Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies

Everyday discrimination and barriers to primary care, mental health, and substance use services: Findings from a community-based cohort of sex workers in Vancouver, Canada (2015-2024)

We evaluated the association between discrimination and access to primary, mental health, and substance use services among sex workers. Using baseline and semi-annual questionnaire data from a community-based cohort of sex workers in Vancouver, Canada (09/2015-02/2024), we used bivariate and multivariable logistic regression with generalized estimating equations to analyze the relationship between discrimination and access to primary care, mental health, and substance use services. Among 518 participants (2768 observations), the median discrimination score was 19 (IQR:11-25), indicating substantial discrimination. In separate multivariate models, every one-point increase in discrimination was associated with increased odds of experiencing barriers to health services (adjusted odds ratio (AOR):1.03, 95%CI:1.02-1.04), unable to access health services when needed (AOR:1.03, 95%CI:1.01-1.04), unmet need for mental health services (AOR:1.04, 95%CI:1.03-1.06), experiencing barriers to counseling for sexual trauma (AOR:1.04, 95%CI:1.02-1.05), and unmet need for substance use treatment (AOR:1.07, 95%CI:1.04-1.09). Discrimination is highly prevalent and associated with reduced access to primary, mental health, and substance use services among sex workers. There is a need for anti-discrimination efforts, including provider training and sex worker partnerships in primary care, alongside policy reforms.

"He showed me a knife and said they would kill me and no one would know or care": a qualitative study into the experiences of transnational sex workers in Ghana

BACKGROUND

Sex work in Ghana is deeply intertwined with economic hardship, criminalization, and social stigma, which subjects female sex workers (FSWs) to significant vulnerabilities. In Ghana, many FSWs, particularly immigrants, face compounded challenges, including physical and sexual abuse, police harassment, and discrimination, which are exacerbated by their migrant status. This study aims to address the gap in understanding the specific lived experiences of transnational FSWs in Ghana, with a focus on the intersection of gender, migration, and economic vulnerability.

METHODS

This study utilized a qualitative phenomenological approach to explore the lived experiences of transnational FSWs in Ghana's two largest cities, Accra and Kumasi. Participants were purposively selected through snowball sampling technique until thematic saturation was achieved, interviewing fourteen FSWs. In-depth interviews were conducted in English. Data collection took place in November and December 2024, with basic demographic data gathered at the beginning of each interview, and thematic analysis was employed to analyze the anonymized transcripts.

RESULTS

Economic necessity was the primary driver behind migration and entry into sex work for FSWs, with many revealing that promises of legitimate employment often led to coerced involvement into the trade. Participants also reported high levels of violence, including physical assault, theft, and sexual coercion from clients, often in isolated locations. They also experienced harassment and exploitation by law enforcement, which compounded their vulnerability. Additionally, discrimination based on nationality also exacerbated their vulnerability, as foreign FSWs were often treated more harshly than their Ghanaian counterparts by clients, police, and the public.

CONCLUSION

This study's findings highlight the urgent need for comprehensive policy reforms that address the root causes of migrant sex work, including better economic opportunities for women and the decriminalization or regulation of sex work to protect sex workers from the risks associated with its illegal status, such as police harassment, exploitation, and lack of legal protections.

Community-administered naloxone for overdose reversal: The role of sex worker-led programming and occupational violence in a community-based cohort (2018-2024)

BACKGROUND

Amidst the ongoing toxic drug crisis, sex workers who use drugs face high overdose risk alongside structural barriers to harm reduction services. Previous work has noted that occupational violence and peer-led programs can influence health outcomes for sex workers. Given the potential for community-administered take-home naloxone (THN) to reduce overdose-related harm, we evaluated longitudinal trends and uptake of THN administration, and the associations between exposure to sex work-specific programs and occupational violence and harassment with THN administration over 5.5-years (2018-2024).

METHODS

Data was derived from An Evaluation of Sex Workers' Health Access, a prospective, community-based cohort of sex workers in Vancouver, Canada from September 2018-March 2024. We plotted semi-annual trends of THN administration (Aim 1) and used bivariate logistic regression with generalized estimating equations (GEE) to characterize uptake of THN administration (Aim 2). Lastly, we employed bivariate and multivariable GEE to evaluate the association between exposure to sex-work specific programs and occupational violence and harassment with THN administration (Aim 3).

RESULTS

Among 427 participants, 57.9 % (N = 247) reported administering THN at least once. Exposure to sex work-specific programs was strongly associated with THN administration (Adjusted Odds Ratio [AOR] 1.26, 95 % Confidence Interval [CI] 1.02-1.55), as was exposure to violence from clients (AOR 1.72, 95 %CI 1.22-2.41) and community (AOR 1.76, 95 %CI 1.25-2.46), and police harassment (AOR 1.54, 95 %CI 1.07-2.21).

CONCLUSION

Over 5.5 years, over half of participants administered THN, which was associated with exposure to sex work-specific programs and occupational violence. Violence from clients, community members, and police independently increased the likelihood of THN administration. Findings suggest that marginalized sex workers, particularly those who use drugs in occupational settings, are uniquely positioned to respond to overdoses. This supports the feasibility of implementing sex worker-specific overdose interventions and highlights the need to expand community-based, sex worker-led safety, violence prevention, and care interventions to strengthen overdose prevention efforts and improve naloxone cascade metrics.

Culturally Centering the Voices of Transgender Sex Workers in Singapore: Health, Materiality and Violence

The transgender sex worker experience of health in Singapore is multidimensional, working at the intersections of culture, social class, and gendered marginalization. Drawing on in-depth interviews with transgender sex workers in the context of Singapore's extreme neoliberalism and located within a larger culture-centered intervention that emerged through an academic-activist-community partnership, this study foregrounds the everyday meanings of health among transgender sex workers who are marginalized. We offer a discursive register for theorizing violence as disruption of health. Participants narrate health as the negotiation of stigmas coded into their everyday lives, the forms of material violence they experience, and the struggles with accessing secure housing. The theorizing of violence as threat to health by transgender sex workers shapes the health advocacy and health activism that takes the form of a 360 degrees campaign. This essay pushes the literature on the culture-centered approach (CCA) by centering voice as the basis for structurally transformative articulations amidst neoliberal authoritarianism.

Statistical Methods for Baseline Adjustment and Cohort Analysis in Korean National Health Insurance Claims Data: A Review of PSM, IPTW, and Survival Analysis With Future Directions

The utilization of health insurance claims data has expanded significantly, enabling researchers to conduct epidemiological studies on a large scale. This review examines key statistical methods for addressing baseline differences and conducting cohort analyses using Korean National Health Insurance claims data. Propensity score matching and inverse probability of treatment weighting are widely used to mitigate selection bias and enhance causal inference in observational studies. These methods help improve study validity by balancing covariates between treatment and control groups. Additionally, survival analysis techniques, such as the Cox proportional hazards model, are essential for assessing time-to-event outcomes and estimating hazard ratios while accounting for censoring. However, the application of these statistical methods is accompanied by challenges, including unmeasured confounding, instability in weight estimation, and violations of model assumptions. To address these limitations, emerging approaches, such as Doubly robust estimation, machine learning-based causal inference, and the marginal structural model, have gained prominence. These techniques offer greater flexibility and robustness in real-world data analysis. Future research should focus on refining methodologies for integrating high-dimensional health datasets and leveraging artificial intelligence to enhance predictive modeling and causal inference. Furthermore, the expansion of international collaborations and the adoption of standardized data models will facilitate large-scale multi-center studies. Ethical considerations, including data privacy and algorithmic transparency, should also be prioritized to ensure responsible data use. Maximizing the utility of health insurance claims data requires interdisciplinary collaboration, methodological advancements, and the implementation of rigorous statistical techniques to support evidence-based healthcare policy and improve public health outcomes.

A Qualitative Phenomenological Study of the Lived Experiences of Female Sex Workers in a Bangladesh Brothel

AIM

The purpose of this study was to explore the lived experiences of female sex workers in the Kandapara Brothel in Tangail to build a better understanding of their lived perspective.

DESIGN

This qualitative study was based on the philosophical underpinnings of Giorgi's descriptive phenomenological philosophy.

METHODS

A purposive, convenience sample of 24 participants (N = 24) was recruited in the brothel, sufficient for data saturation. The inclusion criteria included (a) must work in the brothel and (b) must be ≥ 18 years old. In-depth interviews were conducted, and transcript data were reduced, managed and coded.

