Stigmatizing and inaccessible: The perspectives of female sex workers on barriers to reproductive healthcare utilization - A scoping review

AIM

To systematically map the extent, range and nature of qualitative studies that explored female sex workers' own perspectives on barriers to accessing reproductive healthcare services.

DESIGN

A scoping review of the literature utilizing Arksey and O'Malley's method.

DATA SOURCES/REVIEW METHODS

A search of the electronic databases MEDLINE/ PubMed, PsycNET, Sociological Abstracts, ProQuest, ScienceDirect, HeinOnline, Scopus, Web of Science and Google Scholar was conducted for items published in English between 2001 and 2021.

RESULTS

Twenty-one studies were included in the review, the majority of which were conducted in lower-middle-income countries. RHC themes studied were diverse, with a few more studies focusing on STI/HIV, contraceptive use and pregnancy than those focusing on childbirth and postnatal care. The findings indicate barriers in four main domains: socio-legal barriers, health services-related barriers, interpersonal barriers and personal history-related barriers. Stigma was a major multifaceted barrier.

CONCLUSION

Female sex workers experience exclusion in utilizing reproductive healthcare services globally. As such, healthcare services are advised to adopt a nonjudgemental approach, to enhance physical accessibility and to train nurses and other healthcare professionals on reproductive health needs of female sex workers. Finally, knowledge production processes on the RHC of FSW should adopt a holistic view of FSW, by exploring their needs and barriers related to childbirth and maternity care and by including the perspectives of FSW in high-income countries.

IMPACT

The review offered an in-depth understanding of female sex workers' own perspectives regarding needs and barriers in utilizing reproductive healthcare services. Findings indicated socio-legal barriers, health services-related barriers, interpersonal barriers and personal history-related barriers. The review could inform the training of nurses and other healthcare professionals in reproductive healthcare services globally. Researchers should adopt a holistic view of female sex workers, by exploring their family planning needs, including barriers related to childbirth, maternity and postpartum care.

REPORTING METHOD

We adhered to the EQUATOR guidelines PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation.

Understanding Risk Factors for Oropharyngeal Gonorrhea Among Sex Workers Attending Sexual Health Clinics in 2 Australian Cities: Mixed Methods Study

BACKGROUND

The risk factors for oropharyngeal gonorrhea have not been examined in sex workers despite the increasing prevalence of gonorrhea infection.

OBJECTIVE

This study aims to determine the risk factors for oropharyngeal gonorrhea in female and gender-diverse sex workers (including cisgender and transgender women, nonbinary and gender fluid sex workers, and those with a different identity) and examine kissing, oral sex, and mouthwash practices with clients.

METHODS

This mixed methods case-control study was conducted from 2018 to 2020 at 2 sexual health clinics in Melbourne, Victoria, and Sydney, New South Wales, Australia. We recruited 83 sex workers diagnosed with oropharyngeal gonorrhea (cases) and 581 sex workers without (controls). Semistructured interviews with 19 sex workers from Melbourne were conducted.

RESULTS

In the case-control study, the median age of 664 sex workers was 30 (IQR 25-36) years. Almost 30% of sex workers (192/664, 28.9%) reported performing condomless fellatio on clients. Performing condomless fellatio with clients was the only behavior associated with oropharyngeal gonorrhea (adjusted odds ratio 3.6, 95% CI 1.7-7.6; P=.001). Most participants (521/664, 78.5%) used mouthwash frequently. In the qualitative study, almost all sex workers reported kissing clients due to demand and generally reported following clients' lead with regard to kissing style and duration. However, they used condoms for fellatio because they considered it a risky practice for contracting sexually transmitted infections, unlike cunnilingus without a dental dam.

CONCLUSIONS

Our study shows that condomless fellatio is a risk factor for oropharyngeal gonorrhea among sex workers despite most sex workers using condoms with their clients for fellatio. Novel interventions, particularly targeting the oropharynx, will be required for oropharyngeal gonorrhea prevention.

Violence suffered by Venezuelan immigrant female sex workers: an intersectional view

OBJECTIVE

To characterize and analyze violence committed against Venezuelan immigrant female sex workers, from the perspective of an intersectional look at social class, gender and race-ethnicity.

METHOD

Exploratory study with a qualitative approach. Data sources: interviews with 15 Venezuelan immigrant women sex workers and 37 Brazilian online media reports that addressed the topic. Data were submitted to thematic content analysis, with the support of Qualitative Data Analysis (WebQDA) software.

RESULTS

Thematic analysis of data from reports and interviews allowed the emergence of three empirical categories: Structural violence and reasons that led to prostitution: a question of social class; Among the forms of violence, the most feared: physical violence; Violence based on gender and race-ethnicity.

CONCLUSION

The study made it possible to recognize that Venezuelan immigrant women who are sex workers in Brazil are subject to different types of violence and exploitation. This scenario is due to a reality of life and work that is based on the exploitation of female workers who experience the consequences of the interweaving of subalternities characteristic of their social insertion of class, gender and race-ethnicity.

Determinants of depressive and alcohol use disorders among female sex workers in Ethiopia: evidence from a national bio-behavioral survey, 2020

BACKGROUND

Female sex workers (FSWs) face an elevated risk of developing mental health disorders and alcohol use disorders (AUD), which in turn increase their vulnerability to HIV and other sexually transmitted infections (STIs) and other negative outcomes. To effectively address both of these health issues, it is crucial to understand the shared key determinants underlying these illnesses, which is a substantial knowledge gap in Ethiopia and elsewhere in the world. Therefore, this study aimed to identify the common key determinants of depression and AUD among FSWs in Ethiopia using a bivariate multivariable ordinal logistic model.

METHODS

We analyzed cross-sectional biobehavioral data collected in 2020 from 16 cities and major towns in Ethiopia using the respondent-driven sampling (RDS) technique, which involved a total of 6,085 FSWs. FSWs who had lived at the study sites for at least a month before the study period were deemed eligible for recruitment. Major depressive disorder (DD) and AUD were screened using the Patient Health Questionnaire (PHQ9) and alcohol use disorder identification test (AUDIT), respectively. We used descriptive statistics to summarize study population characteristics and bivariate multivariable ordinal logistic regression (BMOLR) to identify common determinants of DD and AUD combined and their nonnormal correlation.

RESULTS

Among 6085 FSWs screened for DD and AUD, 13.5% and 4.0% have met the criteria for moderate and severe depressive disorder, respectively, and 20.3% and 34.7% have met the AUDIT criteria for harmful or hazardous behavior and alcohol dependence, respectively. FSW with experience of inconsistent condom use, condom failure, violence, mobility, use of any drugs, non-paying partners, abortion, and selling sex for more than five years were associated with an increase in the severity of both disorders. A high average income from selling sex and the number of paying partners reduced the severity of depression and increased the level of alcohol dependence. Being HIV positive and ever having anal sex were associated only with an increase in depression.

CONCLUSION

Major DD and AUD are prevalent among FSWs in Ethiopia. The findings revealed that common key determinants, which exacerbated the severity of both disorders, were also risk factors for HIV and other STIs. Consequently, integrated STI strategies are essential in the screening, referral, and treatment of depression and AUD. Intervention packages should encompass determinants of depression and AUD, including condom utilization, drug use, mobility between towns, abortion, violence, and counseling services. Additionally, strategies to ensure economic security should be incorporated.

