Policing practices as a structural determinant for HIV among sex workers: a systematic review of empirical findings

Police Harassment and Violence Against Transgender & Gender Diverse Sex Workers in the United States

Sex workers continue to experience high rates of abuse and violence around the world. However, information regarding police-perpetrated harassment and violence against transgender and gender diverse (TGD) sex workers in the United States remains extremely limited. The current study is the first known examination of police interaction, harassment, and violence among TGD sex workers in the United States using a large nationwide dataset. Data from 23,372 TGD people were used. Results revealed that sex workers were more likely to experience police interaction, harassment, and violence compared to non-sex workers. Among sex workers with police interaction while doing sex work, 89.2% reported experiencing at least one type of harassment and/or violence. Regression analyses revealed that individuals with no reported income and trans women were more likely to experience multiple types of police harassment/violence. Taken together, TGD sex workers continue to experience alarming rates of interaction, harassment, and violence from police in the United States. Urgent, and effective intervention is needed to eliminate police harassment and violence toward TGD sex workers and provide support for TGD sex workers who survive this violence.

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.

Contraceptive decision-making through the lens of social determinants of health among female sex workers: A qualitative descriptive study

AIMS

The aim of the study was to examine how female sex worker's motivations, desires, intentions and behaviours towards childbearing and childbearing avoidance inform their contraceptive decision-making. We explored the influence of social determinants of health in the domains of social context (sexual partners and experiences of violence), healthcare access, economic instability on the contraceptive decision-making process.

DESIGN

We conducted a qualitative descriptive study informed by Miller's Theory of Childbearing Motivations, Desires and Intentions through the lens of social determinants of health.

METHODS

Participants were recruited from a parent study, EMERALD, in July-September, 2020. Data were collected from 22 female sex workers ages 18-49 using semi-structured 45 to 60-min audio-recorded interviews and transcribed verbatim. Theory guided the development of the study's interview guide and thematic analytic strategy.

RESULTS

Five themes emerged related to contraceptive decision-making: Motivations (value of fatherhood), Desires (relationships with love), Intentions and Behaviours (drugs overpower everything, contraceptive strategies and having children means being a protector). Women's contraceptive decision-making often included intentions to use contraception. However, social determinants such relationships with clients and intimate partners, interpersonal violence and challenges accessing traditional health care offering contraceptive services often interfered with these intentions and influenced contraceptive behaviours.

CONCLUSION

Women's contraceptive decision-making process included well-informed desires related to childbearing and contraceptive use. However, social determinants across domains of health interfered with autonomous contraceptive decision-making. More effort is needed to examine the influence of social determinants on the reproductive health of this population.

IMPACT

Findings from this study build on existing research that examines social determinants impacting reproductive health among female sex workers. Existing theoretical frameworks may not fully capture the influence constrained reproductive autonomy has on contraceptive decision-making. Future studies examining interpersonal and structural barriers to contraception are warranted.

PATIENT OR PUBLIC CONTRIBUTION

The parent study, EMERALD, collaborated with community service providers in the study intervention.

Who Asks About HIV/STI Status?: An Analysis of Women Who Sell Sex and Inject Drugs

Communication about HIV and sexually transmitted infections (STI) is a cornerstone of risk reduction, yet there is a dearth of research that examines communication patterns among persons with dual risks for HIV/STI acquisition, such as women who sell sex and inject drugs (WSSID). We used logistic regression to identify factors associated with WSSID (N = 211) in Baltimore, Maryland always asking new clients about their HIV/STI status. Most WSSID were non-Hispanic White (73%) and 74% reported current homelessness. 50% of WSSID reported always asking new clients about their HIV/STI status. Experiencing depressive symptoms (adjusted odds ratio [aOR]: 0.53; 95% confidence interval [CI]: 0.29, 0.96) and having condomless sex with clients (aOR 0.31; 95% CI: 0.17, 0.57) were inversely associated with WSSID always asking new clients about their HIV/STI status. Recent entry into sex work (aOR 2.99; 95% CI: 1.30, 6.87) was positively associated with always asking new clients about their HIV/STI status. Enhancing HIV/STI communication in combination with engagement in other risk mitigation strategies may decrease disease incidence among WSSID.

