New Zealand Clinical Trials Registry, ACTRN12616000852459, and is closed to new participants.

FINDINGS

Between Sept 14, 2016, and May 16, 2017, 1728 individuals were approached to take part in the study. Of these, 1155 were eligible for full screening, 1035 were screened, and 882 were eligible, enrolled, and randomly assigned (451 participants from 47 venues in the intervention group; 431 participants from 46 venues in the control group). 401 participants from the intervention group and 385 participants from the control group were included in the primary analysis. Incidence of unintended pregnancy was 15·5 per 100 person-years in the intervention group and 14·7 per 100 person-years in the control group (hazard ratio 0·98, 95% CI 0·69-1·39).

INTERPRETATION

The intervention had no measurable effect on unintended pregnancy incidence. Mobile health interventions, even when acceptable and rigorously designed, are unlikely to have a sufficient effect on behaviour among female sex workers to change pregnancy incidence when used in isolation.

FUNDING

National Health and Medical Research Council of Australia.

Brief Report: Longitudinal Associations Between Place of Sex Work and Client Condom Coercion Among Sex Workers in Baltimore, Maryland

INTRODUCTION

The sex work environment influences sex workers' control over enforcing condom use. Sex work in outdoor and public spaces, compared with indoor spaces, may inhibit condom negotiation. We examined longitudinal associations between public place of sex work and condom coercion among female sex workers.

METHODS

This cohort study involved 5 data collection points over 1 year among female sex workers (N = 246) in Baltimore, Maryland, recruited by targeted sampling. We conducted bivariate analyses to examine associations between currently conducting any sex work in a public place (PPSW, eg, car, abandoned house, street, park/forest, and public bathroom) vs. exclusively indoor sex work (eg, house, motel, and dance club) with sociodemographic, substance use (eg, injection drug use, crack use), and past 3-month condom coercion (eg, client condom refusal/removal). We used logistic regressions with generalized estimating equations and exchangeable correlation structure to examine longitudinal associations between PPSW and subsequent condom coercion, adjusting for sociodemographic and substance use variables.

FINDINGS

Among participants (race/ethnicity: White: 67.5%; Black/African American: 22.8%; Latina/other ethnicity: n = 9.8%; age range: 18-61), most reported daily injection drug use (58.5%), daily crack use (62.2%), and homelessness (62.2%). Most (88.6%) reported any PPSW at baseline. Current PPSW was associated with increased odds of past 3-month condom coercion (adjusted odds ratio [aOR]: 1.85, 95% confidence interval: 1.16 to 2.94, P = 0.01) compared with indoor sex work, as was daily crack use (aOR 1.67, 95% confidence interval: 1.18 to 2.37).

CONCLUSIONS

Public sex work environments were associated with client condom coercion and confer additional sexual health risks in contexts of illegality. Interventions should address risk disparities in social geographies of sex work.

Female Entertainment Workers and Condom Use Negotiation in Post-100% Condom Use Era Cambodia

Beyond the monopoly environment of the early 100% Condom Use Program in Cambodia, less is known about how current female entertainment workers negotiate condom use on their own, and what factors impact that negotiation. This study aims to understand the experiences of current female entertainment workers in negotiating condom use with clients in Cambodia. Data collection occurred over a period of 3 weeks (August-September 2017) with concurrent data transcription and translation. A total of 27 focus group discussions (FGDs) were conducted in the following groups: pilot FGD (5), karaoke bar (5), massage parlor (5), beer garden (5), on-call sex workers (3), cross-venue groups exploring parenting issues (2), and street-based sex workers (2). Female entertainment workers experience a range of control over negotiating condom use with clients. Participants reported times when they were able to take direct action and successfully insist on condom use, times when they agreed to participate in condomless sex for money in the face of economic insecurity, and times when male clients sabotaged their attempts to negotiate condom use with tricks, verbal threats or threats of violence. These experiences are influenced by alcohol use, economic shocks, trust between partners, and experiences with side effects. Our findings support the development of policies that re-invigorate the structural-level condom promotion programs while also acknowledging the many individual-level factors that shape condom use such as alcohol consumption, economic insecurity, trust, and side effects.

HIV prevalence, sexual risk behaviours and HIV testing among female sex workers in three cities in Sri Lanka: Findings from respondent-driven sampling surveys

Sri Lanka has a low-level HIV epidemic. This study aims to provide evidence on HIV, syphilis and hepatitis B (HBV) prevalence, sexual risk behaviours and utilisation of HIV prevention interventions among female sex workers (FSW) in the cities Colombo, Galle, and Kandy. Using respondent-driven sampling (RDS), we recruited a total of 458 FSW in Colombo, 360 in Galle and 362 in Kandy from November 2017 to March 2018. Participants provided biological specimens for testing for infections and completed a behavioural questionnaire. We found no HIV nor HBV infections in Galle and Kandy, and low HIV (0.4%) and HBV surface antigen (0.6%) prevalence in Colombo. FSW in Colombo had higher positivity on Treponema pallidum-particle agglutination test (8.4%) compared to Galle (2.0%) and Kandy (2.5%). About two thirds of FSW heard of HIV in each of the cities. Around 90% of FSW used condom at last sex with a client in both Colombo and Galle, but considerably less in Kandy (57.1%). However, lower proportion of FSW used condoms every time during sex with clients in the past 30 day: 22.9% of FSW in Colombo, 26.6% in Kandy and 68.4% in Galle. Across cities, 17.5%-39.5% of FSW reported being tested for HIV in the past 12 months or knowing HIV positive status. The commonest reasons for never testing for HIV was not knowing where to test (54.2% in Colombo, 41.8% in Galle, 48.1% in Kandy) followed by inconvenient testing location (23.7% in Colombo and 31.1% in Kandy). HIV has not yet been firmly established among FSW in three cities in Sri Lanka, but the vulnerability towards HIV and STIs is substantial. HIV interventions should be intensified by expanding community-based HIV testing approaches, increasingawareness of HIV risks and addressing socio-structural vulnerabilities of FSW to HIV.