Costing of a Combination Intervention (Kyaterekera) Addressing Sexual Risk-Taking Behaviors among Vulnerable Women in Southern Uganda

In Uganda, women engaged in sex work (WESW) are a marginalized population at the intersection of multiple vulnerabilities. The Kyaterekera intervention is targeted at WESW in Rakai and the greater Masaka regions in Uganda and combines a traditional HIV risk-reduction approach with a savings-led economic empowerment intervention and financial literacy training. We estimated the economic costs of the Kyaterekera intervention from a program provider perspective using a prospective activity-based micro-costing method. All program activities and resource uses were measured and valued across the control arm receiving a traditional HIV risk-reduction intervention and the treatment arm receiving a matched individual development savings account and financial literacy training on top of HIV risk reduction. The total per-participant cost by arm was adjusted for inflation and discounted at an annual rate of 3% and presented in 2019 US dollars. The total per-participant costs of the control and intervention arms were estimated at $323 and $1,435, respectively, using the per-protocol sample. When calculated based on the intent-to-treat sample, the per-participant costs were reduced to $183 and $588, respectively. The key cost drivers were the capital invested in individual development accounts and personnel and transportation costs for program operations, linked to WESW's higher mobility and the dispersed pattern of hot spot locations. The findings provide evidence of the economic costs of implementing a targeted intervention for this marginalized population in resource-constrained settings and shed light on the scale of potential investment needed to better achieve the health equity goal of HIV prevention strategies.

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.

Transgender migration and displacement: the experience of khwaja sira sex workers in Lahore

This study uses an aspirations-capabilities framework to provide insight into transgender mobility based on in-depth interviews with 30 khwaja sira sex workers in Lahore. Respondents narrated mobility as a defining and persistent feature of their lives linked to their gender variance and experience of everyday violence and discrimination. Mobilities were experienced as oppressive or liberating depending on how much control they provided sex workers within managing risk in their lives. Respondents differentiated between two main forms of mobility: migration and displacement. Descriptions of migration included movement from their family of birth to a khwaja sira community as well as between khwaja sira communities, and entailed both rural-urban and inter-city travel. Unforced migration was associated with resilience as it increased sex workers control over the social environment. Experiences of forced and intra-city movement resulting from everyday interactions with clients and law enforcement agents were seen as displacement. These experiences resulted in enhanced social, physical, and occupational vulnerability and decreased khwaja sira sex workers' control over their social environment.

Transgender women sex workers' experiences accessing sexual health care in Iran: a qualitative study

BACKGROUND

This study aimed to examine the experiences of transgender women who work in the sex industry regarding their access to health care facilities for sexual health. Transgender women sex workers are recognised worldwide as a high-risk group for HIV and sexually transmitted infections (STIs).

METHODS

In Iran, between January and May 2022, we employed a snowball sampling technique to recruit a diverse group of 22 transgender women sex workers aged 19-42 years. Semi-structured interviews were conducted with these participants to provide insights into their experiences with accessing sexual health care.

RESULTS

The data was analysed using thematic analysis, revealing four overarching themes: experiences of violence, contextual barriers to health, socioeconomic challenges and HIV/STI risk practices, and 11 sub-themes. The results demonstrate that many participants experienced difficulties in accessing sexual health services due to violence, discrimination, financial difficulties and lack of awareness about STIs.

CONCLUSION

Sex workers face extraordinarily challenging occupational risks, including sexual and physical abuse, mental health issues, and HIV and STIs. Targeted public intervention programs and research for this group are urgently needed. Outreach programs engaging with underserved transgender women sex workers have the potential to enhance access to healthcare services, and contribute to the reduction of HIV transmission rates.

Surviving pandemic control measures: The experiences of female sex workers during COVID-19 in Nairobi, Kenya

At the beginning of the COVID-19 pandemic, the Kenya Ministry of Health instituted movement cessation measures and limits on face-to-face meetings. We explore the ways in which female sex workers (FSWs) in Nairobi were affected by the COVID-19 control measures and the ways they coped with the hardships. Forty-seven women were randomly sampled from the Maisha Fiti study, a longitudinal study of 1003 FSWs accessing sexual reproductive health services in Nairobi for an in-depth qualitative interview 4-5 months into the pandemic. We sought to understand the effects of COVID-19 on their lives. Data were transcribed, translated, and coded inductively. The COVID-19 measures disenfranchised FSWs reducing access to healthcare, decreasing income and increasing sexual, physical, and financial abuse by clients and law enforcement. Due to the customer-facing nature of their work, sex workers were hit hard by the COVID-19 restrictions. FSWs experienced poor mental health and strained interpersonal relationships. To cope they skipped meals, reduced alcohol use and smoking, started small businesses to supplement sex work or relocated to their rural homes. Interventions that ensure continuity of access to health services, prevent exploitation, and ensure the social and economic protection of FSWs during times of economic strain are required.

Prevalence of violence victimisation and poly-victimisation among female sex workers in Haiphong, Viet Nam: A cross-sectional study

This cross-sectional study is the first to describe the prevalence of violence and poly-victimisation among 310 female sex workers (FSWs) who were cisgender in Haiphong, Viet Nam. An adapted version of the WHO-Multi-Country Study on Violence against Women Survey Instrument was administered to assess physical, sexual, economic and emotional forms of violence perpetrated by an intimate partner, paying partner/client, and/or others (e.g. relatives, police, strangers and other FSWs) during adulthood. The ACE-Q scale was administered to assess adverse childhood experiences (ACEs) before age 18 years. Our findings showed that FSWs are exposed to high rates of multiple forms of violence by multiple perpetrators. For any male client-perpetrated violence (CPV), lifetime prevalence was 70.0%, with 12-month prevalence 61.3%. Lifetime prevalence of male intimate partner violence (IPV) was 62.1%, and the 12-month prevalence was 58.2%. Lifetime and prior 12-month prevalence of physical and/or sexual violence by other perpetrators (OPV) was 18.1% and 14.2%, respectively. Sixty-five percent of FSWs reported at least one type of ACE. Overall, 21.6 percent of FSWs reported having experienced all three forms of violence (IPV, CPV and OPV) in their lifetime. Policy and programme recommendations for screening and prevention of violence are needed in this setting.

Trajectories of HIV management among virally suppressed and unsuppressed female sex workers in the Dominican Republic: A comparative qualitative analysis

PURPOSE

Despite suboptimal HIV outcomes among female sex workers (FSW), limited research has been conducted on factors that impact viral suppression among this population. Examining narratives of HIV management, we examined how experiences of diagnosis, treatment initiation, and ongoing care behaviours shaped viral suppression outcomes over time.

METHODS

We conducted 20 in-depth interviews with FSW in Santo Domingo, Dominican Republic. Using narrative and thematic qualitative approaches, we developed analytic summaries and matrices to compare trajectories of managing HIV between suppressed and unsuppressed participants.

RESULTS

Regardless of suppression status, participants described similar narratives of overcoming initial challenges to HIV management through personal resilience and social support. Unsuppressed participants identified more delays in initiating antiretroviral therapy and more lapses in adherence due to less active acceptance of their HIV status and more persistent experiences of economic hardship and HIV stigma.