HIV prevention in individuals engaged in sex work

PURPOSE OF REVIEW

People who sell sex remain at disproportionate risk of acquiring HIV and should be prioritized for evidence-based HIV prevention programmes delivered at sufficient scale and intensity for effectiveness. Although new biomedical tools are becoming available, many basic lessons learned early in the HIV pandemic remain salient today and need renewed attention.

RECENT FINDINGS

New preexposure prophylaxis formulations, distribution systems, and delivery mechanisms are being successfully trialled and implemented, adding to well established prevention tools such as male and female condoms and lubricants. The importance of social support networks and community ownership of programmes has been consistently reaffirmed. Serious challenges remain in optimizing HIV prevention for sex workers, including providing services at the scale and intensity necessary for population level impact, addressing culturally sensitive issues of gender identity and sexual orientation, and protecting adolescents and young people who may sell sex. Pervasive social stigma, often reinforced by criminalization and police harassment, further constrain sex workers' access to available services and prevention tools.

SUMMARY

Meaningful community engagement and addressing the multiple social determinants of vulnerability at individual, community, and structural levels remain at the core of preventing HIV among people involved in selling sex.

Association of sex work and social-structural factors with non-fatal overdose among women who use drugs in Vancouver, Canada

BACKGROUND

Women who use drugs (WWUD) and engage in sex work experience disproportionate sex- and drug-related harms, such as HIV, however comparatively little is known about their overdose risk. Therefore, we examined the association between sex work and overdose and secondarily explored the association of social-structural factors, such as policing and gendered violence, with overdose.

METHODS

Data were derived from two community cohort studies based in Vancouver, Canada between 2005 to 2018. We used logistic regression with GEE to examine the associations between a) sex work and nonfatal overdose and b) social-structural and individual variables with overdose among WWUD who engaged in sex work during the study. Sex work, overdose, and other variables were time-updated, captured every six months.

RESULTS

Among 857 WWUD included, 56% engaged in sex work during the study. Forty-three percent of WWUD engaged in sex work had at least one overdose compared to 26% of WWUD who did not. Sex work was not significantly associated with an increased odds of overdose (AOR = 1.14, 95% CI: 0.93-1.40). In the exploratory analysis amongst 476 WWUD engaged in sex work, social-structural variables associated with overdose in the multivariable model included exposure to: punitive policing (OR = 1.97, 95% CI: 1.30-2.96) and physical or sexual violence (OR = 2.55, 95% CI: 1.88-3.46).

CONCLUSIONS

WWUD engaged in sex work had an increased overdose burden that may be driven by social-structural factors rather than sex work itself. Interventions that address policing and gendered violence represent potential targets for effective overdose prevention.

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.

External resilience in the context of drug use and socio-structural vulnerabilities: a qualitative exploration among women who use drugs and sell sex in Baltimore, Maryland

Background

Resilience is a commonly used construct in substance use and mental health research. Yet it is often narrowly defined by only its internal qualities (e.g., adaptability, hardiness) and overlooks its external qualities (e.g., supportive relationships, navigating one’s environment). Further, substance use is often viewed as antithetical to resilience despite populations like women who use drugs and sell sex (WWUD-SS) surviving significant hardships. This study aims to fill a gap in the literature by characterizing external resilience among WWUD-SS and understanding the ways that socio-structural vulnerabilities (e.g., poverty, stigma) and substance use shape external resilience.

Methods

WWUD-SS (N = 18) enrolled in an ongoing cohort study were purposively sampled for age, race, and recruitment location and participated in semi-structured, in-depth interviews aimed to elucidate external resilience (i.e., social support and resource utilization). WWUD-SS were queried about recent difficult experiences with a focus on how they did or did not use social support or formal resources (e.g., clinic, crisis hotline) in response.