ETHICS

The university institutional review board and ethics committee approved the study, and participants provided written informed consent.

FINDINGS

A qualitative analysis of transcribed in-depth interviews revealed four major themes: (1) Early Trauma and Dysregulation, which reflects the trauma experienced by the women working in the brothel and being trafficked at a very early age; (2) Internal life describes the emotional experience and gratitude; the feelings of the sex workers in the brothel, (3) External life reflects the view of the greater Bangladeshi society of the sex workers and (4) The Brothel Life examines the relationships, competition, isolation, health concerns and workers' desire/uncertainty to leave the brothel. The four themes, while appearing separate, overlap with the other themes.

CONCLUSIONS

This phenomenological study illustrates the complexity of brothel workers' lived experiences. Understanding sex workers' lived experiences through a caring lens promotes care that allows for self-determination, reflection, growth, acceptance and, most of all, healing.

Incentivizing adherence to pre-exposure prophylaxis for HIV prevention: a randomized pilot trial among male sex workers in Mexico

Low adherence to preventative medications against life-long health conditions is a major contributor to global morbidity and mortality. We implemented a pilot randomized controlled trial in Mexico to measure the extent to which conditional economic incentives help male sex workers increase their adherence to pre-exposure prophylaxis (PrEP) for HIV prevention. We followed n = 110 male sex workers over 6 months. At each quarterly visit (at months 0, 3, and 6), all workers received a $10 transport reimbursement, a free 3-month PrEP supply, and completed socio-behavioral surveys. The primary outcome was an objective biomarker of medication adherence based on tenofovir (TFV) drug concentration levels in hair collected at each visit. Individuals randomized to the intervention received incentives based on a grading system as a function of PrEP adherence: those with high (> 0.043 ng/mg TFV concentration), medium (0.011 to 0.042 ng/mg), or low (< 0.011 ng/mg) adherence received $20, $10, or $0, respectively. Six-month pooled effects of incentives on PrEP adherence were analyzed using population-averaged gamma generalized estimating equation models. We estimated heterogeneous treatment effects by sex worker characteristics. The incentive intervention led to a 28.7% increase in hair antiretroviral concentration levels over 6 months consistent with increased PrEP adherence (p = 0.05). The effect of incentives on PrEP adherence was greater for male sex workers who were street-based (vs. internet) workers (p < 0.10). These pilot findings suggest that modest conditional economic incentives could be effective, at scale, for improving PrEP adherence among male sex workers, and should be tested in larger implementation trials. ClinicalTrials.gov Identifier: NCT03674983.

Epidemiological Profile and Risk Factors Related to Sexually Transmitted Infections in Sex Workers in Granada (Spain)

Background: Sex work is one of the oldest trades in the world. It is the practice of sexual activity in exchange for money or material goods. It has traditionally been carried out by women, although in recent years, there has been an increase in the number of male sex workers. Sex workers have been recognized as a population at high risk of contracting and transmitting sexually transmitted infections and human immunodeficiency virus and have had limited access to multiple services, including health care. Objective: The aim was to identify the epidemiological profile and risk factors of a population of sex workers in the province of Granada, southern Spain. Methods: An analytical cross-sectional study was conducted by reviewing the medical records at a specific sexually transmitted infection center in Spain. Results: A total of 157 sex workers' records were analyzed, most of whom were women, who mainly identified as heterosexual, with a mean age of 28.52 years and a high percentage of foreign nationality. Some sexual behaviors associated with the acquisition of sexually transmitted infections were also analyzed. Conclusions: The results revealed a deficient coverage of the health needs of a highly vulnerable and stigmatized social group, highlighting the need for interventions to prevent risky habits, as well as to promote behaviors aimed at achieving better sexual health.

Health vulnerabilities of the female sex workers: A qualitative investigation from South-western region of Bangladesh

Health issues of the marginalized social groups are often ignored in our society. In the present study, the authors investigate the health vulnerabilities of female sex workers (FSWs) in the South-western region of Bangladesh using a qualitative research approach. Twenty in-depth interviews were conducted with the female sex workers and some key informants using a semi-structured interview guide. The interviews were audio-tapped, transcribed, and analysed thematically. Five themes emerged from the data revealing an overall poor physical, mental, and sexual/reproductive health status of the female sex workers. There were different factors including lack of healthcare knowledge, and difficulty in accessing quality healthcare services contributing towards the vulnerable health status of these women in prostitution. It is an immediate necessity to bring attention to the socially vulnerable female sex workers through specialized healthcare support and services in addition to the promotion of social awareness.

Jitegemee (rely on yourself): a cross-sectional study on acceptability, feasibility and design considerations for a personal savings intervention to reduce HIV risk among female sex workers in Siaya County, Kenya

OBJECTIVES

The primary objective was to assess the acceptability of a savings intervention in which female sex workers (FSW) would save part of their earnings and call back (withdraw) when faced with a financial need that could force them into HIV risk practices. The secondary objectives were to assess its feasibility, concerns and design considerations.

DESIGN

A cross-sectional survey. Participants were asked for views on the intervention, their earnings, saving and spending practices, and suggestions for the intervention package.

SETTING

Kisumu and Siaya counties, Kenya.

PARTICIPANTS

FSWs aged ≥18 years, self-identifying as sex workers and living in Kisumu or Siaya county.

OUTCOME MEASURES

The primary outcome was the proportion of participants who believed the Jitegemee intervention would be acceptable to FSWs in Kenya. The secondary outcomes were the proportion who: could generate money to save (assessed from income, spending and loaning practices), reported potential challenges with the intervention and suggested components to inform the intervention package.

RESULTS

We enrolled 369 FSWs, 88% aged 18-39 years, 78% unmarried, 94% cared for ≥1 child(ren) and 78% were household heads. Over half (52.1%) had been in sex trade for ≤4 years, with 62.3% reporting <10 clients the previous month. Jitegemee was highly acceptable, at 94.8%; however, participants suggested adding: financial literacy, including saving, spending and loans management (74.8%), forming saving groups (37.5%) and goal-setting (24.1%). Those who did not care for children were 4.86 times more likely to save (adjusted OR (aOR)=4.86, p=0.18), non-household heads were less likely to save (aOR=0.57, p=0.28) and those in the sex trade for 1-4 years and 5-9 years were four to five times more likely to save than those <1 year (aOR=4.49, p=0.01 and aOR=5.22, p=0.01, respectively).

CONCLUSIONS

Jitegemee intervention was highly acceptable; however, several recommendations were suggested to make the design more appealing and potentially effective.

Sex workers' professional agency, quality of life, and problematic substance use in Finland

INTRODUCTION

Sex workers suffer considerable marginalization that limits their choices and exposes them to various types of harm. Hence, it is important to examine sex workers' professional agency and its association with quality of life. In the current study, we investigated professional agency, quality of life, and problematic substance use among sex workers in Finland.

METHODS

Using an online survey, we collected data from 136 sex workers contacted through Finnish sex work organizations and social media platforms. We conducted correlational analyses between the study variables and linear regression analyses with professional agency as the independent variable and quality of life and problematic alcohol and drug use as dependent variables.

RESULTS

As expected, in the regression analyses, professional agency was strongly positively associated with quality of life (β = 0.86, p < 0.001) and negatively associated with problematic alcohol (β = -0.38, p = 0.002) and drug (β = -0.69, p < 0.001) use. Professional agency explained as much as 73% of the variance in quality of life. Most sex workers rated their quality of life as either good or very good.

CONCLUSION

Our results underscore the importance of professional agency to sex workers' well-being, explaining a substantial proportion of the variance in quality of life. Promoting agency should therefore be at the heart of sex work policymaking. However, as most of the respondents were Finnish-born cis women, our results might not generalize to foreign-born, male, and gender diverse sex workers. Future studies should prioritize reaching these populations to ensure broader representativeness.

Social-structural barriers to primary care among sex workers: findings from a community-based cohort in Vancouver, Canada (2014-2021)

BACKGROUND

Due to social-structural marginalization, sex workers experience health inequities including a high prevalence of sexually transmitted and blood-borne infections, mental health disorders, trauma, and substance use, alongside a multitude of barriers to HIV and substance use services. Given limited evidence on sex workers' broader primary healthcare access, we aimed to examine social-structural factors associated with primary care use among sex workers over 7 years.