CONCLUSIONS

We found that individual, interpersonal and structural factors, including stigma and economic precarity, differentiated trajectories towards viral suppression among FSW indicating the importance of multilevel interventions. Improved access to mental health services and social support could promote greater early acceptance of HIV status and progress towards viral suppression among FSW.

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.

50 shades of lockdown: sex workers' hidden world during COVID pandemic

BACKGROUND

The COVID-19 pandemic had a huge impact on psychological health and socioeconomic structures. The consequences of COVID-19 on the physical, psychological, and social spheres have been extensively studied, except for aspects concerning sexuality and sex workers, in terms of physical, social and economic impact, but also as a possible cause for viral transmission.

METHODS

With the intention of counteracting the lack of research, from September 2020 to August 2022, we distributed an anonymous questionnaire to Sex Workers' associations aimed at investigating the impact of the pandemics on sex workers. In the period examined we received and reviewed 147 questionnaires from women, men, and transsexuals.

CONCLUSIONS

The prevention of the viral transmission during a pandemic is of utmost importance but should not be exclusively promoted at the expense of other important prevention initiatives. Safeguarding psycho-physical health of the general population, including effective health educational communications emphasizing the importance of sexual activity in mental and physical health should be part of ongoing health objectives. These approaches need to include sex workers of all genders-particularly racialized and marginalized sex workers-in public health planning and messaging alongside structural interventions. Full decriminalization of sex work and access to workplace protections are key to protecting both sex workers' and clients' health. Sex workers of all genders have often been among the first hit by epidemics and the last to be protected-it is long past time to change that.

Understanding drivers of female sex workers' experiences of external/enacted and internalised stigma: findings from a cross-sectional community-centric national study in South Africa

To deepen our understanding of sex work stigma, and to its drivers and their interrelation, we conducted an analysis using structural equation modelling of the South African National Sex Worker Survey. We enrolled 3005 women in sex work using multi-stage sampling across all South Africa's provinces. Experience of external/enacted and internalised stigma was widespread. Non-partner rape, intimate partner violence and partner controlling behaviour (often expressions of external/enacted stigma) compounded internalised stigma. These experiences of violence, other manifestations of external/enacted stigma and food insecurity, were key drivers of internalised stigma, and often had an impact on mental health. We found that considerable protection against stigma emanated from viewing sex work positively. This resistance to stigma provided opportunities to shift the narrative. Reducing sex workers' exposure to external/enacted stigmatising behaviour, including by enabling more to work indoors, and providing greater protection from partner violence and rape, are critical for better health and well-being. Ending the criminalisation of sex work is foundational for safer working conditions and better health outcomes for sex workers, similarly providing adequately funded mental and physical health and social care through sex work specific programmes.

Invisible and stigmatized: A systematic review of mental health and risk factors among sex workers

INTRODUCTION

Sex work is a common phenomenon, but socially invisible and stigmatized. Due to exposure to work-related risks, sex workers (SWs) are vulnerable to developing health problems. However, little attention has been paid to their mental health. The purpose of this systematic review was to synthesize the existing literature on mental health and to explore risk factors related to psychopathology in sex workers.

METHODS

A systematic review (CRD42021268990) was conducted on the Web of Science, PubMed, Scopus, and PsycInfo for peer reviewer papers published between 2010 and 2022. The Newcastle-Ottawa Scale (NOS) was used to examine the quality of the studies. Of the 527 studies identified, 30 met the inclusion criteria.

RESULTS

Mental health problems were prevalent among sex workers. Depression was the most common mental health problem; however, other psychological problems were also high, including anxiety, substance abuse, and suicidal ideation. Sex workers are exposed to numerous work-related risks, including violence and high-risk sexual behaviors. Despite the high prevalence of mental health problems, SWs often encounter significant barriers to accessing healthcare services.

CONCLUSION

These results suggest the need to focus on preventive measures to promote psychological well-being among sex workers.

Reforming the registration policy of female sex workers in Senegal? Evidence from a discrete choice experiment

Evidence suggests that treating sexually transmitted infections (STIs) amongst female sex workers (FSWs) is a cost-effective strategy to reduce the spread of HIV/AIDS. Senegal is the only African country where sex work is regulated by a public health policy which aims to monitor and routinely treat STIs. The law requires FSWs to be at least 21 years old, register with a health centre and the police, carry an up-to-date registration booklet, attend monthly health check-ups, and test negative for STIs. Despite health and legal benefits of registration, 80% of FSWs in Senegal are not registered. Hence, the potential health benefits of the policy have not materialised. To understand why FSWs do not want to register and to define policy changes that would increase the registration rate of FSWs in Senegal, we designed and implemented a discrete choice experiment (DCE) completed by 241 registered and 273 non-registered FSWs. Participants made choices between a series of hypothetical but realistic registration policy changes. Conditional logit models were used to analyse the DCE data. The results highlighted that confidentiality at the health facility was an important element, registered and non-registered FWs were respectively 26.0 percentage points (pp) and 22.1 pp more likely to prefer a policy that guaranteed confidentiality at the health centre. Similarly, both groups preferred a policy where their health record was only held at the health centre and not with the police. Several interventions to increase FSW registration rate and improve their wellbeing may be implemented without modifying the law. For example, the introduction of psychosocial support in the registration policy package, replacing the registration booklet by a QR code, the use of electronic medical files and the integration of FSWs routine visits with maternal health appointments to increase confidentiality have the potential to encourage registration of FSWs.

A Confounding Discourse Analysis of Vietnamese Sex Workers' Talk in the City of Kaiyuan, China

BACKGROUND

Vietnamese female sex workers (VFSWs) cross the border into Kaiyuan City, Yunnan Province yearly. However, very little is known about both the health and psychological issues VFSWs experience. The objectives of this study were to explore the dominant discourses that emerged from the VFSWs' talk. The interviews occurred between May 2018 and June 2018 with 20 VFSWs who worked in Kaiyuan City, China. The English translated transcripts were analyzed using an eclectic feminist method of discourse analysis. Two discourses emerged. First, "Agency when working in Karaoke Bars and other Indoor Venues", and second, "Negative Impacts on Psychological Well-being and Other Problems from Migration." As for Discourse 1, the VFSWs positioned themselves as having agency over choosing their clientele as well as agency over what they were willing to negotiate with their clients to establish boundaries of their bodies. As for the Discourse 2, while there was a discourse of agency in their work there was also a contrasting, confounding discourse around the negative impact on psychological well-being and reports of stress as a migrant worker. Discourse 1 and Discourse 2 are confounding. When analyzed together, the discourses suggest that the impacts on psychological well-being may be more related to the migrant status of the women, supporting the notion of systemically influenced agency.

Experiences of Sex Workers in Chicago during COVID-19: A Qualitative Study

COVID-19 exacerbated health disparities, financial insecurity, and occupational safety for many within marginalized populations. This study, which took place between 2019 and 2022, aimed to explore the way in which sex workers (n = 36) in Chicago were impacted by COVID-19. We analyzed the transcripts of 36 individual interviews with a diverse group of sex workers using thematic analysis. Five general themes emerged regarding the detrimental impact of COVID-19 on sex workers: (1) the impact of COVID-19 on physical health; (2) the economic impact of COVID-19; (3) the impact of COVID-19 on safety; (4) the impact of COVID-19 on mental health; and (5) adaptive strategies for working during COVID-19. Participants reported that their physical and mental health, economic stability, and safety worsened due to COVID-19 and that adaptive strategies did not serve to improve working conditions. Findings highlight the ways in which sex workers are particularly vulnerable during a public health crisis, such as COVID-19. In response to these findings, targeted resources, an increased access to funding, community-empowered interventions and policy changes are needed to protect the health and safety of sex workers in Chicago.