Results

Participants were a median age of 37 years, 50% identified as Black, and 50% reported currently injecting drugs. Participants described reluctance to ask for support and often felt resigned to address problems alone. Participants also distinguished between transactional relationships (help is contingent upon receiving something in return) versus genuine (non-transactional or altruistic) support, including the role of family members who do and do not use drugs. Resource utilization was rare, and “self-medication” through substance use was common absent other perceived options for help.

Conclusions

External resilience appears limited among WWUD-SS and shaped by the social and economic contexts of a street-involved life. WWUD-SS’ ability to exercise external resilience may be undercut by experiencing structural vulnerabilities and competition for material resources that create transactional relationships and diminish the perceived value of social support. Internalized stigma, reflecting the larger society’s stigmatized views of drug use, sex work, and poverty, left WWUD-SS eschewing help from outside sources. Focus on internal resilience alone offers an incomplete picture of the construct in drug-using populations. Improving connections to community resources may be a targeted way to strengthen external resilience, as are policies addressing structural vulnerabilities for marginalized communities.

The Importance of Sexual Orientation in the Association Between Social Cohesion and Client Condom Coercion Among Women Who Exchange Sex in Baltimore, Maryland

Among women who exchange sex (WES), social cohesion is associated with multi-level HIV-risk reduction factors, and client condom coercion (CCC) is associated with increased HIV-risk. Sexual minority WES (SM-WES) face exacerbated HIV-risk, yet relevant research is scant. We examined the role of sexual orientation in the relationship between social cohesion and CCC among cisgender WES (n = 384) in Baltimore, Maryland using stratified logistic regression, controlling for potential confounders. Forty-five percent of WES experienced CCC. SM-WES reported significantly higher social cohesion than heterosexual WES. The relationship between social cohesion and CCC differed by sexual orientation. Among SM-WES, higher social cohesion was independently associated with decreased odds of experiencing CCC, controlling for food insecurity, crack use, police harassment, and method of finding clients. Among heterosexual WES, no significant association was found. Ongoing research and practice with WES should (1) collect sexual orientation data to allow for deeper understanding and tailored interventions, (2) leverage and nurture social cohesion and (3) tailor interventions to populations with attention to sexual orientation.

Cultivating PEARL (Promoting Empowerment and Risk Reduction): Formative Research for a PrEP Intervention Among Female Sex Workers in Baltimore, Maryland

Pre-exposure prophylaxis (PrEP) is a vital component of comprehensive HIV prevention among female sex workers (FSW). There are limited PrEP interventions targeting FSW in the U.S., who have high HIV risk. Formative research was conducted to inform PEARL (Promoting Empowerment And Risk Reduction), a PrEP intervention for FSW in Baltimore, MD, including a community forum, key informant interviews with providers, and focus group discussions with FSW. FSW and providers acknowledged challenges to building rapport and establishing continuity in care settings. FSW reported low PrEP awareness, with high interest once aware. FSW and providers reported uptake barriers including perceived financial issues, lack of PrEP awareness, and mistrust of the pharmaceutical industry. Concerns were raised about substance use and daily PrEP adherence. Developing a tailored PrEP intervention for FSW necessitates multiple perspectives (e.g. FSW, service providers). Resumen La profilaxis preexposición (PrEP) es un componente vital de la prevención integral del VIH para las trabajadoras sexuales (TSF). En los Estados Unidos, hay pocas intervenciones de PrEP dirigidas a las TSF, quienes experiencian un riesgo elevado de contraer el VIH. Se realizó una investigación formativa para informar a PEARL (Promoción del empoderamiento y la reducción de riesgos), una intervención de PrEP para TSF en Baltimore, MD-la cual incluyó un foro comunitario, entrevistas con proveedores de servicios a las TSF y discusiones entre grupos focales de TSF. TSF y proveedores de servicio reconocieron los retos de mantener buenas relaciones y establecer continuidad en los servicios de salud. TSF exhibieron conocimiento limitado sobre la PrEP, pero expresaron gran interés en la PrEP después de estar informadas. TSF y los proveedores de servicios hablaron de barreras aceptando a la PrEP, incluyendo problemas financieros percibidos, falta de conocimiento sobre la PrEP y desconfianza en la industria farmacéutica. Se expresaron preocupaciones sobre el uso de sustancias y la adherencia diaria a la PrEP. El desarrollo de una intervención de PrEP personalizada para TSF requiere varias perspectivas (por ejemplo, TSF, proveedores de servicios).