METHODS

Data were derived from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women (cis and trans) sex workers in Metro Vancouver, from 2014 to 2021. Descriptive statistics were used to summarize the proportion of primary care use in the past six months and to assess primary care trends over time from 2014-2021. We used multivariate logistic regression with generalized estimating equations (GEE) to identify social-structural factors associated with primary care access (seeing a family doctor in the last six months), after adjusting for confounders.

RESULTS

Amongst the 646 participants, most (87.4%) accessed primary care at some point during the study period, and primary care use in the last 6 months was relatively stable (ranging from 60-78%) across each follow-up period. At first available observation, participants faced a high burden of sexually transmitted and blood-borne infections (STBBIs) (48.0%, 11.5%, and 10.4% were HCV, HIV, or STI seropositive, respectively), 56.8% were diagnosed with a mental health disorder, 8.1% had recently overdosed, and 14.7% were recently hospitalized. In multivariable GEE analysis, exposure to intimate partner violence was associated with reduced primary care use (Adjusted odds ratios (AOR) 0.63, 95% Confidence interval (CI): 0.49-0.82), and limited English fluency was marginally associated (AOR 0.76 CI: 0.51-1.14).

CONCLUSIONS

This study characterized primary care use and its social-structural determinants among sex workers over 7 years. Participants faced a high burden of STBBIs and other health disparities, and a proportion faced gaps in primary care utilization. Scale-up of trauma-informed, culturally and linguistically tailored, sex worker-friendly primary care models are needed, alongside structural interventions to decriminalize and destigmatize sex work and substance use.

Multidimensional analysis of stigma among female sex workers in Northern Uganda: Principal component and factor analyses

BACKGROUND

Female sex workers (FSWs) face significant stigma, which hinders their access to healthcare, social support, and fundamental human rights. Stigma is often compounded by criminalization, violence, and discriminatory attitudes, particularly in low-income regions like Northern Uganda.

OBJECTIVES

This study aims to analyze the underlying dimensions of stigma among FSWs in Gulu City, Northern Uganda, to provide insights for targeted interventions.

DESIGN

A community-based cross-sectional study was conducted from February to March 2023 in Gulu City, Northern Uganda.

METHODS

A total of 314 FSWs aged 18-49 years participated in the study, yielding a response rate of 83.9%. Participants were recruited using consecutive sampling from hotspots such as bars, brothels, streets, and community health centers. Data were collected through face-to-face interviews using a pre-tested semi-structured questionnaire. Descriptive statistics summarized sociodemographic and economic characteristics. Principal component analysis (PCA) with varimax rotation was applied to identify the primary components of stigma. Factor retention was guided by eigenvalues >1.0, scree plot analysis, and factor loadings ⩾0.35. Reliability was assessed using Cronbach's alpha. Multivariate analysis examined the association between stigma and demographic variables.

RESULTS

The mean age of participants was 28.8 years (standard deviation = 6.4), with most having completed primary education (46.2%). A majority resided in urban areas (93.3%), and 70.7% reported experiencing violence from clients. PCA identified three key dimensions of stigma: social stigma, healthcare-related stigma, and self-stigma. Social stigma encompassed community rejection and discrimination, while healthcare-related stigma involved negative attitudes and experiences within health settings. Self-stigma reflected internalized shame and reduced self-worth among participants. The cumulative variance explained by the three components was 67.2%, with strong internal reliability (Cronbach's alpha = 0.88). Factors significantly associated with stigma included age, education level, and experience of violence (p < 0.05).

CONCLUSION

The multidimensional nature of stigma among FSWs in Gulu City highlights the urgent need for holistic interventions. Addressing community stigma, improving healthcare provider attitudes, and offering psychosocial support to reduce self-stigma are critical for improving health outcomes and quality of life. The use of PCA provided a robust framework to uncover key stigma dimensions and guiding tailored interventions.

Characterizing populations prioritized for PrEP in 19 African countries: a review of national guidance

INTRODUCTION

While African countries have expanded access to HIV pre-exposure prophylaxis (PrEP) since 2015, regional targets for PrEP uptake remain unmet. Understanding which populations are prioritized for PrEP at the policy level is an important step in determining the scope of PrEP distribution across Africa and identifying gaps in programme implementation. We reviewed national guidance to characterize populations prioritized for PrEP in Africa.

METHODS

Between January and June 2023, we searched for current National HIV Treatment and Prevention Guidelines, National HIV Strategic Plans, and the United States President's Emergency Plan for AIDS Relief (PEPFAR) Country Operational Plans (COPs) for all African countries implementing PrEP programmes supported by PEPFAR in 2022. From each document, we summarize the populations prioritized for PrEP within a country and describe PrEP eligibility.

RESULTS

In 2022, 19 African countries implemented PrEP programmes supported by PEPFAR. Eighteen of these countries contributed National Guidelines (2016-2022), 18 contributed National Strategic Plans (2017-2023) and 19 contributed COPs (2022) to this review. Twenty-nine population groups were prioritized for PrEP in these documents. All countries prioritized HIV-serodifferent couples, female sex workers (FSWs), adolescent girls and young women (AGYW), pregnant and breastfeeding women (PBFW) and people who inject drugs (PWID), and most prioritized men who have sex with men (MSM; n = 18), transgender people (n = 18) and people in prisons (n = 17). The remaining 21 populations were prioritized in fewer than two-thirds of countries.

DISCUSSION

FSWs, MSM, PWID, transgender people and people in prisons were typically prioritized for PrEP with no eligibility restrictions. In contrast, most countries had at least one document indicating that HIV-serodifferent couples, AGYW and PBFW were only eligible for PrEP if classified as high risk. Few documents specified how risk was determined, and no document included validated HIV risk assessment tools to guide implementation. We observed similarities in priority populations across countries with different HIV epidemics and inconsistencies in who was prioritized for PrEP within a country's own set of policy documents.

CONCLUSIONS

Understanding how PrEP prioritization policies impact HIV incidence in different epidemiologic settings is critical for strengthening PrEP implementation across the continent.

Navigating healthcare barriers: a cross-sectional study using respondent-driven sampling to assess migrant women sex workers' access to primary care in France

Introduction

Migrant women sex workers (MWSWs) are affected by higher morbidity rates, reflecting the complex health risks associated with sex work and migration which they face. This study aimed to assess MWSWs' use of primary care services in France, as well as the factors associated with having a family doctor.

Methods

This cross-sectional observational study of 135 cisgender and transgender MWSWs is part of the larger Favoriser l'Accès à la Santé Sexuelle des Travailleuses du Sexe project, which aims to improve global knowledge of and access to sexual healthcare among this population. MWSWs aged 18 years and older were enrolled over 1 year between 2022 and 2023. The primary outcome was the percentage of MWSWs who reported having a family doctor. A best model analysis and a regression model were used to examine associations between having a family doctor and MWSWs' health and social characteristics.

Results

Only 33% of participants reported having a family doctor. Among these, 24% had disclosed they were sex workers to the latter. In general, MWSWs had poor access to preventive healthcare (33% had been HIV tested in the previous year, 33% had used contraception and 19% reported lifetime cervical cancer screening). In contrast, most participants (63.5%) perceived they were in good health. In the multivariate analysis, having a family doctor was not significantly associated with better health outcomes or with the quality of healthcare.

Conclusions

The majority of MWSWs did not have a family doctor; this fact compounds existing health vulnerabilities faced by this marginalised population. Improved targeted interventions are needed to increase healthcare access and quality for MWSWs. These interventions should include strategies to enhance communication with healthcare providers about this population's specific needs.

Barriers and facilitators of HIV partner status notification in low- and lower-middle-income countries: A mixed-methods systematic review

BACKGROUND

The uptake of HIV partner status notification remains limited in low- and lower-middle-income countries. This mixed-methods systematic review aims to summarize the barriers and facilitators of HIV partner status notification in these settings.

METHODS

We searched PubMed, Embase, CINAHL, PsychINFO, Scopus, and Web of Science from January 01, 2000, to August 31, 2023, for empirical qualitative and quantitative studies. Two independent reviewers completed the title, abstract, full-text screening, and data extraction. The risk of bias was assessed using a mixed-methods appraisal tool (MMAT), and the study findings were summarized narratively.