Conducting Violence and Mental Health Research with Female Sex Workers during the COVID-19 Pandemic: Ethical Considerations, Challenges, and Lessons Learned from the Maisha Fiti Study in Nairobi, Kenya

Conducting violence and mental health research during the COVID-19 pandemic with vulnerable groups such as female sex workers (FSWs) required care to ensure that participants and the research team were not harmed. Potential risks and harm avoidance needed to be considered as well as ensuring data reliability. In March 2020, COVID-19 restrictions were imposed in Kenya during follow-up data collection for the Maisha Fiti study (n = 1003); hence data collection was paused. In June 2020, the study clinic was re-opened after consultations with violence and mental health experts and the FSW community. Between June 2020 and January 2021, data were collected in person and remotely following ethical procedures. A total of 885/1003 (88.2%) FSWs participated in the follow-up behavioural-biological survey and 47/47 (100%) participated in the qualitative in-depth interviews. A total of 26/885 (2.9%) quantitative surveys and 3/47 (6.4%) qualitative interviews were conducted remotely. Researching sensitive topics like sex work, violence, and mental health must guarantee study participants' safety and privacy. Collecting data at the height of COVID-19 was crucial in understanding the relationships between the COVID-19 pandemic, violence against women, and mental health. Relationships established with study participants during the baseline survey-before the pandemic-enabled us to complete data collection. In this paper, we discuss key issues involved in undertaking violence and mental health research with a vulnerable population such as FSWs during a pandemic. Lessons learned could be useful to others researching sensitive topics such as violence and mental health with vulnerable populations.

Impact of the COVID-19 Health Crisis on Trans Women and Cis Men Sex Workers in Spain

The objective of the study was to describe the impact of the COVID-19 pandemic on sex workers in accessing health and social services. A qualitative study was conducted using semi-structured interviews with 29 participants in Barcelona, Spain. Data were analyzed using thematic analysis. Four themes were identified: (1) impact of COVID-19 on physical/mental health, (2) barriers and facilitators to health/social service access, (3) health decision-making, and (4) suggestions for future pandemic situations. Barriers to accessing health services were structural. Non-governmental organization support was the main facilitating factor. A person-centered, intersectional approach is suggested for future practice, considering co-occurring syndemic factors.

Mental health and HIV risk differs by co-occurring structural vulnerabilities among women who sell sex

Female sex workers (FSW) experience many structural vulnerabilities (SV; e.g., violence, economic insecurity) which contribute to increased risk of HIV and mental distress. However, little research has examined how SV co-occur to shape HIV risk, and none have studied mental distress. Among FSW (n = 385) in Baltimore, Maryland, latent class analysis of five binary indicators (housing insecurity; financial dependence on others; client-perpetrated physical or sexual violence; food insecurity) determined classes of SV and differential HIV risk behavior and mental health outcomes. A 3-class model fit the data best: minimal SV (i.e., low probabilities of all indicators); material needs (i.e., housing, food insecurity); and high SV (i.e., high probability of all indicators). Compared to minimal SV, high SV and material needs had significantly greater adjusted probability of drug injection and poorer adjusted depression, post-traumatic stress disorder, and mental distress scores. The high SV class had significantly higher probability of reporting condomless sex with clients compared to material needs and minimal SV. Results show the deleterious effect of co-occurring SV on HIV risk behaviors among FSW with particular emphasis on co-occurring food and housing insecurities. This is the first study of co-occurring SV on mental health outcomes in this key population.

Maternal health and maternal health service utilization among female sex workers: A scoping review

BACKGROUND

High proportions of female sex workers (FSWs) become pregnant and have children. Many FSWs are at increased risk of maternal health complications due to factors such as poverty, violence, and healthcare barriers. Despite this, FSWs' maternal health and use of maternal health services (MHS) receive limited attention.

OBJECTIVES

The objectives of this scoping review are to (1) synthesize existing data on FSWs' maternal health and MHS utilization and (2) assess the state of peer-reviewed literature on FSWs' maternal health in regard to methodological approaches and reported outcomes.

ELIGIBILITY CRITERIA

Included articles were peer-reviewed, published in English, and reported empirical data on FSWs for outcomes related to antenatal care, pregnancy, and labor complications, postnatal and delivery care, and/or barriers to MHS.

SOURCES OF EVIDENCE

Article searches were conducted in PubMed, Web of Science, Global Health, Sociological Abstracts, Sociological Index, PsychInfo, and CINAHL.

CHARTING METHODS

Information extracted from eligible articles included publication year, study design, location, sample size, outcome measures, and findings. The "Three Delays" model was used to synthesize findings on barriers to MHS as relevant to phase I, II, or III delays.

RESULTS

Eighteen publications met the eligibility criteria. Studies were conducted in 11 countries and primarily reported quantitative data from cross-sectional surveys. The most frequently reported outcome was antenatal care utilization (n = 14), whereas few studies reported findings related to postnatal care and breastfeeding counseling (n = 2). Across publications, there was a substantial range in the proportion of FSWs who reported accessing different types of MHS.

CONCLUSION

Literature on FSWs' maternal health is limited and heterogenous. More research is needed that specifically focuses on measuring outcomes related to FSWs' maternal health and examines associated factors. Such work can inform future research directions and public health interventions for FSWs-a population of marginalized women whose maternal health has been overlooked in existing efforts.

Police Violence: Reducing the Harms of Policing Through Public Health-Informed Alternative Response Programs

Police violence is a public health issue in need of public health solutions. Reducing police contact through public health-informed alternative response programs separate from law enforcement agencies is one strategy to reduce police perpetration of physical, emotional, and sexual violence. Such programs may improve health outcomes, especially for communities that are disproportionately harmed by the police, such as Black, Latino/a, Native American, and transgender communities; nonbinary residents; people who are drug users, sex workers, or houseless; and people who experience mental health challenges. The use of alternative response teams is increasing across the United States. This article provides a public health rationale and framework for developing and implementing alternative response programs informed by public health principles of care, equity, and prevention. We conclude with recommendations for public health researchers and practitioners to guide inquiries into policing as a public health problem and expand the use of public health-informed alternative response programs. (Am J Public Health. 2023;113(S1):S37-S42. https://doi.org/10.2105/AJPH.2022.307107).