Utilisation of HIV services by female sex workers in Zimbabwe during the COVID-19 pandemic: a descriptive phenomenological study

This study focuses on female sex workers as a key population group that suffers a degree of vulnerability according to the World Health Organisation (WHO). Key populations refer to people at heightened risk of contracting the human immunodeficiency virus (HIV) due to specific behaviours and social and legal environments which increase their vulnerability to the virus. Key populations are disproportionately affected by HIV, yet they have less access to HIV services compared to the general population. The coronavirus (COVID-19) lockdown and its restrictive measures have further widened the inequalities and gaps in accessing HIV services for this group. A descriptive phenomenological study was undertaken to explore female sex workers' experiences of utilisation of HIV services during COVID-19. The study setting was the Bulawayo Metropolitan Province, Zimbabwe. Data were collected through in-depth individual interviews with 10 female sex workers. Purposive sampling coupled with snowballing was utilised for recruiting participants. Data were analysed guided by the seven-step Colaizzi technique. Rigour was ensured through adhering to Lincoln and Guba's trustworthiness criteria. The study found that the COVID-19 pandemic adversely affected the livelihoods of sex workers and their utilisation of HIV services. There was limited access to HIV services due to an initial lack of travel authorisation letters and financial challenges experienced by study participants. In addition, the quality of care in health care facilities was further compromised by poor screening processes and reduced provider-client interactions. Maintaining access to HIV services for female sex workers during pandemics is critical for the country to attain HIV epidemic control.

Mapping Interests in Event-Driven and Long-Acting Pre-exposure Prophylaxis Formulations onto the HIV Risk Environment of Street-Based Female Sex Workers: A Latent Class Analysis

Despite growing availability, HIV pre-exposure prophylaxis (PrEP) uptake and adherence remains suboptimal among female sex workers (FSW) in the United States. Using cross-sectional data from a survey of 236 street-based cisgender FSW in Baltimore, Maryland, we examined interest in event-driven and long-acting PrEP formulations. Latent class analysis identified discrete patterns of interest in five novel PrEP agents. Multinomial latent class regression then examined factors associated with probabilistic class membership. A three-class solution emerged as the best-fit latent class model: Injectable Acceptors (~ 24% of sample), Universal Acceptors (~ 18%), and Non-Acceptors (~ 58%). Compared to Non-Acceptors, Universal Acceptors had significantly (p < 0.05) higher odds of reporting condomless vaginal sex with clients, client condom coercion, and client-perpetrated physical violence. Relative to Non-Acceptors, Injectable Acceptors were distinguished by significantly higher rates of condomless vaginal sex with clients and injection drug use. Expanding PrEP options for FSW could help overcome barriers to PrEP initiation and persistence.