The influence of migration in substance use practices and HIV/STI-related risks of female sex workers at a dynamic border crossing

We explored the association of international migration with substance use and HIV/STI risk factors among female sex workers (FSW). Using modified time-location sampling, we recruited 266 FSW at the Mexico-Guatemala border. Crude and adjusted logistic regression models were used to evaluate the relationships. HIV risks, such as frequent hard drug use and drug use in another country, were greater for migrant compared to nonmigrant FSW. However, more migrant versus nonmigrant FSW reported consistent condom use with clients and having a health card. Our study highlights regional patterns of substance use among FSW and risk or protective behaviors related to migration status.

Association of Violence Against Female Sex Workers Who Use Drugs With Nonfatal Drug Overdose in Kazakhstan

IMPORTANCE

Female sex workers (FSWs) who use drugs face increased risk of intimate partner violence (IPV) and nonpartner violence (NPV). The association between violence and drug overdose is unknown.

OBJECTIVE

To examine the association between IPV, NPV, and nonfatal drug overdose among FSWs who use drugs in Kazakhstan.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 400 adult FSWs in Kazakhstan who reported illicit drug use in the past year, exchanged sex for money or drugs, and reported having unprotected sex in the past 90 days. Baseline data were collected from February 2015 to May 2017 from Project Nova, an HIV prevention study among FSWs who use drugs in Kazakhstan. Data analysis was conducted from April 2019 to March 2020.

EXPOSURES

Lifetime and recent (past 90 day) experiences of physical, sexual, and psychological IPV and NPV using the Revised Conflict Tactics Scale. Subtypes of violence were identified using exploratory factor analysis.

MAIN OUTCOMES AND MEASURES

Lifetime and recent incidence of nonfatal overdose; sociodemographic characteristics as well as lifetime and recent sex work and drug use behaviors were also collected.

RESULTS

The 400 participants had a mean (SD) age of 34.1 (8.4) years. Most experienced food insecurity (358 [89.5%]) and homelessness (232 [58.0%]) in the past 90 days; one-third (130 [32.5%]) reported a history of incarceration. Most (359 [89.7%]) experienced some form of violence; 150 (37.5%) reported a lifetime nonfatal overdose, of whom 27 (18.0%) reported nonfatal overdose in the past 90 days. Lifetime severe physical violence (adjusted odds ratio [aOR], 1.27; 95% CI, 1.02-1.59; P = .03), engagement in sex work for more than 10 years (aOR, 2.54; 95% CI, 1.50-4.28; P < .001), and a history of incarceration (aOR, 4.34; 95% CI, 2.58-7.32; P < .001) were associated with greater odds of nonfatal overdose. Engaging in sex work for more than 10 years (aOR, 3.97; 95% CI, 1.36-11.61; P = .01) and a history of incarceration (aOR, 3.63; 95% CI, 1.39-9.48; P = .008) were associated with greater odds of recent nonfatal overdose.

CONCLUSIONS AND RELEVANCE

In this study, violence against FSWs who use drugs in Kazakhstan was associated with increased odds of nonfatal overdose. Harm reduction programs for women should consider including services to address gender-based violence and the needs of women after incarceration.

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

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

Structural barriers to condom access in a community-based cohort of sex workers in Vancouver, Canada: influence of policing, violence and end-demand criminalisation

OBJECTIVES

Sex workers (SWs) face a disproportionate burden of HIV/sexually transmitted infections (STIs), violence and other human rights violations. While recent HIV prevention research has largely focused on the HIV cascade, condoms remain a cornerstone of HIV prevention, requiring further research attention. Given serious concerns regarding barriers to condom use, including policing, violence and 'end-demand' sex work criminalisation, we evaluated structural correlates of difficulty accessing condoms among SWs in Vancouver over an 8-year period.

METHODS

Baseline and prospective data were drawn from a community-based cohort of women SWs (2010-2018). SWs completed semi-annual questionnaires administered by a team that included lived experience (SWs). Multivariable logistic regression using generalised estimating equations (GEE) modelled correlates of difficulty accessing condoms over time.

RESULTS

Among 884 participants, 19.1% reported difficulty accessing condoms during the study. In multivariable GEE analysis, exposure to end-demand legislation was not associated with improved condom access; identifying as a sexual/gender minority (adjusted odds ratio (aOR) 1.62, 95% CI 1.16 to 2.27), servicing outdoors (aOR 1.52, 95% CI 1.17 to 1.97), physical/sexual workplace violence (aOR 1.98, 95% CI 1.44 to 2.72), community violence (aOR 1.79, 95% CI 1.27 to 2.52) and police harassment (aOR 1.66, 95% CI 1.24 to 2.24) were associated with enhanced difficulty accessing condoms.

CONCLUSIONS

One-fifth of SWs faced challenges accessing condoms, suggesting the need to scale-up SW-tailored HIV/STI prevention. Despite the purported goal of 'protecting communities', end-demand criminalisation did not mitigate barriers to condom access, while sexual/gender minorities and those facing workplace violence, harassment or those who worked outdoors experienced poorest condom accessibility. Decriminalisation of sex work is needed to support SWs' labour rights, including access to HIV/STI prevention supplies.

High HIV and syphilis prevalence among female sex workers in Juba, South Sudan

HIV prevalence is estimated to be 2.7% in South Sudan; however, little is known about the young country’s epidemic. We conducted a respondent-driven sampling biobehavioral survey in Juba of female sex workers (FSW) aged ≥15 years who sold or exchanged sex in the last 6 months to learn more about this population. We enrolled 838 FSW from November 2015 to March 2016 and estimated HIV prevalence to be 37.8%. Prevalence of active syphilis was 7.3%. FSW were from South Sudan and most neighboring countries. Comprehensive knowledge of HIV was 11.1% and 64.2% of FSW had never spoken with an outreach worker. In multivariable analysis, HIV was associated with being from Uganda (aOR: 3.3, 95% CI: 1.7–6.1) or Kenya (aOR: 4.3, 95% CI: 1.5–13.0) versus from South Sudan. Our survey suggests that FSW may play a critical role in South Sudan’s HIV epidemic and highlights the importance of tailoring services to the unique needs of FSW of all nationalities in Juba.