Validation of a Brief Internalized Sex-work Stigma Scale among Female Sex Workers in Kenya

Female sex workers (FSW) often face severe stigma and discrimination and are extremely vulnerable to HIV and other sexually transmitted infections. In the fields of HIV and mental health, internalized stigma is associated with poor health care engagement. Due to the lack of valid, standardized measures for internalized sex work-related stigma, its dimensions and role are not well-understood. This study aimed to validate the six-item Internalized AIDS-Related Stigma Scale adapted to capture internalized sex work-related stigma by examining the scale's psychometric properties and performance among a cross-sectional, snowball sample of FSW (N = 497) in Kenya. While the original pre-hypothesized six-item model yielded acceptable CFI and SRMR values (CFI = 0.978 and SRMR = 0.038), the RMSEA was higher than desirable (RMSEA = 0.145). Our final four-item model demonstrated improved goodness of fit indices (RMSEA = 0.053; CFI = 0.999; and SRMR = 0.005). Both the pre-hypothesized six-item and reduced final four-item model demonstrated good internal consistency (Cronbach's alphas of 0.8162 and 0.8754, respectively). Higher levels of internalized stigma were associated with depression, riskier sexual behavior, and reduced condom use. This very brief measure will allow for reliable assessment of internalized stigma among FSW. Further investigation of internalized stigma among male sex workers, particularly the intersection of sex work-related and same-sex behavior-related stigmas, is needed.

Sexual and Reproductive Health Service Needs Associated with Underage Initiation of Selling Sex among Adult Female Sex Workers in Guinea-Bissau

OBJECTIVE

To assess the prevalence and predictors of underage initiation of selling sex among female sex workers (FSW) in Guinea-Bissau.

METHODS

505 adult FSW recruited using respondent-driven sampling were surveyed in 2017. Multivariable logistic regression was used to identify demographic, behavioral, and psychosocial characteristics associated with initiation of selling sex while underage (<18 years).

RESULTS

A total of 26.3% (133/505) of FSW started selling sex before age 18. Underage initiation of selling sex was associated with experiencing forced sex before age 18 (adjusted odds ratio (aOR): 6.74; 95% confidence interval (CI): 2.05-22.13), and never being tested for HIV (aOR: 0.43; 95% CI: 0.20-0.91). Despite having lower odds of wanting to have children or more children (aOR: 0.31; 95% CI: 0.17-0.56), FSW who started selling sex while underage had lower odds of using highly effective contraception such as implants (aOR: 0.43; 95% CI: 0.24-0.77). Among those who were ever pregnant, a lower percentage of FSW who started selling sex while underage accessed antenatal care (56.6% vs. 74.7%, p = 0.008).

CONCLUSIONS

These data suggest that early initiation of selling sex among adult FSW in Guinea-Bissau is common. Social services for youth and integrated HIV and reproductive health services are critical to address the persisting sexual and reproductive health needs of FSW who started selling sex while underage.

Formative assessment to identify perceived benefits and barriers of HIV oral self-testing among female sex workers, service providers, outreach workers, and peer educators to inform scale-up in Kenya

In Kenya, HIV prevalence estimates among female sex workers (FSWs) are almost five times higher than among women in the general population. However, only 68% of infected FSWs are aware of their HIV-positive status. We aimed to identify perceived benefits, opportunities, and barriers of HIV self-testing (HIVST) in improving testing coverage among FSWs. Twenty focus group discussions were conducted with 77 service providers, 42 peer educators (PEs) and outreach workers, and 37 FSWs attending drop-in centers (DiCEs) in four regions of Kenya. An additional 8 FSWs with HIV-negative or unknown status-completed in-depth interviews. Data were analyzed thematically. Acceptability of HIVST was high, with cited benefits including confidentiality, convenience, and ease of use. Barriers included absence of counseling, potential for inaccurate results, fear of partner reaction, possible misuse, and fear that HIVST could lead to further stigmatization. PEs and DiCEs were the preferred models for distributing HIVST kits. FSWs wanted kits made available free or at a nominal cost (100 Kenya Shillings or ∼USD 1). Linkage to confirmatory testing, the efficiency of distributing HIVST kits using peers and DiCEs, and the types and content of effective HIVST messaging require further research.

Solidarity, support and competition among communities of female and male sex workers in Mombasa, Kenya

Female and male sex workers are at elevated risk for HIV infection, psychological distress and other adverse health outcomes. It is therefore important to understand how sex workers' social relationships with one another might inform psychosocial support services for this population. We conducted semi-structured interviews to examine the formation and nature of social networks of 25 female and 25 male sex workers recruited from bars and clubs in Mombasa, Kenya. Relationships between and among female and male participants were often formed based on a mutual understanding of the challenging nature of sex work. Both groups described their relationships in terms of friendship and brotherhood/sisterhood and highlighted the following benefits of sex worker social networks: economic benefits, access to information about HIV/STIs and protection, and support against violence from clients and law enforcement agents. Social networks were often threatened by competition for clients and hence could result in conflict. However, sex workers explained that their sense of solidarity and reliance on one another for health, protection and economic well-being helped minimise conflict. The social networks of sex workers could therefore be used to leverage or optimise access to HIV prevention and care.

A Systematic Review of Gender-Based Violence Prevention and Response Interventions for HIV Key Populations: Female Sex Workers, Men Who Have Sex With Men, and People Who Inject Drugs

Gender-based violence (GBV) is that perpetrated based on sex, gender identity, or perceived adherence to socially defined gender norms. This human rights violation is disproportionately experienced by HIV key populations including female sex workers (FSW), people who inject drugs (PWID), and men who have sex with men (MSM). Consequently, addressing GBV is a global priority in HIV response. There is limited consensus about optimal interventions and little known about effectiveness. Our systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered in International Prospective Register of Systematic Reviews. Peer-reviewed and non-peer-reviewed literature were searched for articles that described a GBV prevention or response intervention specifically for key populations including FSW, PWID, and MSM. Results were organized by level(s) of implementation and pillars of a comprehensive GBV response: prevention, survivor support, and accountability/justice. Of 4,287 articles following removal of duplicates, 32 unique interventions (21 FSW, seven PWID, and nine MSM, not mutually exclusive) met inclusion criteria, representing 13 countries. Multisectoral interventions blended empowerment, advocacy, and crisis response with reductions in violence. Individual-level interventions included violence screening and response services. Violence-related safety promotion and risk reduction counseling within HIV risk reduction programming reduced violence. Quantitative evaluations were limited. Violence prevention and response interventions for FSW, PWID, and MSM span individual, community, and multisectoral levels with evidence of promising practices at each level. The strongest evidence supported addressing violence in the context of sexually transmitted infection/HIV risk reduction. As interventions continue to emerge, the rigor of accompanying evaluations must simultaneously advance to enable clarity on the health and safety impact of GBV prevention and response programming.

Understanding how social support influences peer-delivered HIV prevention interventions among Ugandan female sex workers: a case study from HIV self-testing

BACKGROUND

Female sex workers (FSWs) have tightly connected peer networks and remain at high risk of HIV acquisition. Peer delivery of HIV prevention interventions, such as HIV self-testing (HIVST), is a recommended implementation strategy for increasing intervention uptake and continuation among FSWs. We analyzed qualitative data from a peer-delivered HIVST intervention among FSWs in urban Uganda to understand the ways social support within this peer network can motivate or discourage the uptake of peer-delivered HIVST.

METHODS

Between February and April 2017, we conducted in-depth interviews (IDIs) with FSWs (n = 30) and focus group discussions (FGDs) with FSW peer educators (PEs, n = 5) finishing participation in a four-month randomized implementation trial testing models of peer-delivered HIVST in Kampala. FSW participants were ≥ 18 years old, self-reported exchanging sex for money or goods (past month) and had not recently tested for HIV (past 3 months). FSW PEs either directly distributed HIVST kits to participants or provided coupons exchangeable for HIVST kits from specified healthcare facilities. In the IDIs and FGDs, we asked participants to share their experiences receiving or delivering peer-delivered HIVST, respectively. Using a hybrid deductive and inductive coding approach, we arranged findings along the dimensions of an established social support theory: informational, instrumental, and emotional support.