Co-occurring Threats to Agency Among Female Sex Workers in Baltimore, Maryland

Driven largely by the unequal distribution of power, female sex workers (FSW) globally bear a disproportionately high burden of HIV, sexually transmitted infections, and interpersonal violence. Prior literature has identified a number of multi-level factors that may serve to constrain FSWs' agency, or their ability to define and take action to realize goals. Among these are work-based violence and substance use, which are potentiated by the criminalization of sex work and structural vulnerability. Quantitative research related to U.S.-based FSWs' own sense of agency, as well as the barriers that may impede it, is sparse. We sought to identify patterns of various threats to agency and explore to what extent they were associated with perceived agency among a cohort of 381 FSW in Baltimore, Maryland, United States, using latent class analysis. Latent class indictors were past-six-month experience of client-perpetrated sexual violence, client-perpetrated physical violence, homelessness, food insecurity, arrest, daily crack-cocaine use, and daily heroin use. Perceived agency was measured using the short form of the Pearlin Mastery Scale. We identified three typologies of threatened agency among women in our sample: a "threatened by structural factors, drug use, and violence" class, a "threatened by structural factors and drug use" class, and a "less threatened" class. Mean perceived agency score was significantly lower for the class characterized by client-perpetrated violence than for either of the other classes. This suggests violence, in the context of deeper, structural power imbalances embedded in hunger, homelessness, and drug use, may dramatically reduce one's sense of agency and operate as a critical barrier to empowerment. Our study adds important insights to the broader FSW community empowerment literature and supports the need for interventions to bolster both individual and collective agency among U.S.-based FSW, including interventions to prevent sex work-related violence.

Typologies and Correlates of Police Violence Against Female Sex Workers Who Inject Drugs at the México-United States Border: Limits of De Jure Decriminalization in Advancing Health and Human Rights

Decriminalization of sex work is increasingly promoted as a structural measure to improve the health of vulnerable groups. In México, sex work is not illegal, but knowledge of policies' street-level impact is limited. This study describes typologies of police violence against female sex workers who inject drugs (FSWID), identifying risk and protective factors for violence exposure to inform policy responses. Survey data were collected during 2008-2010 among HIV-negative FSWID in a behavioral intervention in Tijuana and Ciudad Juarez (N = 584). Latent class analysis identified typologies of police violence in the past 6 months: asked for money, money taken, syringes taken, asked for sex, and sexually assaulted. Structural equation modeling (SEM) predicted latent class membership using sociodemographic, behavioral and risk environment factors, controlling for age, education, marital status, and city. Recent police violence was reported by 68% of FSWID, with three typologies emerging: Low (36.6%); Material (47.8%): having money/syringes taken or being asked for money; and Material/Sexual (15.7%): material violence and being asked for sex or sexually assaulted. In multivariable SEM, Material Violence was associated with: being jailed [adjusted Odds Ratio (aOR) = 4.34], HIV testing (aOR = 2.18), and trading sex indoors (aOR = 1.66). Factors associated with Material/Sexual Violence included: being jailed (aOR = 41.18), injecting with clients (aOR = 3.12), earning more money for sex without a condom (aOR = 2.88), being raped by a client (aOR = 2.13), drinking with clients (aOR = 2.03), receiving substance use treatment (aOR = 1.95), being <18 when first trading sex (aOR = .43), trading sex outdoors (aOR = .53), and poor working conditions (aOR = .56). Despite de jure decriminalization of sex work, police violence against FSWID at the México-United States border is pervasive with implications for sex- and drug-related harms. Closing gaps in policy implementation and mitigating material/sexual violence from police is imperative to decreasing economic vulnerability, risk of overdose and HIV, and improving engagement in HIV and harm reduction services.

Social Support Associated with Condom Use Behavior Among Female Sex Workers in Iran

BACKGROUND

Despite the widespread knowledge about social support and health, there is little information about the association between social support and HIV risk behaviors such as condom use among female sex workers (FSWs) in Iran. This study aimed to determine the association between social support and frequency of condom use among FSWs in Tehran, Iran.

METHODS

Using mixed sampling methods, we recruited 170 FSWs in Tehran in 2017. We measured self-reported social support by face-to-face interviews using a standardized questionnaire. Linear regression was used to assess the association between socio-demographic characteristics (age, education level, marital status, and place of living), transactional sex characteristics (age at first transactional sex and frequency of transactional sex in the last month), HIV knowledge, social support network characteristics (social network size, duration of tie, intimacy, social support), and condom use behavior.