RESULTS

Out of the 2094 studies identified, 59 relevant studies were included. Common barriers included fear of stigma and discrimination, violence, abandonment, breach of confidentiality and trust, low HIV-risk perception, and limited knowledge of HIV and HIV testing. Facilitators of HIV partner status notification were feelings of love and closeness in marital relationships, feelings of protecting self and partners, and HIV counseling services.

CONCLUSION

Efforts to improve HIV partner status notification in low- and lower-middle-income countries should consider barriers and facilitators across all its components, including notification, testing, and linkage to treatment. In addition, HIV partner services must be adapted to the unique needs of key populations.

Association between sex work occupational stigma and inconsistent condom use: findings from a community-based cohort of women sex workers in Vancouver, Canada (2014-2022)

BACKGROUND

Women sex workers face substantial health inequities due to structural barriers including criminalisation and stigma. Stigma has been associated with HIV-related inequities among marginalised populations, however, we know less about the impacts of sex work-specific occupational stigma on HIV/sexually transmitted infection (STI) risk among women sex workers. Given these research gaps and the disproportionate burden of stigma faced by sex workers, we evaluated the association between sex work occupational stigma and recent inconsistent condom use with clients, over an 8-year period (2014-2022).

METHODS

Baseline and semiannual questionnaire data from a prospective, community-based cohort of sex workers in Vancouver, Canada from September 2014 to February 2022 were used. We employed complete-case bivariate and multivariate logistic regression analysis using generalised estimating equations to analyse the relationship between sex work occupational stigma and inconsistent condom use for vaginal/anal sex with clients in the past 6 months.

RESULTS

Among 574 participants, the cumulative prevalence of inconsistent condom use by clients and sex work occupational stigma in the last 6 months was 32.1% (n=184) and 59.9% (n=344), respectively, over the 8-year period. In adjusted multivariable analysis, exposure to sex work occupational stigma was associated with almost twofold increased odds of recent inconsistent condom use with clients (adjusted OR 1.93, 95% CI 1.23 to 3.03) over the 8-year period.

CONCLUSION

Multilevel interventions addressing the role of occupational stigma are needed for HIV and STI prevention efforts, including scale-up of sex worker-led/delivered sexual health services and structural changes to decriminalise and destigmatise sex work.

The protective association of social cohesion on sex workers' experiences of violence and access to community support: Impacts of resource sharing, trust and connection among a community-based cohort in Metro Vancouver, Canada (2010-2022)

OBJECTIVES

To measure recent social cohesion (resource sharing, trust and support) and its association with (1) sexual/physical violence, and (2) engagement with sex work-specific services among women sex workers in Metro Vancouver, Canada.

METHODS

Prospective data (January 2010-August 2022) were drawn from an open cohort of 900+ women sex workers. We developed multivariable logistic regression confounder models with generalized estimating equations (GEE) to examine associations between social cohesion and recent (1) physical/sexual violence and (2) engagement with sex work-specific services.

RESULTS

Of 918 participants, 36.8% were Indigenous and 32.1% were Black/Women of Colour. At baseline, the median social cohesion score was 19 (IQR 16-22), out of 36, with higher levels among participants who work with other sex workers. In separate multivariable confounder models with GEE, social cohesion was associated with lower odds of recent physical/sexual violence (Adjusted Odds Ratio 0.98 per point on scale, 95% Confidence Interval 0.97, 0.99) and recent use of sex work-specific services, although only statistically significant for physical/sexual violence.

CONCLUSIONS

Findings support the need to eliminate policing of work environments that promote sex workers' social cohesion and physical safety through full decriminalization.

The (mis)use of evidence in contested rights: commentary on the UN Special Rapporteur on violence against women and girls' report on "prostitution and violence"

Readers of Sexual and Reproductive Health Matter are no strangers to interrogating evidence in all its forms, assessing which claims it can support, and about challenges and uncertainties in international norms in the fields of sexual and reproductive rights and health. Questions of evidence, positionality and the role of testimony are particularly live in the context of sex work and human rights. As an exploration about good and bad practices in research and evidence, in this Commentary we highlight the errors, mistakes and wrongly shaped conclusions arising in the recent report by the UN Special Rapporteur on violence against women and girls about prostitution law, sex worker health and rights, and the status of international human rights law on sex work and trafficking. We do this not only to reinforce more accurate information about the status of human rights law, public health evidence and the needs of people of all genders in the sex sector, but also as an opportunity to remind us of the principles around evidence, transparency, and self-determination. We are conscious of the current vulnerability of global rights and health systems. Our Commentary seeks to contextualise our criticisms to this current moment of rights and health systems' fragility and multi-pronged attacks on the emancipatory potential of rights for persons in the sex sector as workers especially as they intersect with racist stereotypes. Practices of deploying evidence matter for rights advocacy: its legitimacy as well as its efficacy depend on good practices.

“I don't think I can help you anymore.” Sex workers' experiences of accessing mental health services in Ireland

This paper is based on a study funded by the National Office for Suicide Prevention (NOSP), exploring sex worker mental health through a qualitative study of eighteen sex workers living and working in the Republic of Ireland and with participants from service provider organizations. This paper utilizes and adapts the concept of minority stress to explain how it is the social world that contributes to difficulties in managing mental health, not just for the LGBTQ+ community but explicitly for sex workers, through intersectional stigma and discrimination. Ireland introduced the Criminal Law Amendment Act (2017) based on the Nordic model of client criminalization, which sought to prosecute those that purchase sex while reducing the legal culpability of sex workers. The paper explores how the mental health of sex workers living and working under the law is impacted and the difficulties negotiating access to mental health services once participants disclose their sex work.

Intersecting Stigma and the HIV Care Cascade: Qualitative Insights from Sex Workers, Men who have Sex with Men, and Transgender Women Living with HIV in Jamaica

In Jamaica, stigma experiences of sex workers (SW), gay men and other men who have sex with men (MSM), and transgender women living with HIV remain understudied. To address this gap, we explored experiences of stigma and linkages with the HIV care cascade among key populations living with HIV in Jamaica, including cisgender women SW, MSM, and transgender women. This qualitative study involved n = 9 focus groups (FG), n = 1 FG per population living with HIV (SW, MSM, transgender women) in each of three sites (Kingston, St. Ann, Montego Bay). We also conducted key informant (KI) interviews. We applied thematic analysis informed by the Health Stigma and Discrimination (HSD) Framework. FG participants (n = 67) included SW (n = 18), MSM (n = 28), and trans women (n = 21); we interviewed n = 10 KI (n = 5 cisgender women, n = 5 cisgender men). Participant discussions revealed that stigma drivers included low HIV treatment literacy, notably misinformation about antiretroviral therapy (ART) benefits and HIV acquisition risks, and a lack of legal protection from discrimination. Stigma targets health (HIV) and intersecting social identities (sex work, LGBTQ identities, gender non-conformity, low socio-economic status). Stigma manifestations included enacted stigma in communities and families, and internalized stigma-including lateral violence. HIV care cascade impacts included reduced and/or delayed HIV care engagement and ART adherence challenges/disruptions. Participants discussed strategies to live positively with HIV, including ART adherence as stigma resistance; social support and solidarity; and accessing affirming institutional support. In addition to addressing intersecting stigma, future research and programing should bolster multi-level stigma-resistance strategies to live positively with HIV.

Facilitators and Barriers to Pre-Exposure Prophylaxis Uptake Willingness for Full-Service Sex Workers: A Social-Ecological Approach

Full-service sex workers (FSSWs) are at heightened risk of contracting HIV due to facing multi-level challenges to sexual health. This study investigated factors associated with willingness to use Pre-Exposure Prophylaxis (PrEP) - a daily HIV preventative medication, among FSSWs. Using social-ecological theory, an online survey was developed with initial guidance from a local sex worker advocacy organization to assess barriers and facilitators to PrEP uptake willingness. The survey was disseminated with the assistance of local and national sex work advocacy organizations. In our sample of FSSWs (n=83), two barriers and two facilitators initially were associated with PrEP uptake. However, in adopting a more conservative analysis, only anticipating stigmatizing disapproval from others for using PrEP and providing others with PrEP knowledge maintained statistical significance. These two variables collectively explained nearly 30% of the variance in PrEP uptake willingness. Implications for both future research and clinical work with FSSWs are discussed.