Mental health problems among female sex workers in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

The psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs). Key risk factors include poverty, low education, violence, alcohol and drug use, human immunodeficiency virus (HIV), and stigma and discrimination. This systematic review and meta-analysis aimed to quantify the prevalence of mental health problems among FSWs in LMICs, and to examine associations with common risk factors.

METHOD AND FINDINGS

The review protocol was registered with PROSPERO, number CRD42016049179. We searched 6 electronic databases for peer-reviewed, quantitative studies from inception to 26 April 2020. Study quality was assessed with the Centre for Evidence-Based Management (CEBM) Critical Appraisal Tool. Pooled prevalence estimates were calculated for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal behaviour. Meta-analyses examined associations between these disorders and violence, alcohol/drug use, condom use, and HIV/sexually transmitted infection (STI). A total of 1,046 studies were identified, and 68 papers reporting on 56 unique studies were eligible for inclusion. These were geographically diverse (26 countries), representing all LMIC regions, and included 24,940 participants. All studies were cross-sectional and used a range of measurement tools; none reported a mental health intervention. Of the 56 studies, 14 scored as strong quality, 34 scored as moderate, and 8 scored as weak. The average age of participants was 28.9 years (age range: 11-64 years), with just under half (46%) having up to primary education or less. The pooled prevalence rates for mental disorders among FSWs in LMICs were as follows: depression 41.8% (95% CI 35.8%-48.0%), anxiety 21.0% (95% CI: 4.8%-58.4%), PTSD 19.7% (95% CI 3.2%-64.6%), psychological distress 40.8% (95% CI 20.7%-64.4%), recent suicide ideation 22.8% (95% CI 13.2%-36.5%), and recent suicide attempt 6.3% (95% CI 3.4%-11.4%). Meta-analyses found significant associations between violence experience and depression, violence experience and recent suicidal behaviour, alcohol use and recent suicidal behaviour, illicit drug use and depression, depression and inconsistent condom use with clients, and depression and HIV infection. Key study limitations include a paucity of longitudinal studies (necessary to assess causality), non-random sampling of participants by many studies, and the use of different measurement tools and cut-off scores to measure mental health problems and other common risk factors.

CONCLUSIONS

In this study, we found that mental health problems are highly prevalent among FSWs in LMICs and are strongly associated with common risk factors. Study findings support the concept of overlapping vulnerabilities and highlight the urgent need for interventions designed to improve the mental health and well-being of FSWs.

Assessing an inclusive model to increase access to comprehensive gender-based violence response services and improve HIV outcomes in Puerto Plata, Dominican Republic

Experiences of gender-based violence (GBV) are associated with increased vulnerability to HIV and difficulty accessing HIV services; at the same time, people living with HIV are at an increased risk of GBV. Key populations most affected by HIV - gay and other men who have sex with men, female sex workers and transgender women - also experience a disproportionate burden of GBV. In Puerto Plata, Dominican Republic, a local civil society organisation has led efforts to improve and integrate GBV and HIV services while making them welcoming to key population members and people living with HIV. According to interviews with service providers and service users and an analysis of service statistics, the intervention improved service quality and coordination, increased disclosures of violence and increased GBV response service uptake among the general population, key population members and people living with HIV. Findings also suggest that the intervention increased the uptake of HIV services, including HIV testing and post-exposure prophylaxis, and improved mental health among those receiving GBV response services. This case study of integrated GBV and HIV services describes a new model for simultaneously, synergistically and inclusively addressing two major epidemics negatively affecting health and well-being in affected communities today.

High burden of self-reported sexually transmitted infections among key populations in Mozambique: the urgent need for an integrated surveillance system

BACKGROUND

Key populations - men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID) - are at high risk for sexually transmitted infections (STI) given their sexual risk behaviours along with social, legal and structural barriers to prevention, care and treatment services. The purpose of this secondary analysis is to assess the prevalence of self-reported STIs and to describe associated risk factors among participations of the first Biological Behavioural Surveillance (BBS) in Mozambique.

METHODS

Responses from the first BBS surveys conducted in 2011-2014 were aggregated across survey-cities to produce pooled estimates for each population. Aggregate weighted estimates were computed to analyse self-reported STI prevalence. Unweighted pooled estimates were used in multivariable logistic regression to identify risk factors associated with self-reported STI.

RESULTS

The prevalence of self-reported STI was 11.9% (95% CI, 7.8-16.0), 33.6% (95% CI, 29.0-41.3), and 22.0% (95% CI, 17.0-27.0) among MSM, FSW and PWID, respectively. MSM who were circumcised, had HIV, reported drug use, reported receptive anal sex, and non-condom use with their last male partner had greater odds of STI self-report. STI-self report among FSW was associated with living in Beira, being married, employment aside from sex work, physical violence, sexual violence, drug use, access to comprehensive HIV prevention services, non-condom use with last client, and sexual relationship with a non-client romantic partner. Among PWID, risk factors for self-reported STI included living in Nampula/Nacala, access to HIV prevention services, and sex work.

CONCLUSION

The high-burden of STIs among survey participants requires integrated HIV and STI prevention, treatment, and harm reduction services that address overlapping risk behaviours, especially injection drug use and sex work. A robust public health response requires the creation of a national STI surveillance system for better screening and diagnostic procedures within these vulnerable populations.