RESULTS

Of the total of 1193 persons in FSW's social networks, 615 (51%) were sexual partners, 529 (44%) were peer sex workers, and 36 (5%) were family members. The participants perceived moderate social support from sexual partners, low from peer sex workers, and very low from family members. Adjusted for individual and other network characteristics, peer sex worker social support (b = 0.28, 95%CI 0.06, 0.50), and family support (b = 1.12, 95%CI 0.028, 2.23) were significantly associated with condom use.

CONCLUSION

Family and peer sex worker social support are associated with condom use, but less strongly than HIV knowledge or place of living. However, very few FSWs are socially connected with families. Interventions to promote condom use among this vulnerable population should also consider social and familial support.

Seeing pre-screened, regular clients associated with lower odds of workplace sexual violence and condom refusal amidst sex work criminalization: findings of a community-based cohort of sex workers in Metro Vancouver, Canada (2010-2019)

Background

Research that accurately represents how characteristics of sex work clients relate to sex workers’ labour conditions is crucial for informing evidence-based legislation which upholds sex workers’ human rights. As little quantitative research has examined how seeing regulars (repeat clients) impacts sex workers’ occupational safety, particularly under ‘end-demand’ criminalization in Canada, our study aimed to explore how seeing mostly regulars shapes workplace sexual violence and client condom refusal.

Methods

We drew on longitudinal data from a community-based open cohort of 900+ sex workers in Vancouver, recruited via time-location sampling during day and late-night outreach to indoor, outdoor, and online solicitation spaces. We used logistic regression analyses and multivariable GEE confounder models to 1) describe correlates of seeing mostly pre-screened, regular clients, 2) identify associations between seeing mostly regulars and odds of experiencing occupational outcomes of workplace sexual violence and client condom refusal, and 3) examine the interaction between seeing mostly regulars and work environment on workplace sexual violence and client condom refusal.

Results

Participants’ median age was 35, and 55.6% had completed high school. Over the 9-year study (n=925), 20.9% (193) experienced 282 events of workplace sexual violence and 40.2% (372) faced 702 events of client condom refusal. In multivariable GEE confounder models, seeing mostly regulars was associated with reduced odds of sexual violence (AOR 0.73, 95%CI 0.53-1.02, p=0.067) and client condom refusal (AOR 0.70, 95%CI 0.57-0.86). In multivariable GEE confounder models examining the additive interaction between seeing mostly regulars and work environment, participants who saw mostly regulars and primarily worked in outdoor or informal indoor venues faced significantly lower odds of experiencing workplace sexual violence (AOR 0.69, 95%CI 0.49-0.95) and client condom refusal (AOR 0.64, 95%CI 0.52 -0.80) relative to those who worked in the same venues and did not see mostly regulars.

Conclusion

Our findings highlight protective effects of seeing pre-screened regulars within a criminalized setting. Removal of ‘end-demand’ client criminalization is needed to enable sex workers to effectively screen clients, support HIV/STI prevention, and advance sex workers’ human rights.

ART uptake and adherence among female sex workers (FSW) globally: A scoping review

We conducted the first scoping literature review on ART uptake and adherence among Female Sex Workers (FSW), following PRISMA-ScR guidelines. Searches were conducted in PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting an ART uptake or adherence result among FSW aged 18 or older; peer-reviewed; published in English between 1996 and 2018. Our search identified 6,735 studies; 30 met eligibility requirements. ART uptake ranges from 0 to 100% and adherence ranges from 50-90%, depending on measurement methods. Uptake and adherence influencing factors are mapped onto a social ecological model (SEM). Knowledge and beliefs, substance use, food insecurity and sex-work engagement were negatively associated, while older age, relationships and social support were positively associated with ART uptake and adherence. Standardised methods to measure uptake and adherence prevalence must be established for data comparison. Evidence regarding ART uptake and adherence barriers and facilitators span multiple SEM levels, although more research is needed regarding structural and occupational level influencers. Results suggest that the multi-level ART uptake and adherence barriers faced by FSW require complex multi-level evidence-based interventions. Study findings can inform ART interventions, future research, and offer guidance to other support services with FSW, such as PrEP interventions.