RESULTS

The median age of participants was 30 years (IQR: 27-33) and PEs was 33 years (IQR: 29-37). We found that social support within FSW peer networks both motivated and discouraged uptake of peer-delivered HIVST. For example, sharing positive HIVST experiences (informational support), directly delivering HIVST kits (instrumental support), and encouraging linkage to care (emotional support) motivated HIVST uptake among FSWs. Conversely, the spread of misinformation (informational support), limited HIVST kit availability fostering mistrust of PEs (instrumental support), and fear of social exclusion following HIV status disclosure (emotional support) discouraged HIVST uptake among FSWs.

CONCLUSIONS

In Uganda, social support (e.g., informational, instrumental, and emotional support) among FSW peers can work in ways that both motivate and discourage peer-delivered intervention uptake. Future FSW peer-delivered HIV prevention interventions should be designed around the dimensions of social support within FSW peer networks to maximize initial and repeat intervention delivery and uptake.

Gender-Based Violence and Factors Associated with Victimization among Female Entertainment Workers in Cambodia: A Cross-Sectional Study

Women working in the entertainment industry are confronted with various forms of gender-based violence (GBV). However, their vulnerability remains understudied, particularly in resource-limited settings. This study aims to examine the prevalence of GBV among female entertainment workers (FEWs) in Cambodia and identify factors associated with victimization. We conducted a cross-sectional study in November 2018 for the impact evaluation of a randomized controlled trial. We used a stratified random sampling method to recruit 600 FEWs from different entertainment venues in the capital city and three other provinces. Female data collectors administered a structured questionnaire, and we performed multiple logistic regression analyses. Of the total, 60.5% had experienced a form of GBV during their lifetime; of whom, 37.5% experienced the GBV in the past 6 months. The prevalence of emotional abuse, forced substance use, physical abuse, and forced sex was 51.5%, 25.0%, 20.6%, and 2.9%, respectively. Forced substance use and forced sex were mainly perpetrated by clients, physical abuse by intimate partners, and emotional abuse by others such as entertainment establishment owners or managers. FEWs victimized by clients (relative risk ratio [RRR] = 0.19, 95% confidence interval [CI] = [0.07, 0.53]) and others (RRR = 0.11, 95% CI = [0.03, 0.44]) were less likely to be married compared with victims of intimate partner violence. Factors associated with sexual harassment were working in beer gardens (adjusted odds ratio [aOR] = 2.39, 95% CI = [1.20, 4.73]) and restaurants/cafés (aOR = 1.65, 95% CI = [1.01, 2.69]), and having higher acceptance of violence against women (aOR = 1.12, 95% CI = [1.01, 1.24]). FEWs in Cambodia experience high levels and unique forms of GBV as they are confronted with different types of perpetrators. Interventions need to be tailored to fit the specific needs of FEWs. Interventions aimed at reducing client-perpetrated violence should specifically focus on forced substance use and forced sex, while physical abuse by intimate partners should also be addressed.

How do you expect us to survive? Lamentation of female sex workers in Zimbabwe during COVID-19 lockdown

The restrictive measures taken to curb and mitigate the spread of the corona virus (COVID-19) had negative implications on the vulnerable populations. Of the latter, the most severely affected were sex workers, whose work venues and customers were locked down. This descriptive phenomenological study explored effects of COVID-19 on female sex workers in Bulawayo, Zimbabwe. Snowballing sampling was used to recruit participants. Data were collected through in-depth face-to-face individual interviews with ten female sex workers. The sample size was determined by data saturation. Colaizzi's seven-step content analysis approach was followed to guide data analysis. Rigour was ensured by adhering to Guba and Lincoln's trustworthiness criteria. The study found that the measures impacted negatively on sex workers' income, making it difficult for them to get money for food and rentals. In response, some sex workers adopted innovative entrepreneurship. Others engaged in risky sexual behaviours, further aggravating their situation emotionally and psychologically. It is recommended that the government and policy makers provide psychosocial and economic support to protect the rights of female sex workers in order to maintain the gains made in HIV response.

Mental Health and Protective Factors for Transgender and Gender-Diverse Youths Who Trade Sex: A Minnesota Statewide School-Based Study, 2019

Objectives. To describe the prevalence of sex trading by gender and by associations with mental health concerns and protective factors. Methods. We used data from 9th and 11th graders who completed the 2019 Minnesota Student Survey. The analytic sample (n = 67 806) included transgender and gender-diverse (TGD) youths and cisgender youths who reported trading sex. Data on 7 mental health measures and 4 school-related and health care-related protective factors were collected. Results. The prevalence of sex trading (5.9%) was 5 times higher among TGD students than cisgender students (1.2%). In addition, the prevalence of all mental health concerns was high among TGD students who traded sex (e.g., 75.9% reported a lifetime suicide attempt, as compared with 45.9% of cisgender students who traded sex). Fewer statistical differences were found across protective factors. When TGD students who traded sex were compared according to sex assigned at birth, no statistically significant differences were found. Conclusions. Our findings support strong calls for increased competence regarding gender and sex trading or exploitation in clinical and school-based settings to decrease health disparities among TGD youths. Public Health Implications. In this study, we have presented unique prevalence estimates of mental health disparities among TGD students in the United States who trade sex. Our results indicate that TGD students who trade sex are at risk for mental health symptoms and that sensitivity to both gender and sex trading or exploitation will be critical to meeting the needs of this group in clinical as well as school-based settings.

'It is stigma that makes my work dangerous': experiences and consequences of disclosure, stigma and discrimination among sex workers in Western Australia

Western Australia criminalises sex work whilst some other Australian jurisdictions have decriminalised the industry. This article examines the role of Western Australia's legislation in reinforcing stigma and discrimination of sex workers. It draws on stigma and discrimination-specific results from open-ended survey responses and interview data collected as part of a larger cross-sectional mixed-methods study. Experiences and/or anticipation of stigma and discrimination resulted in some sex workers concealing their involvement in sex work from family, friends and their home communities. This was a major barrier to accessing health care and protective services and impacted negatively on their mental health and wellbeing. There is a need for policy change and support to shift society's perception of sex work to that of a legitimate occupation to decrease sex workers' experiences of stigma and discrimination and improve their access to and utilisation of health care and protective services. These findings highlight the need for the decriminalisation of the Western Australian sex industry and the development of training programmes for police and healthcare workers to reduce the stigma and discrimination experienced by sex workers in these settings.

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.