Major financial problems, low mental well-being and reduced HIV/STI testing among sex workers in the Netherlands during the COVID-19 pandemic: a repeated cross-sectional survey

OBJECTIVES

To determine associations between the banning of sex work during the COVID-19 pandemic, and work, financial problems, mental well-being and HIV/sexually transmittable infection (STI) testing among sex workers in the Netherlands.

DESIGN

Two cross-sectional online surveys. The first survey covered two time-periods: pre-COVID-19 (1 January 2019 to 31 December 2019) and period 1 (15 March 2020 to 1 July 2020). The second survey covered period 2 (1 January 2021 to 31 December 2021).

SETTING

The Netherlands PARTICIPANTS: In total, 106 (first survey) and 196 (second survey) sex workers participated. Most of the participants in the first and second survey were cisgender women (respectively, 76.4% and 66.5%), followed by cisgender men (respectively, 12.3% and 15.7%) and the combination of transgender men, transgender women, non-binary or other (respectively, 11.3% and 17.6%). Most participants were born in the Netherlands (respectively, 61.4% and 69.7%).

PRIMARY AND SECONDARY OUTCOME MEASURES

We provide descriptive statistics of self-reported work during and prior to COVID-19 measures, financial problems due to COVID-19 measures and HIV/STI testing and mental well-being during the COVID-19 pandemic. We also performed logistic and linear regression analyses to identify risk factors associated with reporting financial problems due to COVID-19 measures, not testing for HIV/STIs and lower mental well-being during the COVID-19 pandemic.

RESULTS

In periods 1 and 2, respectively, 69.6% and 62.0% reported financial problems due to the COVID-19 measures. Among those who reported to have had sex with clients, the percentage not HIV/STI testing was: 4.5% (95% CI: 0.9; 12.5) pre-COVID-19, 28.2% (95% CI: 15.0; 44.9) in period 1, and 15.2% (95% CI: 9.7; 22.3) in period 2. In the multivariate analysis, reported financial problems due to the COVID-19 pandemic was associated with not HIV/STI testing (OR: 12.1, p<0.001) and lower mental well-being (B: -2.7, p<0.001).

CONCLUSION

The COVID-19 pandemic control measures in the Netherlands were associated with major financial problems, low mental well-being and reduced HIV/STI testing among sex workers.

A Qualitative Systematic Review of Stigma, Violence, Victimization, and Associated Coping Among Transgender People Engaged in Sex Work

Globally, transgender people engaged in sex work experience disproportionately high risks of victimization. While qualitative studies on the perspectives of transgender people engaged in sex work can shed light on their intersecting experiences, a qualitative synthesis could offer a systematic understanding and inform anti-oppressive practices and policies. This review explores the experience of stigma, violence, victimization, and associated coping strategies among transgender people engaged in sex work. We conducted a literature search in November 2023 on MEDLINE, Social Work Abstracts, and CINAHL PLUS from EBSCOhost, APA PsycInfo, ASSIA, and Sociological Abstracts from ProQuest and SCOPUS (PROSPERO ID: CRD42023478844). From 1,085 studies retrieved, 64 were included in this review. Thematic synthesis identified seven themes: (a) individual struggle, (b) interpersonal violence, (c) community transphobia and exclusion, (d) systemic oppression, (e) individual coping strategies, (f) community resources, and (g) organizational support as coping resources. This review contributes to the discussion around the health vulnerabilities of transgender people engaged in sex work that inherently result from intersecting victimization in a larger global context, including trafficking, urban planning, migration, and COVID-19. Identification of the coping strategies of transgender people engaged in sex work also highlights their resilience and sites of empowerment. Policymakers and professionals should be mindful of the intersectional identities of transgender people engaged in sex work and initiate peer- and community-led interventions to support them in building intersectional solidarity and resisting victimization.

Patterns of inconsistent condom use and risky sexual behaviors among female sex workers in Mozambique

BACKGROUND

Female sex workers (FSWs) in Mozambique face significant health risks, including high HIV prevalence, combination of factors, including inconsistent condom use, engagement in risky sexual behaviors, and various socio-ecological determinants of health. Understanding the determinants of these practices is crucial for developing targeted interventions.

METHODS

This cross-sectional study analyzed data from the second round of Biobehavioral Survey (BBS) conducted from 2019 to 2020 in five urban areas to examine determinants of inconsistent condom use and risky sexual behaviors among FSWs. Modified Poisson regression models were used to assess the effect of various socio-demographic, economic, and behavioral factors on the outcomes, providing adjusted relative risk (aRR) with 95% confidence intervals (CI).

RESULTS

Among the 2,565 FSWs who reported inconsistent condom use, younger FSWs (15-24 years old, 29.1%), single (27.3%), with secondary or higher education (26.1%), nationals (25.9%), and residents of Tete City (30.5%) had a higher prevalence of inconsistent condom use. Initiating sex work < 18 years (31.0%), binge drinking (23.7%), and experiencing physical violence (29.0%) were significantly associated with this behavior. Among the 2,564 FSWs reporting risky sexual behaviors, a higher prevalence was observed in FSWs aged 15-24 (75.6%), those with secondary or higher education (75.8%), nationals (74.4%), and those residing in Quelimane (87.3%). Early sexual debut (< 15 years, 79.3%), initiating sex work before 18 years of age (77.7%), and illicit drug use (82.2%) were all associated with increased risky sexual practices. Inconsistent condom use among FSWs was significantly associated with residing in Tete (aRR = 2.4, 95% CI: 1.77-3.25), not being aware of female condom (aRR = 1.22, 95% CI: 1.03-1.45) and having experienced sexual a physical violence. Moreover, being married was significantly linked to risky sexual behavior among female sex workers (aRR = 1.27, 95% CI: 1.19-1.37), along with initiating sexual activity before age 15, having at least five years of sex work experience, engaging in binge drinking, and experiencing sexual and physical violence.

CONCLUSION

The study highlights the complex set of factors as age, education, geographic location, years of sex work services, early sexual debut, and illicit drug use that influence sexual risks behavior among FSWs in Mozambique. Tailored interventions addressing not only sexual health education and services, but also economic empowerment and illicit drug use is imperative for mitigating these risks.

Stressful Life Events Among Women Suffering Homelessness and Prostitution in Spain

The aim of the study was to analyze the differences in suffering stressful life events (SLE) among women experiencing homelessness who had or had not been in prostitution. Data were collected from a sample of 135 women experiencing homelessness in Madrid. A total of 81% of the women interviewed had never been in prostitution, while 19% had been in prostitution at some point in their lives. Participants were recruited from shelters, drop-in centers, and public spaces. The information was collected using a structured interview. The results showed that women experiencing homelessness who had been in prostitution suffered a greater number of SLE, both in childhood and adolescence and throughout life. The interviewed who had been in prostitution were between two and nine times more likely to have experienced during their childhood and adolescence violence in their family, as well as to have run away from home, experienced abuse, attempted suicide, and used drugs excessively. Furthermore, during their lifetime, the interviewed who had been in prostitution were between two and four times more likely to suffer from serious physical and mental health issues, excessive alcohol consumption, intimate partner violence, physical violence from others, suicide attempts, police reporting, and unwanted pregnancies. Additionally, they were four to six times more likely to have been sexually assaulted or convicted/imprisoned for a crime, seven times more likely to have been arrested, and a striking 32 times more likely to have used drugs excessively.

The Legality of Labor and Perceptions of Deservingness of Rights and Services for Sex Workers

Access to social services like healthcare, education, housing, and welfare are integral to creating an equitable society. While many populations inherently benefit from these services, sex workers are often denied these rights and services because of the nature of their work. The purpose of this study was to examine perceptions of deservingness of sex workers for a wide range of rights and services. This study distinguished those attitudes across legal and illegal forms of sex work, identified attitudinal and demographic correlates associated with those perceptions, and examined potential interactions between respondents' gender and age. Participants included a nationwide sample of adults from the USA (n = 549). Results indicated that participants perceived legal sex work as more deserving of rights and services compared to illegal sex work. Perceptions of deservingness were associated with attitudes toward abortion, LGBTQ+ rights, and perceptions of government legitimacy. Overall, older individuals were less willing to extend rights and services to sex workers and women were more likely to perceive sex workers as deserving of rights and services. There was an interaction between gender and age. For illegal sex work, gender differences in perceptions converged as participants aged, whereas for legal sex work, gender differences were exacerbated with age, with men reporting particularly restrictive perceptions of deservingness.