HIV and Other Sexually Transmitted Infections Among Female Sex Workers in Iran: A Systematic Review and Meta-Analysis

Given the high burden of HIV and other sexually transmitted infections (STIs) among female sex workers (FSW) and their potential role in bridging HIV/STIs into the general population, estimating the prevalence of HIV/STIs among FSW is essential for future research and policy developments. This systematic review and meta-analysis synthesize the available HIV/STIs data among FSW in Iran. We searched MEDLINE, PsycINFO, CINAHL, Embase, Web of Science, Google Scholar, and Iranian databases from inception through to January 2018. Inclusion criteria were original quantitative studies that measured HIV/STIs prevalence among FSW. Pooled prevalence estimates were calculated using random-effects meta-analyses. Out of a total of 299 screened studies, 12 were included with total study participants of 4328 FSW. Heterogeneity was present but meta-regression analyses revealed no significant association between HIV prevalence and year of publication, city, and age. Pooled HIV prevalence was 2.23% (95% confidence interval [CI] 0.82, 3.64). We estimated the prevalence of other STIs as 0.77% (95% CI 0.01, 1.53) for hepatitis B, 6.18% (95% CI 1.32, 11.04) for hepatitis C, 0.33% (95% CI 0.00, 0.66) for syphilis, 1.47% (95% CI 0.22, 2.71) for gonorrhea, 9.80% (95% CI 4.70, 14.91) for chlamydia, and 6.18% (95% CI 4.92, 7.43) for trichomonas vaginalis. Based on the existing evidence, HIV and STIs prevalence among FSW are relatively low in Iran. Strategies for timely diagnosis and treatment of HIV and other STIs among FSW and their sexual and injecting partners are needed to reduce the burden of HIV/STIs among these vulnerable populations in Iran.

Sustaining consistent condom use among female sex workers by addressing their vulnerabilities and strengthening community-led organizations in India

Introduction

Between 2014 and 2017, a program aimed at reducing HIV risk and promoting safe sex through consistent use of condoms sought to work through addressing social and economic vulnerabilities and strengthening community-led organizations (COs) of female sex workers (FSWs). This study examines if the program was effective by studying relationship between strengthening of COs, vulnerability reduction, and sustaining of consistent condom use behavior among FSWs.

Methods

We used a longitudinal study design to assess the change in outcomes. A three-stage sampling design was used to select FSWs for the study. Panel data of 2085 FSWs selected from 38 COs across five states of India was used to examine the change in various outcomes from 2015 (Survey Round 1) to 2017 (Survey Round 2). The CO level program pillar measuring institutional development assessed performance of COs in six domains critical for any organization’s functionality and sustainability: governance, project management, financial management, program monitoring, advocacy and networking, and resource mobilization. Overall, 32 indicators from all these domains were used to compute the CO strength score. A score was computed by taking mean of average dimension scores. The overall score was divided into two groups based on the median cutoff; COs which scored below the median were considered to have low CO strength, while COs which scored above or equal to median were considered to have high CO strength. Multivariable regression modeling techniques were used to examine the effect of program pillars on outcome measures.

Results

Analyses showed a significant improvement in the strength of the COs over time; percentage of COs having high strength improved from 50% in 2015 to 87% in Round 2. The improvement in CO’s strength increased financial security (Adjusted Odds Ratio [AOR]: 2.18, p<0.01), social welfare security (AOR: 1.71, p<0.01), and socio-legal security (AOR: 2.20, p<0.01) among FSWs. Further, improvement in financial security led to significant increase in consistent condom use with client among FSWs (AOR: 1.69, p<0.01) who were members of COs having high strength. Sustained consistent condom use was positively associated with young age (<30 years), ability to negotiate with clients for condom use, membership in self-help groups, high self-efficacy, self-confidence, and client solicitation in streets and brothels.

Conclusions

Improving financial security and strengthening FSW led CO can improve sustained and consistent condom use. In addition, the program should focus on enhancing ability of FSWs to negotiate with clients for condom use, promote membership in self-help groups and target FSWs who are 30 years or older, and soliciting from homes to sustain consistent condom use across all FSWs.

Structural vulnerabilities and HIV risk among sexual minority female sex workers (SM-FSW) by identity and behavior in Baltimore, MD

BACKGROUND

Research suggests sexual minority female sex workers (SM-FSW) face elevated structural vulnerability and HIV risk compared to their heterosexual counterparts. Structural vulnerabilities reflect societal level factors (e.g., sexism, homophobia, racism) that constrain an individual's agency, particularly related to health outcomes. This study examines the association between SM status by identity and behavior, structural vulnerability, and HIV risk among a sample of street-based FSW.

METHODS

The current study utilizes baseline data from the SAPPHIRE study, a prospective cohort of cis gender and transgender FSW in Baltimore, MD, recruited through targeted time-location sampling from April 2016 to January 2017. The current analysis focuses on cisgender women. The baseline survey ascertained demographics, substance use, intimate partner violence (IPV), and sex work characteristics. Multivariable models were constructed using self-identity and behaviorally defined SM status as independent variables with vulnerability outcomes (e.g., injection drug use, injection speedball, binge drinking, homelessness, physical IPV, ever had a pimp, and being a minor at sex work entry (age < 18)) as dependent variables.

RESULTS

Of the participants (n = 247), 25.5% (n = 63) self-identified as a SM by identity (e.g., gay or bisexual), and 8.5% (n = 21) reported SM behavior (e.g., same-gender sexual behavior) in the past 3 months. In multivariable logistic regression models, SM status by identity was associated with increased odds of injection drug use, binge drinking, homelessness, physical IPV, and being a minor at sex work entry. SM status by behavior was associated with increased odds of binge drinking, homelessness, ever having a pimp, and being a minor at sex work entry.

CONCLUSION

The study indicates disproportionate structural vulnerability and heightened HIV risk among SM-FSW, as compared to their heterosexual counterparts, with differences in their profile by sexual identity and behavior. Findings suggest a need for nuanced interventions tailored to these populations.

The HIV care continuum and HIV-1 drug resistance among female sex workers: a key population in Guinea-Bissau

INTRODUCTION

Female sex workers (FSW) are considered a key group for HIV transmissions in sub-Saharan Africa. The HIV Care Continuum and HIV drug resistance (HIVDR) among FSW has not been well studied in most countries in West Africa. In the current study we describe the HIV Care continuum and prevalence of HIVDR among FSW in Guinea-Bissau.