The Impact of the Coronavirus Disease (COVID-19) on the Health and Social Needs of Sex Workers in Singapore

We evaluated the impact of the coronavirus disease (COVID-19) on the sex work industry and assessed how it has impacted the health and social conditions of sex workers in Singapore. We conducted a sequential exploratory mixed methods study amidst the COVID-19 pandemic from April to October 2020, including in-depth interviews with 24 stakeholders from the sex work industry and surveyor-administered structured surveys with 171 sex workers. COVID-19 had a substantial impact on sex workers' income. The illegality of sex work, stigma, and the lack of work documentation were cited as exclusionary factors for access to alternative jobs or government relief. Sex workers had experienced an increase in food insecurity (57.3%), housing insecurity (32.8%), and sexual compromise (8.2%), as well as a decrease in access to medical services (16.4%). Being transgender female was positively associated with increased food insecurity (aPR = 1.23, 95% CI [1.08, 1.41]), housing insecurity (aPR = 1.28, 95% CI [1.03, 1.60]), and decreased access to medical services (aPR = 1.74, 95% CI [1.23, 2.46]); being a venue-based sex worker was positively associated with increased food insecurity (aPR = 1.46, 95% CI [1.00, 2.13]), and being a non-Singaporean citizen or permanent resident was positively associated with increased housing insecurity (aPR = 2.59, 95% CI [1.73, 3.85]). Our findings suggest that COVID-19 has led to a loss of income for sex workers, greater food and housing insecurity, increased sexual compromise, and reduced access to medical services for sex workers. A lack of access to government relief among sex workers exacerbated such conditions. Efforts to address such population health inequities should be implemented.

Mobility for sex work and recent experiences of gender-based violence among female sex workers in Iringa, Tanzania: A longitudinal analysis

Female sex workers are highly mobile, which may influence their risk of experiencing physical and sexual violence. However, there remains a paucity of research, particularly longitudinal, from Sub-Saharan Africa exploring mobility and gender-based violence among female sex workers. To address this gap, this study examined the longitudinal relationship between work-related mobility and recent experience of physical or sexual gender-based violence from a client or partner among female sex workers in Iringa, Tanzania. A secondary data analysis was conducted using baseline and 18-month follow-up data from Project Shikamana, a community empowerment-based combination HIV prevention intervention. Responses from 387 female sex workers aged 18 years and older participating in both baseline and follow-up were analyzed. Unadjusted and adjusted Poisson regression models with robust variance estimations, accounting for clustering of female sex workers' responses over time, were fit. Final models adjusted for socio-demographic characteristics and aspects of participants' living situations and work environments. Recent physical or sexual violence from a client or partner was common (baseline: 40%; follow-up: 29%). Twenty-six percent of female sex workers at baseline, and 11% at follow-up, had recently traveled outside of Iringa for sex work. In the final adjusted longitudinal model, female sex workers recently mobile for sex work had a 25% increased risk of any recent experience of physical or sexual gender-based violence when compared with their non-mobile counterparts (adjusted incidence rate ratio: 1.25; 95% CI: 1.03-1.53; p<0.05). Interventions must identify ways-such as mobile support services, linkages and referrals to health and other social services while traveling, or the use of mobile or digital technology-to address mobile female sex workers' unique needs while traveling. Future quantitative and qualitative research is needed to understand the context of female sex workers' mobility and how and why mobility influences risk environments and experiences of gender-based violence.

Application of Integrated Behavioral Model (IBM) to measure intention to get early screening and treatment of Sexually Transmitted Infections (STIs) among HIV at- risk sub-populations in Ethiopia

Background

Sexually Transmitted Infections (STIs) increase the risk of contracting Human Immunodeficiency Virus (HIV). Hence, early screening and treatment of STIs as a behavioral practice will reduce the odds of HIV infection among at risk and vulnerable sub-populations. To that end, HIV prevention strategies need to design evidence-based interventions using behavioral models or theories to help at-risk individuals adopt early screening and treatment of STI as preventive health behavior. In this study, commercial sex workers were considered as HIV at-risk sub-populations.

Objective

Measuring to what extent that Integrated Behavioral Model constructs explain individuals' intention to practice early screening and treatment of sexually transmitted infections as healthy behavior of interest in HIV prevention.

Design

Integrated Behavioral Model (IBM) measurement survey was conducted using Respondent Driven Sampling (RDS) in six towns located in the main transport corridors of Ethiopia. Respondents' answers to model construct-based questions and intention to practice the health behavior of interest were measured using Likert Scale. Analysis was done to assess the correlation and level of association of model construct-based questions with intention to practice the preventive health behavior.

Results

Respondents' attitude explained 32%, perceived control 2%, normative influence 21%, and self-efficacy 53 % of their intention to get early screening and treatment of sexually transmitted infections.

Conclusion

Self-efficacy explained the variability of respondents' intention to get early screening and treatment of STIs most, while perceived control was the least. Hence, HIV prevention behavioral interventions targeting early screening and treatment of STIs should give high emphasis to self-efficacy.

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.

Substance Use, Mental Health Problems, and Physical and Sexual Violence Additively Increase HIV Risk Between Male Sex Workers and Their Male Clients in Northeastern United States

BACKGROUND

Male sex workers (MSW) are disproportionately affected by HIV/AIDS, with an estimated HIV prevalence in the United States of 19.3%. Existing research suggests that MSW are also at risk of adverse psychosocial problems. Cross-sectional studies of MSW have suggested that co-occurring epidemics or a "syndemic" of psychosocial problems may increase vulnerability to HIV acquisition/transmission by elevated sexual risk. To the best of our knowledge, there are no published studies examining this relationship longitudinally among MSW. This study examined how a syndemic of 6 psychosocial problems result in additive risk for condomless anal sex (CAS) with male clients among a multicity, longitudinal cohort of MSW.

SETTING

Community-based organization and health center in 2 Northeastern US cities.

METHODS

Between 2015 and 2017, 100 MSW from Boston, MA and Providence, RI completed behavioral/psychosocial surveys at baseline, 6 months, and 12months. Generalized estimating equation modeling was used to examine the prospective relationship of additive psychosocial problems and subsequent CAS with male clients, adjusting for age, site, race/ethnicity, MSW-type, and HIV serostatus.

RESULTS

Mean age = 34.7 (SD = 11.8); 62% racial/ethnic minority; and 20% HIV+. The prevalence of 6 psychosocial syndemic problems was substantial at baseline and remained high at each time point (all within the past 6 months): 74% problematic depressive symptoms, 27% polydrug use (3+ drugs, not including stimulants), 57% stimulant (methamphetamine/cocaine/crack) use, 44% hazardous drinking, 15% experienced client-specific physical/sexual violence, and 57% childhood sexual abuse. Looking at the number of psychosocial problems experienced, 7% had zero, 27% had 1, 24% had 2, 27% had 3, and 15% had 4 or more. We identified a statistically significant positive "dose-response" relationship between the number of psychosocial problems and CAS with male clients over time, with the greatest odds of engaging in CAS with a male client over follow-up among those with 4 or more psychosocial problems (adjusted odds ratio = 5.18, 95% CI: 1.61 to 16.62).

CONCLUSIONS

Internet escorts and street-based MSW are likely to experience psychosocial problems and engaging in HIV sexual risk with male clients. The accumulation of psychosocial problems additively predicted CAS with male clients in a prospective cohort of MSW. The specification of psychosocial problems presents distinct treatment targets for HIV prevention among MSW in the United States.