Application of 'CDC- Public Security Bureau-NGO' Joint Prevention and Control Mechanism Allied AIDS prevention and control in Guigang, Guangxi

BACKGROUND

HIV/AIDS has emerged as a nationwide epidemic and has taken the forefront position as the primary infectious killer of adults in China. The control and prevention of the disease have been hampered by a weak link in the form of heterosexual transmission. However, conventional intervention measures have demonstrated suboptimal efficacy in reducing the incidence of new HIV infections. In light of the current epidemiological characteristics, we have developed and executed an innovative intervention model known as the Joint Prevention and Control Mechanism of the 'CDC-Public Security Bureau-NGO'. The purpose of this research is to assess the impact of this model on the AIDS awareness, HIV infection rates, sexual behavior, and associated factors among female sex workers and elderly clients. Through the provision of robust evidence of the efficacy of this innovative model, we seek to advocate for its implementation in future interventions.

METHODS

The research design of this study incorporates both a serial cross-sectional study and time-series analysis from 2014 to 2021, including a 4-year traditional intervention (2014-2017) and the 4-year 'CDC-Public Security Bureau-NGO' innovative intervention (2018-2021), was conducted to evaluate the effects of the new intervention. The GM(1, 1) model was performed to predict the proportion of HIV infection without implementing the innovative intervention in 2018-2021; P and C values were used to evaluate the performance of the model. Mann-Kendall test and descriptive methods were used to analyzed the trend of traditional and innovative interventions models on HIV positive detection rate in FSWs and elderly clients.

RESULTS

The condom usage rates during the last commercial sexual encounter for FSWs and elderly clients improved from 74.9% and 9.1%, respectively, to 96.9% and 28.1%. (P < 0.05), newly reported cases of HIV have decreased by 15.56% yearly and the HIV positive detection rate among middle-aged and elderly people has dropped by 14.47%. The innovative intervention model has significantly reduced the HIV infection rates.

CONCLUSIONS

The 'CDC-Public Security Bureau-NGO' innovative intervention has achieved beneficial effects on HIV/AIDS prevention and control and provides a good reference for Guangxi, China.

East London Project: a participatory mixed-method evaluation on how removing enforcement could affect sex workers' safety, health and access to services in East London

Background

Sex workers' risk of violence and ill-health is shaped by their work environments, community and structural factors, including criminalisation.

Aim

We evaluated the impact of removing police enforcement on sex workers' safety, health and access to services.

Design

Mixed-methods participatory study comprising qualitative research, a prospective cohort study, mathematical modelling and routine data collation.

Setting

Three boroughs in London, UK.

Participants

People aged ≥ 18 years, who provided in-person sexual services.

Interventions

Simulated removal of police enforcement.

Outcomes

Primary - recent or past experience of sexual, physical or emotional violence. Secondary - depression/anxiety symptoms, physical health, chlamydia/gonorrhoea, and service access.

Results

A combination of enforcement by police, local authorities and immigration, being denied justice when reporting violence, and linked cuts to specialist health and support services created harmful conditions for sex workers. This disproportionately affected cisgender and transgender women who work on the streets, use drugs, are migrants and/or women of colour. Among women (n = 197), street-based sex workers experienced higher levels than indoor sex workers of recent violence from clients (73% vs. 36%), police (42% vs. 7%) and others (67% vs. 17%); homelessness (65% vs. 7%); anxiety and depression (71% vs 35%); physical ill-health (57% vs 31%); and recent law enforcement (87% vs. 9%). For street-based sex workers, recent arrest was associated with violence from others (adjusted odds ratio (AOR)) 2.77, 95% confidence interval (CI) 1.11 to 6.94). Displacement by police was associated with client violence (AOR 4.35; 95% CI 1.36 to 13.90) as were financial difficulties (AOR 4.66; CI 1.64 to 13.24). Among indoor sex workers, unstable residency (AOR 3.19; 95% CI 1.36 to 7.49) and financial difficulties (AOR 3.66; 95% CI 1.64 to 8.18) contributed to risk of client violence. Among all genders (n = 288), ethnically and racially minoritised sex workers (26.4%) reported more police encounters than white sex workers, partly linked to increased representation in street settings (51.4% vs. 30.7%; p = 0.002) but associations remained after adjusting for work setting. Simulated removal of police displacement and homelessness was associated with a 71% reduction in violence (95% credible interval 55% to 83%). Participants called for a redirection of funds from enforcement towards respectful, peer-led services.

Limitations

Restriction to one urban locality prevents generalisability of findings. More interviews with under-represented participants (e.g. trans/non-binary sex workers) may have yielded further insights into inequities. Correlation between different risk factors restricted outcomes of interest for the modelling analyses, which were largely limited to experience of violence.

Conclusion

Our research adds to international evidence on the harms of criminalisation and enforcement, particularly for women who work on street and/or are racially or ethnically minoritised. Findings add weight to calls to decriminalise sex work, tackle institutionally racist, misogynist and otherwise discriminatory practices against sex workers in police and other agencies, and to (re)commission experience-based, peer-led services by and for sex workers particularly benefiting the most marginalised communities.

Future work

Realist informed trials, co-produced with sex workers, would provide rigorous evidence on effective approaches to protect sex workers' health, safety and rights.

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 15/55/58.

The Question of Moral Worth in a Controversial Market: Moral Justification Regimes and Boundary Work Among Israeli Men Who Pay for Sex Abroad

This study examined the internal moral debate that takes place among Israeli men who pay for sex (MWPS) while traveling abroad. We explored how they construct their sense of moral worth and present themselves as moral subjects in light of the intensified stigmatization of their actions. Using the theoretical frameworks of pragmatic morality and boundary work, we conceptualize four main moral justification regimes that MWPS use to construct themselves as moral subjects: Cultural normalization; Conditional freedom of choice; The altruistic act of charity; and Unpacking the Stigma Discourse. The findings highlight how these justification regimes are anchored in three intersecting fields - cultural, spatial, and power relations - which produce various matrices of conflict, compromise, or collaboration in different situations. Thus, the flexible switching between various justification regimes reveals how MWPS define themselves and their activities and negotiate various moral dispositions - akin to various cultural logics - in the context of moral taint and stigma.

Optimising the public health benefits of sex work regulation in Senegal: Results from qualitative interviews with policy stakeholders

CONTEXT

There is compelling evidence that eliminating sexually transmitted infections (STIs) among female sex workers (FSWs) is a cost-effective approach to reducing the spread of HIV/AIDS. Although many countries recognise sex work as a public health issue, few have implemented public health policies specifically aimed at controlling the transmission of HIV/AIDS among FSWs. In particular, Senegal stands out as the only African country to regulate sex work through a specific public health policy that requires FSWs to register with a health centre. Despite the potential health and legal benefits associated with registration, a staggering 80% of FSWs in Senegal remain unregistered. This low registration rate hinders the realisation of the policy's full potential for public health benefits. The reluctance of FSWs to register is due to inherent flaws in the policy design, where the disadvantages of registration outweigh the benefits for FSWs.

OBJECTIVE

To identify which modifications to the current registration policy have the potential to increase uptake of registration by FSWs and to assess their feasibility in the context of Senegal.

METHOD

We conducted a qualitative policy research study using semi-structured in-depth interviews with 22 national stakeholders in this policy, including representatives from the police, government and non-governmental organisations (NGOs) in Dakar, Senegal, as well as FSWs' leaders. The interview data were thematically coded using the interview topic guide and other recurring themes and analysed using thematic analysis on Nvivo 12.

RESULTS

A total of 20 relevant themes were selected, focusing primarily on assessing the feasibility of potential interventions and identifying potential barriers and associated risks. We found that, without changing current legislation, improving relationships between FSWs and police officers, providing accurate and accessible information about the rules and benefits of the policy, and offering psychosocial support have the potential to improve both the registration rate of FSWs and their wellbeing. Policy features designed to increase registration by improving FSWs' confidentiality, and thus their confidence in the services offered, were also discussed.

CONCLUSIONS

The study highlighted that several national public health policies could be changed to increase the registration rate of FSWs and improve their wellbeing without overturning constitutional law.