METHODS

A venue-based recruitment and peer-referral of FSW was used in seven cities in Guinea-Bissau from October 2014 to September 2017. We administered a questionnaire, performed discriminatory HIV-testing and collected blood specimens for CD4 count, viral load and HIVDR genotyping.

RESULTS

The survey included 440 FSW. The overall HIV-prevalence among FSW was 26.8%. Of the HIV-1 (HIV-1 single- or dually HIV-1/HIV-2) infected FSW (N = 104), 58.7% were previously diagnosed with HIV-1 at enrolment and 41.4% reported taking antiretroviral therapy (ART) compared to 28.6% of the HIV-2 single-infected FSW (N = 14). Among HIV-1 infected FSW on ART (N = 43), 55.8% were virally suppressed (< 1000 copies/ml) and of all HIV-1 infected FSW, 29.8% were virally suppressed. Among ART experienced FSW (N = 22), 50.0% had HIVDR. HIVDR was also found in 9.4% of treatment naïve FSW (N = 53).

CONCLUSION

The majority of FSW who knew their HIV status received ART, however a large proportion of FSW were not aware of their HIV positive status. This translated into a great majority of the HIV-infected FSW not being virally suppressed. Amongst treatment naïve FSW nearly a tenth had HIVDR, suggesting that sexual transmission of HIVDR is occurring in this at-risk-population.

Adverse childhood experiences and propensity to participate in the commercialized sex market

BACKGROUND

Previous research has tied adverse childhood experiences (ACEs) to a variety of deleterious mental health, physical, and behavioral outcomes. There has been some examination of the relationship between ACEs and selling sexual services, but not on the relation of ACEs to purchasing.

OBJECTIVE

We hypothesize a cumulative impact of ACEs on the propensity to purchase and buy and sell sex. We further hypothesize that childhood sexual abuse will have unique impacts on buying and selling.

PARTICIPANTS & SETTING

We recruited participants who had ever/never exchanged money or things of values for sex through Amazon MTurk (n = 930).

METHODS

Using logistic regression, we examined how cumulative ACEs and each separate ACE increased propensity to buy or sell sex. We controlled for sex, age, race, employment status, and sexuality.

RESULTS

Utilizing the analysis from cumulative ACEs found that the propensity to buy (odds ratio 1.11***) and sell sex (odds ratio 1.094**) increased as cumulative ACE score increased. Bisexuals had high propensity of both buying (odds ratio 2.12) and selling sex (odds ratio 2.74). Women (odds ratio 0.53) and people of color (odds ratio 0.65) where more likely to sell than others. For odds of buying sex, childhood sexual abuse (odds ratio 1.57) had the most impact. For selling sex, childhood sexual abuse (odds ratio 1.96) and household physical violence (odds ratio 2.73) increased propensity while household mental abuse (odds ratio 0.57) decreased propensity.

CONCLUSIONS

Understanding the impact of ACEs is important to understand participation as a buyer and seller in the commercialized sex market.

Low program access despite high burden of sexual, structural, and reproductive health vulnerabilities among young women who sell sex in Mombasa, Kenya

BACKGROUND

Across Sub-Saharan Africa, young women who sell sex (YSW) face institutional barriers in accessing sexual health and HIV prevention programs designed for female sex workers. In 2018, Kenya developed a national framework to guide service provision for YSW aged 14-24 years. To help inform the implementation of the framework, we estimated the burden of vulnerabilities related to the Sustainable Development Goals (SDGs related to health and gender equality) and program contact among YSW.

METHODS

We used data from Transitions, a 2015 bio-behavioural cross-sectional survey of 408 YSW aged 14-24 years in Mombasa, Kenya. We estimated the prevalence of sexual (inconsistent condom use), structural (financial, violence), and reproductive health vulnerabilities; and characterized engagement with local HIV programs tailored to sex workers. We then compared the prevalence of vulnerabilities by age group (14-18 years, N = 117; 19-24 years, N = 291) and by program contact (ever contacted by local program for sex workers).

RESULTS

47.3% reported inconsistent condom use with any partner in the previous week (no difference by age-group, p = 1.00). Structural vulnerabilities were common and did not vary by age: 83.6% did not have a regular source of income; 29.9 and 29.2% had experienced physical and sexual violence, respectively. 26.5% reported at least one pregnancy before age 18, and 18.5% used a non-reliable form of contraception with little variability by age. 25.7% were aware of at least one program, and only 13.7% of YSW had ever been contacted by a program (8.5% of those aged 14-18 years; and 15.8% of those aged 19-24 years, p = 0.06). Sexual, structural, and reproductive health vulnerabilities did not vary by program contact.

CONCLUSIONS

SDG-related vulnerabilities begin early in the lives of YSW who are not currently reached by programs designed for female sex workers.

Confidential, accessible point-of-care sexual health services to support the participation of key populations in biobehavioural surveys: Lessons for Papua New Guinea and other settings where reach of key populations is limited

To achieve the UNAIDS 90-90-90 targets at a national level, many countries must accelerate service coverage among key populations. To do this, key population programs have adopted methods similar to those used in respondent-driven sampling (RDS) to expand reach. A deeper understanding of factors from RDS surveys that enhance health service engagement can improve key population programs. To understand the in-depth lives of key populations, acceptance of expanded point-of-care biological testing and determine drivers of participation in RDS surveys, we conducted semi-structured interviews with 111 key population participants (12-65 years) were purposefully selected from six biobehavioral surveys (BBS) in three cities in Papua New Guinea. Key populations were female sex workers, men who have sex with men, and transgender women. Four reasons motivated individuals to participate in the BBS: peer referrals; private, confidential, and stigma-free study facilities; "one-stop shop" services that provided multiple tests and with same-day results, sexually transmitted infection treatment, and referrals; and the desire to know ones' health status. Biobehavioral surveys, and programs offering key population services can incorporate the approach we used to facilitate key population engagement in the HIV cascade.