The role of local business employees and community members in the HIV risk environment of female sex workers in an urban setting: associations between negative interactions and inconsistent condom use

Background

The role of business employees and community members in the HIV risk environment of female sex workers (FSW) is underexplored, despite sex work often located in commercial and residential urban areas. We explored the effect of negative interactions between business employees and community members on inconsistent condom use with clients of female sex workers.

Methods

This study uses baseline data from the EMERALD study, a community empowerment intervention with FSW. We recruited a sample of 361 FSW in Baltimore, Maryland using targeted sampling techniques in ten zones characterized by high rates of sex work, located throughout the city. Participants were recruited between September 2017 and January 2019 and completed a survey, HIV rapid testing, and self-administered gonorrhea and chlamydia testing. The outcome, inconsistent condom use, was defined as not reporting “always” using condoms with paying clients. Poisson regressions with robust variance were used to model the effect of business employee and/or community member interactions on inconsistent condom use.

Results

Over half (54%) the sample was between 18 and 40 years old, 44% Black or another race, and experienced a range of structural vulnerabilities such as housing instability and food insecurity. Forty-four percent of the sample reported inconsistent condom use with clients. FSW reported being reported to the police weekly or daily for selling drugs (14% by employees, 17% by community), for selling sex (19% by employees, 21% by community), and experiencing weekly or daily verbal or physical threats (18% by employees, 24% by community). In multivariable models, being reported to the police for selling sex weekly or daily by community members (vs. never, aRR = 1.42, 95% CI = 1.08, 1.86) and business owners (vs. never, aRR = 1.36, 95% CI = 1.05, 1.76) increased risk of inconsistent condom use, as did monthly verbal or physical threats by community members (vs. never, aRR = 1.43, 95% CI = 1.08, 1.91).

Conclusions

Results show that both actors play important roles in FSWs’ HIV risk environment. Businesses and community members are important targets for holistic HIV prevention interventions among FSW in communities where they coexist in close proximity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12293-4.

Structural, everyday, and symbolic violence and the heightened vulnerability to HIV of women who use drugs in Tanzania

Women who use drugs shoulder a disproportionate burden of the HIV epidemic in Tanzania. The mechanisms through which violence contributes to their excessively high rates of HIV have not been explored. In this paper, we use concepts of everyday, symbolic, and structural violence to critically examine the relationship between violence and heightened HIV vulnerability of women who use drugs in Dar es Salaam, Tanzania. We conducted cross-sectional surveys with 200 women who use drugs and follow-up, in-depth interviews with 30 survey participants who identified as living with HIV between November 2018 and March 2019. We drew from grounded theory methods to analyze qualitative data and complemented qualitative findings with survey results. Structural violence perpetuated constraints on women's economic opportunities and reduced their agency in sexual encounters manifesting in their disproportionately high rates of HIV. Nearly all women in our study engaged in sex work to meet basic needs and to support their drug use. Their involvement in overlapping drug use and sex work scenes exposed them to physical and sexual violence. Despite the pervasiveness of structural and everyday violence, some women reenacted agency by adopting strategies to maintain control and safety, and to exercise harm reduction. A multi-pronged, structural harm reduction strategy is critical to reducing violence experienced by women who use drugs and their ability to protect themselves from HIV.