HIV incidence among women engaging in sex work in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Women who engage in sex work in sub-Saharan Africa have a high risk of acquiring HIV infection. HIV incidence has declined among all women in sub-Saharan Africa, but trends among women who engage in sex work are poorly characterised. We synthesised data on HIV incidence among women who engage in sex work in sub-Saharan Africa and compared these with the total female population to understand relative incidence and trends over time.

METHODS

We searched MEDLINE, Embase, Global Health, and Google Scholar from Jan 1, 1990, to Feb 28, 2024, and grey literature for studies that reported empirical estimates of HIV incidence among women who engage in sex work in any sub-Saharan Africa country. We calculated incidence rate ratios (IRRs) compared with total female population incidence estimates matched for age, district, and year, did a meta-analysis of IRRs, and used a continuous mixed-effects model to estimate changes in IRR over time.

FINDINGS

From 32 studies done between 1985 and 2020, 2194 new HIV infections were observed among women who engage in sex work over 51 490 person-years. Median HIV incidence was 4·3 per 100 person years (IQR 2·8-7·0 per 100 person-years). Incidence among women who engage in sex work was eight times higher than matched total population women (IRR 7·8 [95% CI 5·1-11·8]), with larger relative difference in western and central Africa (19·9 [9·6-41·0]) than in eastern and southern Africa (4·9 [3·4-7·1]). There was no evidence that IRRs changed over time (IRR per 5 years: 0·9 [0·7-1·2]).

INTERPRETATION

Across sub-Saharan Africa, HIV incidence among women who engage in sex work remains disproportionately high compared with the total female population. However, constant relative incidence over time indicates HIV incidence among women who engage in sex work has declined at a similar rate. Location-specific data for women who engage in sex work incidence are sparse, but improved surveillance and standardisation of incidence measurement approaches could fill these gaps. Sustained and enhanced HIV prevention for women who engage in sex work is crucial to address continuing inequalities and ensure declines in new HIV infections.

FUNDING

Bill & Melinda Gates Foundation, UK Research and Innovation, National Institutes of Health.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

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

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

Sexual health beliefs and prevention of sexually transmitted infections among cisgender women sex workers in Colombia

INTRODUCTION

The stigma and social discrimination against cisgender women sex workers lead many of them to live in conditions characterized by social inequality, marginalization, persecution, and limited opportunities for sexual health literacy. Consequently, they are often compelled to establish a framework of preventive beliefs with little scientific validity, which they use to identify, mitigate, or avoid sexual health risks arising from their interactions with clients. This study investigates the sexual health beliefs that influence self-care practices aimed at preventing sexually transmitted infections among cisgender women sex workers in Colombia.

METHODS

We conducted a qualitative study framed in Hermeneutic Phenomenology. In-depth interviews and discussion groups were conducted with 34 cisgender women sex workers over 18 years of age in the center of the cities of Bogotá and Barranquilla in Colombia.

RESULTS

Seven themes emerged from the reflective and inductive thematic analysis of the narratives: (1) popular habits for the prevention of contagion, (2) ocular assessment of genitals, (3) condom lubrication, (4) suspicion of a hidden infection in the client, (5) saliva and oral contact as a source of contagion, (6) avoidance of semen contact, (7) and trust in God as protection.

CONCLUSIONS

The findings reflect the need for health and social professionals to promote participatory and inclusive cooperation with sex workers to update the framework of preventive beliefs that help them guide sexual health self-care with autonomy and self-efficacy, strengthening favorable beliefs and negotiating unfavorable ones. It is also essential to have a sex worker-informed sexual health policy that guides the promotion of sexual health that is sensitive to the needs and consistent with the risks of sex work and ensures friendly and non-oppressive preventive care environments for sex workers.

Pandemic-related challenges accessing food and primary healthcare among sex workers during the COVID-19 pandemic: findings from a community-based cohort in Vancouver, Canada

INTRODUCTION

Globally, the COVID-19 pandemic upended healthcare services and created economic vulnerability for many. Criminalization of sex work meant sex workers were largely ineligible for Canada's government-based financial pandemic relief, the Canadian Emergency Response Benefit. Sex workers' loss of income and inability to access financial support services during the pandemic resulted in many unable to pay rent or mortgage, and in need of assistance with basic needs items including food. Little is known about the unique experiences of sex workers who faced challenges in accessing food during the pandemic and its impact on healthcare access. Thus, we aimed to identify the association between pandemic-related challenges accessing food and primary healthcare among sex workers.

METHODS

Prospective data were drawn from a cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers' Health Access, AESHA; 2010-present). Data were collected via questionnaires administered bi-annually from October 2020-August 2021. We used univariate and multivariable logistic regression with generalized estimating equations to assess the association between pandemic-related challenges accessing food and challenges accessing primary healthcare over the study period.

RESULTS

Of 170 participants, 41% experienced pandemic-related challenges in accessing food and 26% reported challenges accessing healthcare. Median age was 45 years (IQR:36-53), 56% were of Indigenous ancestry, 86% experienced intimate partner violence in the last six months, and 62% reported non-injection substance use in the last six months. Experiencing pandemic-related challenges accessing food was positively associated with challenges accessing primary healthcare (Adjusted Odds Ratio: 1.99, 95% Confidence Interval: 1.02-3.88) after adjustment for confounders.

CONCLUSIONS

Findings provide insight about the potential role community-based healthcare delivery settings (e.g., community clinics) can play in ameliorating access to basic needs such as food among those who are highly marginalized. Future pandemic response efforts should also take the most marginalized populations' needs into consideration by establishing strategies to ensure continuity of essential services providing food and other basic needs. Lastly, policies are needed establishing basic income support and improve access to food resources for marginalized women in times of crisis.

AN EVALUATION OF INDOOR SEX WORKERS' PSYCHOSOCIAL OCCUPATIONAL HEALTH AND SAFETY IN METRO VANCOUVER, CANADA

Criminalization of sex work is linked to increased risk of violence and lack of workplace protections for sex workers. Most jurisdictions globally prohibit some or all aspects of sex work with New Zealand constituting a notable exception, where sex work has been decriminalized and regulated via OHS guidelines. We used the Guide to Occupational Health and Safety in the New Zealand Sex Industry (NZ Guide) as an analytical framework to examine the lived-experiences of psychosocial OHS conditions of indoor sex workers in Metro Vancouver under end-demand criminalization. We drew on 47 semi-structured interviews, conducted in English, Mandarin, and Cantonese in 2017-2018, with indoor sex workers and third parties providing services for them. Participants' narratives were analyzed using a coding framework based on the NZ Guide's psychosocial factors section, including safety and security from violence and complaints processes, which highlighted specific OHS shortcomings in the context of end-demand sex work legislation in indoor sex work environments. Participants identified a significant lack of OHS support, including a lack of safety training, right to refuse services, and access to justice in the context of labour rights violations or fraud, robbery or violence. Our findings emphasize the benefits of full decriminalization of sex work to facilitate sex workers' access to OHS through development and implementation of OHS guidelines designed by and for the indoor sex industry. OHS guidelines should focus on labour rights and protections, including development of sex workers' right to refuse services and access to justice.

Evaluation of health status of transgender sex workers in Turkey: A qualitative study

OBJECTIVE

Sex workers can be disadvantaged in terms of overall health due to challenging living and working conditions. This research aimed to evaluate the health status and experiences related to sexually transmitted infections (STDs) of unregistered transgender sex workers in Turkey.

DESIGN

It employed a phenomenological qualitative research design. SITE: Data were collected in Istanbul between March 2021 and November 2021.

PARTICIPANTS

Data were collected through in-depth interviews involving 24 people (19 sex workers and 5 physicians).

METHODS

Key statements were listed during data analysis, and clusters of meanings were formed based on these statements. The participants' statements were used for contextual and structural descriptions.

RESULTS

Sex workers suffer from chronic illnesses such as asthma, chronic obstructive pulmonary disease (COPD), diabetes, allergic diseases, and neurological disorders. Among the health issues affecting them, the most notable ones are STDs, psychological problems, and the risk of suicide. Sex workers also face a dilemma between choosing public hospitals and private hospitals. Majority of sex workers undergo regular testing for STDs, with the frequency varying from person to person. Reasons for not undergoing regular testing include lack of social security coverage, financial constraints, lack of information, and feeling undervalued. Some individuals are being subjected to mandatory testing.

CONCLUSIONS

It is recommended that sex workers who seek and request healthcare services should be provided with detailed information and education, particularly regarding psychological problems and STDs.