Contributors to posttraumatic stress symptoms in women sex workers

Previous research has demonstrated that women who sell sex (women sex workers [WSWs]) consistently report high levels of posttraumatic stress symptoms. The present study explores multiple factors that may contribute to the variation in WSWs' experiences of posttraumatic stress symptoms, including workers' racial identity, experiences of discrimination and control over their working conditions, the site of selling sex, and their clients' perceived sexual entitlement and violence. The study sample consisted of 314 self-identified WSWs. Online invitations to participate in a 30-min survey were sent to WSWs in the United States and Canada who advertise their services online on sites such as Facebook, the Erotic Review, and Backpages. The hypothesized structure of associations between the variables was tested using structural equation modeling. The model accounted for 68% of the variation in the traumatic stress reported, with direct and indirect effects for workers' racial identity, the site where they sell sex, and experiences of discrimination, especially by police. Clients' violence, on the contrary, was indirectly associated with traumatic stress, as violent clients were also significantly more likely to be perceived as sexually entitled, which, in turn, was the strongest predictor of higher traumatic stress. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Perceived barriers to pre-exposure prophylaxis use and the role of syndemic factors among female sex workers in the Mexico-United States border region: a latent class analysis

Female sex workers (FSWs) experience syndemic factors (e.g., polydrug use, hazardous alcohol consumption, client-perpetrated violence, depression, and sexually transmitted infections) that often heighten vulnerability to HIV and limit healthcare utilization. We hypothesized that syndemic factors will limit FSWs' uptake of pre-exposure prophylaxis (PrEP). From 2016 to 2017, 295 HIV-negative FSWs were enrolled in a behavioral HIV prevention trial in Tijuana and Ciudad Juarez, Mexico, underwent STI testing, and completed surveys on syndemic factors and perceived barriers to PrEP use. Syndemic scores (0-5) were calculated by summing syndemic factors. Latent class analysis (LCA) was used to identify homogeneous classes with respect to perceived barriers to PrEP use. We identified four classes: (1) perceived healthcare access barriers (8.3%), (2) perceived financial barriers (18.7%), (3) high level of perceived barriers (19.9%), and (4) low level of perceived barriers (53.0%) to PrEP use. Those experiencing three (adjusted odds ratio [aOR] = 3.63, 95% confidence interval [CI] = 1.24-10.67) and four or five (aOR = 6.30, 95% CI = 1.70-23.35) syndemic factors had a higher odds of membership in the class characterized by a high level of perceived barriers than in the class characterized by a low level of perceived barriers. Addressing syndemic factors may maximize PrEP's impact among FSWs along Mexico's northern border.

Prevalence and factors associated with psychological distress among key populations in Togo, 2017

OBJECTIVES

Mental health is a largely neglected issue among in Sub-Saharan Africa, especially among key populations at risk for HIV. The aim of this study was to estimate the prevalence of psychological distress (PD) and to assess the factors associated among males who have sex with males (MSM), female sex workers (FSW) and drug users (DU) in Togo in 2017.

STUDY DESIGN

A cross-sectional bio-behavioral study was conducted in August and September 2017 using a respondent-driven sampling (RDS) method, in eight cities in Togo.

METHODS

A standardized questionnaire was used to record sociodemographic characteristics and sexual behaviors. The Alcohol Use Disorders Identification Test (AUDIT) and a subset of questions from the Tobacco Questions for Survey were used to assess alcohol and tobacco consumption respectively. PD was assessed with the Kessler Psychological Distress Scale. A blood sample was taken to test for HIV. Descriptive statistics, univariable and multivariable ordinal regression models were used for analysis.

RESULTS

A total of 2044 key populations including 449 DU, 952 FSW and 643 MSM with a median age of 25 years, interquartile range (IQR) [21-32] were recruited. The overall prevalence of mild PD among the three populations was 19.9% (95%CI = [18.3-21.8]) and was 19.2% (95%CI = [17.5-20.9]) for severe/moderate PD. HIV prevalence was 13.7% (95%CI = [12.2-15.2]). High age (≥ 25 years) [aOR = 1.24 (95% CI: 1.02-1.50)], being HIV positive [aOR = 1.80 (95% CI: 1.31-2.48)] and hazardous alcohol consumption [aOR = 1.52 (95% CI: 1.22-1.87)] were risk factors for PD. Secondary [aOR = 0.52 (95% CI: 0.42-0.64)] or higher [aOR = 0.46 (95% CI: 0.32-0.64)] education levels were protective factors associated with PD. FSW [OR = 0.55 (95% CI: 0.43-0.68)] and MSM [OR = 0.33 (95% CI: 0.24-0.44)] were less likely to report PD compared with DU.

CONCLUSION AND RECOMMENDATIONS

This is the first study conducted among a large, nationally representative sample of key populations in Togo. The prevalence of PD is high among these populations in Togo and was associated to HIV infection. The present study indicates that mental health care must be integrated within health programs in Togo with a special focus to key populations through interventions such as social support groups.

Uptake, engagement, and adherence to pre-exposure prophylaxis offered after population HIV testing in rural Kenya and Uganda: 72-week interim analysis of observational data from the SEARCH study

BACKGROUND

Optimal strategies for pre-exposure prophylaxis (PrEP) engagement in generalised HIV epidemics are unknown. We aimed to assess PrEP uptake and engagement after population-level HIV testing and universal PrEP access to characterise gaps in the PrEP cascade in rural Kenya and Uganda.