Early Assessment of Integrated Knowledge Translation Efforts to Mobilize Sex Workers in Their Communities

Researchers have recently increased their efforts to find more effective strategies to reduce the gap between the production of academic knowledge and its uptake in policy and practice. We focus attention on sex workers in Canada who have limited access to societal resources and are hampered by punitive laws prohibiting their work. The initial aim of our study was to work with sex worker organizations and allied agencies to develop a training program for sex workers to help them understand Canada's most recent criminal justice approach to adult sex commerce. What has emerged from our integrated knowledge translation process during the first year of the study's operation has been a change to a broader focus on mobilizing sex workers around their occupational and social rights. In this paper, we first give an overview of recent changes in Canada's prostitution laws and then report qualitative findings from interviews with members of our partner organizations. Interviewees appreciated the change in research direction and the emergent collaborative process among themselves and the authors, but also noted challenges regarding shifting research timelines, balancing power between themselves and the academic researchers, and reaching consensus on research plans among community partners themselves. We discuss the findings in relation to successful knowledge translation strategies that aim to ensure the research questions we ask, and the empirical processes we engage in, are advantageous to those we aim to benefit.

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.

Myths, misconceptions, othering and stigmatizing responses to Covid-19 in South Africa: A rapid qualitative assessment

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a new strain of virus in the Coronavirus family that has not been previously identified. Since SARS-CoV-2 is a new virus, everyone is at risk of catching the Coronavirus disease 2019 (Covid-19). No one has immunity to the virus. Despite this, misconceptions about specific groups of people who are immune to Covid-19 emerged with the onset of the pandemic. This paper explores South African communities' misconceptions about who is most vulnerable to Covid-19. A rapid qualitative assessment was conducted remotely in Gauteng, KwaZulu-Natal and the Western Cape provinces of South Africa. Recruitment of study participants took place through established relationships with civil society organizations and contacts made by researchers. In total, 60 key informant interviews and one focus group discussion was conducted. Atlas.ti.8 Windows was used to facilitate qualitative data analysis. The qualitative data was coded, and thematic analysis used to identify themes. The results show a high level of awareness and knowledge of the transmission and prevention of SARS-CoV-2. Qualitative data revealed that there is awareness of elderly people and those with immunocompromised conditions being more vulnerable to catching Covid-19. However, misconceptions of being protected against the virus or having low or no risk were also evident in the data. We found that false information circulated on social media not only instigated confusion, fear and panic, but also contributed to the construction of misconceptions, othering and stigmatizing responses to Covid-19. The study findings bring attention to the importance of developing communication materials adapted to specific communities to help reduce misconceptions, othering and stigmatization around Covid-19.

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.

"I did not plan to have a baby. This is the outcome of our work": a qualitative study exploring unintended pregnancy among female sex workers

BACKGROUND

High number of unintended pregnancies-often leading to induced abortions-are reported among female sex workers (FSWs), highlighting a major unmet need for contraception. To better understand barriers to contraceptive use, we explored FSW's pregnancy perceptions and experiences of unintended pregnancy. We hypothesized that sex work exacerbates barriers to contraceptive use and that FSW's pregnancy perceptions and experiences of unintended pregnancy influence future commitment to contraceptive use.

METHODS

We conducted in-depth interviews with 11 FSWs (January-June 2019) in Dar es Salaam, Tanzania. We purposively sampled FSWs with a positive pregnancy test from those participating in a HIV vaccine preparedness cohort. We used open ended questions to explore how FSWs make decisions when facing barriers to contraceptive use, dealing with unintended pregnancy and adhering to contraceptive use after experiencing unintended pregnancy. All interviews were conducted in Kiswahili, audio-recorded, transcribed and translated into English. Grounded theory approach was used to analyse transcripts. Open and selective coding was performed using Nvivo software.

RESULTS

FSWs reported that sex work impedes good contraceptive behaviour because sex workers felt unable to negotiate consistent condom use, avoided health services due to stigma, missed monthly contraceptive supplies because of inconvenient clinic operating hours or skipped contraceptive pills when intoxicated after taking alcohol. FSWs who perceived pregnancy to be a burden terminated the pregnancy because of fear of loss of income during pregnancy or child rearing expenses in case child support was not assured by their partners. FSWs who perceived pregnancy to be a blessing decided to keep the pregnancy because they desired motherhood and hoped that children would bring prosperity. Family planning counselling and availability of contraceptives during postpartum care influenced the initiation of contraception among FSWs. Financial hardships related to childrearing or painful abortion experiences influenced FSWs' commitment to good contraceptive practices.

CONCLUSION

Our results demonstrate that FSWs face barriers to initiating and adhering to contraceptive use because of sex work stigma, inability to negotiate condoms and failure to access medical services at their convenience. Our findings underscore the need to integrate contraceptive services with HIV programs serving FSWs in their areas of work.

Syndemic Psychosocial Health Conditions Associated with Recent Client-Perpetrated Violence Against Female Entertainment and Sex Workers in Cambodia

Female entertainment and sex workers (FESW) are vulnerable to violence, which impedes safer sex behaviors and increases risk of HIV. FESW are also disproportionately affected by co-occurring psychosocial health conditions, including substance use, depression, and economic insecurity, which increased risk of exposure to violence. We used a syndemic framework to examine the effects of co-occurring psychosocial conditions on the risk of client-perpetrated physical and sexual violence against FESW. Data were collected among 1198 Cambodian FESW on recent client-perpetrated physical and sexual violence, and psychosocial conditions (psychological distress, alcohol consumption, amphetamine-type stimulant (ATS) use, debts, housing, and food insecurity). Bivariate and multivariate logistic regressions were conducted. Prevalence of physical and sexual violence from clients was 4.8% and 6.9%, respectively. Client-perpetrated physical violence was associated with housing insecurity, ATS use, and psychological distress. All psychosocial conditions, except ATS, were associated with exposure to sexual violence. In multivariable models, odds of client-perpetrated physical violence were twice higher among women with ≥ 4 compared to ≤ 3 psychosocial conditions. Risk of sexual violence increased with the number of psychosocial conditions. Compared to those with ≤ 1 condition, FESW with two psychosocial conditions had twice the odds (AOR = 2.08; 95% CI 1.00-4.31) and women with 5-6 psychosocial conditions had eightfold higher odds (AOR = 8.10; 95% CI 3.4-19.31) of sexual violence from clients. Our findings support a syndemic model of co-occurring psychosocial conditions among FESW that are associated with increased risk of violence. Violence prevention interventions targeting FESW should adopt comprehensive approaches that address co-occurring psychosocial conditions.

The Sexuality of Sex Workers: Sexual Arousability and the Sexual Profile of Women Engaged in Prostitution in Serbia

BACKGROUND

In a view of sex work being a sexual behavioural activity, the main objective of our research was to explore the sexuality of sex workers in Serbia regarding to intensity of their sexual arousability.

SUBJECTS AND METHODS

The research was conducted on 30 sex workers and 30 controls of randomly selected social and demographic characteristics, without any signs of psychiatric morbidity. For the evaluation of the intensity of sexual arousability, SAI (Sexual Arousability Index) questionnaire was used.

RESULTS

The analysis of the main total scores of the SAI for the sex workers and control participants showed no statistically significant difference in the overall intensity of arousability (p>0.05). However, item by item analysis of the questionnaire showed qualitative difference in sexuality between sex workers and controls, related to certain aspects of sexuality.

CONCLUSIONS

These findings allow the space for further research in the way of identifying origins of qualitative issues in the sexual profile of sex workers, in correlation to women who are not sex workers, i.e. whether they had been result of potential biological, specific psychodynamic factors, or have been formed as a result of the direct influence of the 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.