Sexual Health Needs Among Men Who Engage in Transactional Sex with Men in the UK

Men who engage in transactional sex with men (MTSM) are a high-risk population for HIV and other sexually transmitted infections. Epidemiological data have so far included them in the broad category of men who have sex with men (MSM), while research on transactional sex typically focused on female sex workers. The internet has substantially changed sex work practices and earlier findings concerning the sexual health needs of MTSM may no longer be applicable. We analyzed quantitative data from MSM based in the UK (n = 11629) taking part in the European MSM Internet Survey (EMIS-2017). Compared to non-MTSM, MTSM (n = 230; 2%) were younger, more likely to self-identify as an ethnic minority, be single, have lower education levels, struggle financially, and-controlling for age-more likely to be living with diagnosed HIV. Commonly unmet needs among all MSM were a lack of confidence in accessing HIV post-exposure prophylaxis, uncertainty about HIV status, and ignorance of where to access hepatitis vaccinations. Compared with other MSM, MTSM were notably less satisfied with the safety of their sexual practices, less confident in their ability to maintain sexual boundaries, and more likely to engage in risk because of absent precautionary resources. Given their greater opportunity for sexual risk, as well as fewer resources for negotiating safety, our findings suggest that services should prioritize MTSM in HIV prevention and sexual health promotion, including assertiveness and social skills training, in addition to knowledge-based education.

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.

MyPEEPS Mobile App for HIV Prevention Among Transmasculine Youth: Adaptation Through Community-Based Feedback and Usability Evaluation

BACKGROUND

Transgender men and transmasculine youth are at high risk for acquiring HIV. Growing research on transgender men demonstrates increased HIV risk and burden compared with the general US population. Despite biomedical advancements in HIV prevention, there remains a dearth of evidence-based, sexual health HIV prevention interventions for young transgender men. MyPEEPS (Male Youth Pursuing Empowerment, Education, and Prevention around Sexuality) Mobile is a web-based app that builds on extensive formative community-informed work to develop an evidence-based HIV prevention intervention. Our study team developed and tested the MyPEEPS Mobile intervention for 13- to 18-year-old cisgender young men in a national randomized controlled trial, which demonstrated efficacy to reduce sexual risk in the short term-at 3-month follow-up. Trans men and transmasculine youth resonated with basic HIV educational information and sexual scenarios of the original MyPEEPS app for cisgender men, but recognized the app's lack of transmasculine specificity.

OBJECTIVE

The purpose of this study is to detail the user-centered design methods to adapt, improve the user interface, and enhance the usability of the MyPEEPS Mobile app for young transgender men and transmasculine youth.

METHODS

The MyPEEPS Mobile app for young transgender men was adapted through a user-centered design approach, which included an iterative review of the adapted prototype by expert advisors and a youth advisory board. The app was then evaluated through a rigorous usability evaluation.

RESULTS

MyPEEPS Mobile is among the first mobile health interventions developed to meet the specific needs of young transgender men and transmasculine youth to reduce HIV risk behaviors. While many of the activities in the original MyPEEPS Mobile were rigorously developed and tested, there was a need to adapt our intervention to meet the specific needs and risk factors among young transgender men and transmasculine youth. The findings from this study describe the adaptation of these activities through feedback from a youth advisory board and expert advisors. Following adaptation of the content, the app underwent a rigorous usability assessment through an evaluation with experts in human-computer interaction (n=5) and targeted end users (n=20).

CONCLUSIONS

Usability and adaptation findings demonstrate that the MyPEEPS Mobile app is highly usable and perceived as potentially useful for targeting HIV risk behaviors in young transgender men and transmasculine youth.

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.

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.

I'm a 45-year-old woman in the body of an 80-year-old: The multiple losses of living and aging in the shadow of prostitution

INTRODUCTION

Research on aging women who are involved in prostitution is currently limited, both in terms of the number of studies conducted and their scope. Nevertheless, the available research suggests that women who are aging while involved in prostitution may confront some unique challenges. Thus, the study aims to explore the experiences of aging as narrated by Arab women in prostitution, using Intersectionality as a theoretical framework.

METHOD

Interpretive phenomenological analysis was used, and semistructured interviews were performed with 12 participants.

FINDINGS

Four themes emerged: "I'm a 45-year-old woman in the body of an 80-year-old:" Loss of physical and mental health; "There is no retirement plan in prostitution: Economic and social losses; As they were taken, my soul went with them too: The loss of the parenting experience and motherhood"; and "I'm going to get older with the disgust clinging to me:" The loss of authentic identity and dignity.

CONCLUSION

The findings demonstrate how aging serves to exacerbate overlapping forms of discrimination and marginalization.

CLINICAL RELEVANCE

Healthcare professionals, including nurses caring for older women in prostitution, should be aware of their unique circumstances, considering the social, economic, and healthcare obstacles they face. By being cognizant of these factors, healthcare practitioners can provide meaningful assistance in their pursuit of improved quality of life.

The impact of policing and homelessness on violence experienced by women who sell sex in London: a modelling study

Street-based sex workers experience considerable homelessness, drug use and police enforcement, making them vulnerable to violence from clients and other perpetrators. We used a deterministic compartmental model of street-based sex workers in London to estimate whether displacement by police and unstable housing/homelessness increases client violence. The model was parameterized and calibrated using data from a cohort study of sex workers, to the baseline percentage homeless (64%), experiencing recent client violence (72%), or recent displacement (78%), and the odds ratios of experiencing violence if homeless (1.97, 95% confidence interval 0.88-4.43) or displaced (4.79, 1.99-12.11), or of experiencing displacement if homeless (3.60, 1.59-8.17). Ending homelessness and police displacement reduces violence by 67% (95% credible interval 53-81%). The effects are non-linear; halving the rate of policing or becoming homeless reduces violence by 5.7% (3.5-10.3%) or 6.7% (3.7-10.2%), respectively. Modelled interventions have small impact with violence reducing by: 5.1% (2.1-11.4%) if the rate of becoming housed increases from 1.4 to 3.2 per person-year (Housing First initiative); 3.9% (2.4-6.9%) if the rate of policing reduces by 39% (level if recent increases had not occurred); and 10.2% (5.9-19.6%) in combination. Violence reduces by 26.5% (22.6-28.2%) if half of housed sex workers transition to indoor sex work. If homelessness decreased and policing increased as occurred during the COVID-19 pandemic in 2020, the impact on violence is negligible, decreasing by 0.7% (8.7% decrease-4.1% increase). Increasing housing and reducing policing among street-based sex workers could substantially reduce violence, but large changes are needed.

'Change creates change' - older female sex workers' experiences through the early COVID-19 pandemic

COVID-19 and associated policy responses created unique social, economic and health risks for sex workers. Through semi-structured interviews we explored pre- and early COVID-19 experiences and work practices of ten cisgender female sex workers 50 years of age and older in Queensland, Australia, analysing the findings using a risk environment framework. Throughout early 2020, participants navigated a complex risk environment, managing economic needs, health and safety, occupational stigma and policing. Australia's policy responses altered the risks and opportunities available to participants. Half the participants continued sex work and half stopped sex work with some accessing economic support and withdrawing superannuation savings. Those who continued sex work drew on life and work experience to reassess changing health, stigma, and policing risks, and adapted their work strategies by increasing client screening and modifying services. Participants relied on information from peer networks and organisations to guide work practices but remained wary of contact tracing, police and the media. Decriminalisation of sex work and the strengthening of sex worker organisation and government partnerships are important in embedding equity in responses to ongoing and new public health threats.

Experiences of interpersonal violence among a diverse sample of male sex workers

A notable portion of men who have sex with men engage in exchange sex-i.e. the trading of sex for money, drugs, shelter or other material goods. Despite the risks for physical and sexual violence, threatening behaviour and robbery that male sex workers confront, very little is known about their experiences of such actions by clients. To gain more insight into male sex workers' experiences of interpersonal violence, we analysed qualitative interview data from 180 men who have sex with men from 8 US cities who engaged in sex work with clients they had met primarily through dating/hookup websites and apps. Participants discussed their experiences of a range of untoward behaviours by clients including physical violence, sexual violence, threats and robbery. Healthcare and social services providers can play a significant role in violence prevention among male sex workers. The decriminalisation of sex work could also potentially reduce the risks many sex workers face by facilitating their reporting of harms suffered.