METHODS

We did a 72-week interim analysis of observational data from the ongoing SEARCH (Sustainable East Africa Research in Community Health) study. Following community sensitisation and PrEP education, we did HIV testing and offered PrEP at health fairs and facilities in 16 rural communities in western Kenya, eastern Uganda, and western Uganda. We provided enhanced PrEP counselling to individuals 15 years and older who were assessed as having an elevated HIV risk on the basis of serodifferent partnership or empirical risk score, or who otherwise self-identified as being at high risk but were not in serodifferent partnerships or identified by the risk score. PrEP follow-up visits were done at facilities, homes, or community locations. We assessed PrEP uptake within 90 days of HIV testing, programme engagement (follow-up visit attendance at week 4, week 12, and every 12 weeks thereafter), refills, self-reported adherence up to 72 weeks, and concentrations of tenofovir in hair samples from individuals reporting HIV risk and adherence during follow-up, and analysed factors associated with uptake and adherence. This study is registered with ClinicalTrials.gov, NCT01864603.

FINDINGS

Between June 6, 2016, and June 23, 2017, 70 379 community residents 15 years or older who had not previously been diagnosed with HIV were tested during population-level HIV testing. Of these individuals, 69 121 tested HIV-negative, 12 935 of whom had elevated HIV risk (1353 [10%] serodifferent partnership, 6938 [54%] risk score, 4644 [36%] otherwise self-identified risk). 3489 (27%) initiated PrEP, 2865 (82%) of whom did so on the same day as HIV testing and 1733 (50%) of whom were men. PrEP uptake was lower among individuals aged 15-24 years (adjusted odds ratio 0·55, 95% CI 0·45-0·68) and mobile individuals (0·61, 0·41-0·91). At week 4, among 3466 individuals who initiated PrEP and did not withdraw or die before the first visit, 2215 (64%) were engaged in the programme, 1701 (49%) received medication refills, and 1388 (40%) self-reported adherence. At week 72, 1832 (56%) of 3274 were engaged, 1070 (33%) received a refill, and 900 (27%) self-reported adherence. Among participants reporting HIV risk at weeks 4-72, refills (89-93%) and self-reported adherence (70-76%) were high. Among sampled participants self-reporting adherence at week 24, the proportion with tenofovir concentrations in the hair reflecting at least four doses taken per week was 66%, and reflecting seven doses per week was 44%. Participants who stopped PrEP accepted HIV testing at 4274 (83%) of 5140 subsequent visits; half of these participants later restarted PrEP. 29 participants of 3489 who initiated PrEP had serious adverse events, including seven deaths. Five adverse events (all grade 3) were assessed as being possibly related to the study drug.

INTERPRETATION

During population-level HIV testing, inclusive risk assessment (combining serodifferent partnership, an empirical risk score, and self-identification of HIV risk) was feasible and identified individuals who could benefit from PrEP. The biggest gap in the PrEP cascade was PrEP uptake, particularly for young and mobile individuals. Participants who initiated PrEP and had perceived HIV risk during follow-up reported taking PrEP, but one-third had drug concentrations consistent with poor adherence, highlighting the need for novel approaches and long-acting formulations as PrEP roll-out expands.

FUNDING

National Institutes of Health, President's Emergency Plan for AIDS Relief, Bill & Melinda Gates Foundation, and Gilead Sciences.

The epidemiology of Hepatitis B, C and D in Germany: A scoping review

BACKGROUND

Germany is considered to be a low prevalence country for viral Hepatitis B, C and D (HBV, HCV, HDV). However, the burden of disease can be high among subpopulations. To meet the world Health Organization (WHO) viral hepatitis (VH) elimination goals, a national strategy was developed by the German government in 2016. We performed a scoping review to understand the baseline epidemiological situation in Germany regarding burden of disease, sequelae and care of HBV, HCV and HDV as a reference to monitor the progress of the national VH elimination and to identify further knowledge gaps and research needs.

METHODS

The protocol of the systematic review was prepared following the PRISMA statement guidelines for scoping reviews. Relevant search terms were used to identify eligible studies according to the research questions. We searched six online databases for original work published between January 2005 and March 2017. Based on the identified references, a matrix was developed presenting the eligible literature by targeted population group and outcome category.

RESULTS

104 publications were eligible for extraction covering 299 outcome results. The population groups targeted in the identified studies included the general population and proxy populations, a range of clinical populations, people who inject drugs, men who have sex with men, healthcare workers, people in prisons and different migrant/mobile populations. Other vulnerable populations (e.g. sex workers) were not targeted. Overall, good evidence was found for HBV and HCV prevalence and HBV vaccination coverage in the GP and proxy populations. Evidence for these outcomes was weaker in populations at risk for VH. For HBV and HCV incidence and mortality, we identified large evidence gaps in all population groups. Outcomes on VH sequelae and care were mainly covered by studies in clinical populations of people living with viral hepatitis. For HDV the overall evidence available was scarce.

CONCLUSIONS

We created a comprehensive evidence-based overview on the current epidemiological situation of viral hepatitis in Germany. We identified knowledge gaps for further research and established a baseline for future monitoring of viral hepatitis elimination goals in Germany.

[Screening of Human Immunodeficiency Virus and Other Sexually Transmitted Infections in a Group of Sex Workers in Indoor Settings in the Porto Metropolitan Area]

INTRODUCTION

Early diagnosis is a crucial tool for containing the human immunodeficiency virus and other sexually transmitted infections, particularly in key populations such as sex workers. Despite its relevance, there is a gap considering epidemiological studies and interventions aimed at the monitoring and diagnosis of sexually transmitted infections in Portugal. The objectives of this study are: (i) to contribute to a better understanding of the epidemiology of sexually transmitted infections; and (ii) to evaluate the transfer of screening methods from clinical settings to the outreach context in hidden populations such as sex workers.

MATERIAL AND METHODS

The screening of sexually transmitted infections (human immunodeficiency virus 1/2, hepatitis B virus, hepatitis C virus, syphilis, chlamydia and gonorrhea) were carried out in a sample of 100 sex workers during the Porto G outreach intervention in the Metropolitan area of Porto, from September 2015 to September 2016.

RESULTS

Six reactive cases for human immunodeficiency virus were identified, five of syphilis, eight of chlamydia and two of gonorrhea. No positive results were detected for hepatitis B virus and hepatitis C virus. The results were discussed considering the risk gradient and sexually transmitted infections vulnerability in the different sex workers' subgroups.

DISCUSSION

The results of this study corroborate the need to promote comprehensive responses to populations most affected by the human immunodeficiency virus and other sexually transmitted infections, such as sex workers. Also, in this group, men who have sex with men and trans women have a higher prevalence than cis women. Intervention strategies should be informed by rigorous epidemiological studies.

CONCLUSION

The adaptation of the screening methodology performed in a clinical setting to the proximity context has shown to be an innovative response in Portugal, especially in sentinel populations.

Comparison between prostitutes' and general women's homicides: The experience of the bureau of legal medicine of Milan and Hinterland over 26 years

We present a retrospective study of prostitutes' homicide in the Milanese area over a 26-year period (1993-2018), and compare the results with general women's homicides: 294 women were killed of whom 71 were prostitutes. In the general population, the type-victim is an Italian woman aged between 31 and 40 years suffering from no particular pathologies or drug dependence. Prostitutes are 10 years younger, mostly Italian, suffering from pathologies probably related to their activities. Prostitutes remain at high risk of violence, due to gaps in the crime prevention system.

What Proportion of Female Sex Workers Practise anal Intercourse and How Frequently? A Systematic Review and Meta-analysis

HIV is more efficiently acquired during receptive anal intercourse (AI) compared to vaginal intercourse (VI) and may contribute substantially to female sex workers' (FSW) high HIV burden. We aim to determine how common and frequent AI is among FSW globally. We searched PubMed, Embase and PsycINFO for studies reporting the proportion of FSW practising AI (prevalence) and/or the number of AI acts (frequency) worldwide from 01/1980 to 10/2018. We assessed the influence of participant and study characteristics on AI prevalence (e.g. continent, study year and interview method) through sub-group analysis. Of 15,830 identified studies, 131 were included. Nearly all (N = 128) reported AI prevalence and few frequency (N = 13), over various recall periods. Most studies used face-to-face interviews (N = 111). Pooled prevalences varied little by recall period (lifetime: 15.7% 95%CI 12.2-19.3%, N = 30, I2 = 99%; past month: 16.2% 95%CI 10.8-21.6%, N = 18, I2 = 99%). The pooled proportion of FSW reporting < 100% condom use tended to be non-significantly higher during AI compared to during VI (e.g. any unprotected VI: 19.1% 95%CI 1.7-36.4, N = 5 and any unprotected AI: 46.4% 95%CI 9.1-83.6, N = 5 in the past week). Across all study participants, between 2.4 and 15.9% (N = 6) of all intercourse acts (AI and VI) were anal. Neither AI prevalence nor frequency varied substantially by any participant or study characteristics. Although varied, AI among FSW is generally common, inconsistently protected with condoms and practiced sufficiently frequently to contribute substantially to HIV acquisition in this risk group. Interventions to address barriers to condom use are needed.

Sex counts: An examination of sexual service advertisements in a UK online directory

Internationally, sex work research, public opinion, policy, laws, and practice are predicated on the assumption that commercial sex is a priori sold by women and bought by men. Scarce attention has been devoted to lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ) sex working as well as women who pay for sex. This is as much an empirical absence as it is a theoretical one, for the ideological claim that women comprise the "vast majority" of sex workers is rarely, if ever, exposed to empirical scrutiny. Focusing on the UK, we address this major gap in evidence in order to challenge the gendered and heterosexist logics that underpin contemporary debates. We do so by presenting large-scale data gained from the quantitative analysis of 25,511 registered member profiles of an online escort directory. Our findings point to heterogeneity rather than homogeneity in the contemporary sex industry including in terms of gender identity, sexual orientation, and advertised client base. For example, while two-thirds of advertisements self-identify as "Female," one in four are listed as "Male;" less than half list their sexual orientation as "Straight;" and nearly two-thirds advertise to women clients. Our study thus challenges prevailing heteronormative assumptions about commercial sex, which erase LGBTQ sex workers and other non-normative identities and practices, and which we argue have important political, practical, and theoretical consequences.

Urban gentrification and declining access to HIV/STI, sexual health, and outreach services amongst women sex workers between 2010-2014: Results of a community-based longitudinal cohort

Despite increasing gentrification across North American cities, little is known about impacts on work and living environments and health access for marginalized women. Drawing upon prospective cohort and external spatial data, we examined changes in land use and sex workers' work/living environments in relation to gentrification exposure in Metro Vancouver (2010-2014), and modeled independent effects of gentrification exposure on reduced utilization of HIV/STI testing, sexual health, and sex worker support services. These decreases occurred despite efforts to scale-up HIV services for marginalized populations. Planning of healthcare, housing, and other support services should be responsive to shifting urban landscapes for marginalized women.

Exploring the Association Between Mobility and Access to HIV Services Among Female Sex Workers in Zimbabwe

Female sex workers (FSW) face structural barriers to HIV-service access, however the effect of their mobility is uncertain. Using cross-sectional data from 2839 FSW in 14 sites in Zimbabwe, we explored the association between mobility (number of trips, distance, duration) in the past 12 months and five HIV-service-access outcomes: exposure to community mobilisation, clinic attendance, HIV testing, antiretroviral treatment initiation, and viral suppression (< 1000 copies per mL). We used modified-Poisson regression, and natural-effects models to estimate how the effect of trip frequency was mediated by distance and duration away. Each additional trip in 12 months was associated with increased community-mobilisation-event attendance (adjusted RR 1.08, 95% CI 1.04-1.12) and attending clinic two-or-more times (adjusted RR 1.02, 95% CI 1.00-1.05). There was little evidence of any other associations, or of mediation. Our findings are consistent with literature that found the effects of mobility to vary by context and outcome. This is the first study to consider many FSW-mobility and HIV-service-access measures together. Future research on mobility and health-related behaviour should use a spectrum of measures.