Exploring the Association Between Depression and Social and Biobehavioral HIV Risk Factors Among Female Sex Workers in Nelson Mandela Bay Municipality, South Africa

The aim of this study was to estimate the prevalence of depression among female sex workers (FSW) in an urban coastal city in South Africa, and to explore the relationship between depression and HIV-related social and biobehavioral determinants. A cross-sectional respondent-driven sampling study was conducted with FSW (n = 410), including a sociobehavioral questionnaire, PHQ-9 (Patient Health Questionnaire-9) based assessment of depression, and biological testing for HIV and syphilis. The prevalence of HIV in the sample was 64.1%. The estimated prevalence of depression was 28.8%. Depression was associated with social vulnerability such as living alone [adjusted prevalence ratio 1.82, 95% confidence interval (CI) 1.15-2.90] and food insecurity (aPR 2.19, 95% CI 1.42-3.38). A positive syphilis test result (aPR 1.46, 95% CI 1.02-2.09) and self-reported sexually transmitted disease symptoms (aPR 1.78, 95% CI 1.29-2.46) was associated with depression, but self-reported condom use and HIV status was not. FSW were also less likely to disclose their occupational status to health care providers (aPR 0.61, 95% CI 0.42-0.89) or undergo sexually transmitted infection screening in the last 12 months if they are depressed (aPR 0.64, 95% CI 0.43-0.95). The results demonstrate that the prevalence of depression is high among FSW and that depressive symptoms are associated with social covariates and biobehavioral HIV risk factors.

Sex workers as mothers: Correlates of engagement in sex work to support children

BACKGROUND

Globally, most female sex workers (FSW) are mothers but are rarely considered as such in public health and social service programs and research. We aimed to quantitatively describe FSW who are mothers and to examine correlates of current engagement in sex work to support children among a cohort of FSW in Baltimore, Maryland, United States (U.S.).

METHODS

The study utilized baseline survey and HIV/STI testing data from the Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) study of women engaged in street-based sex work in Baltimore, Maryland. Variable selection and interpretation were guided by Connell's theory of Gender and Power. We used bivariate and multivariate logistic regression analyses to examine correlates of engagement in sex work to support children among FSW mothers.

RESULTS

Our sample included 214 FSW with children, of whom 27% reported supporting children as a reason for the current engagement in sex work. Median age was 36 years, and mean number of children was 2.88. 20.6% were currently living with any of their minor aged children, and this was significantly more common among mothers engaged in sex work to support children (57.9% vs. 7%; p<0.001). 38.7% had ever lost legal custody of children, which was significantly less common among those supporting children through sex work (26.8% vs. 42.9%; p=0.033). In multivariate analyses, the following were independently associated with engaging in sex work to support children: African-American versus white race (aOR=2.62; 95% CI:1.18-5.82; p=0.018); less housing instability (aOR=0.42; 95% CI:0.20-0.89; p=0.024); initiating sex work at age <23 (aOR=2.59; 95% CI:1.23-5.46; p=0.012); less frequent intoxication during sex with clients (aOR=0.31; 95% CI:0.14-0.67; p=0.003); and reporting mental health as most important health concern (aOR=2.37; 95% CI:1.09-5.17; p=0.029).

CONCLUSIONS

FSW mothers who report engagement in sex work to support children are distinct from their counterparts in key areas related to HIV and other health outcomes. Neglecting to account for this important social role may lead to missed opportunities to meaningfully promote physical and mental health and to engage women on their own terms. Future research and interventions should seek to address FSW as whole social beings and center their experiences and needs as mothers.

HIV and associated factors among female sex workers in Tajikistan: Analysis from a national bio-behavioral survey

Tajikistan, a country of approximately nine million people, has a relatively small but quickly growing HIV epidemic. No peer-reviewed study has assessed factors associated with HIV, or associated risk factors, among female sex workers (FSWs) in Tajikistan. The purpose of the current study is to elucidate the factors associated with HIV status and risk factors in the Tajikistani context and add to the scant literature on risk factors among FSWs in Tajikistan and Central Asia. We used cross-sectional data from an HIV bio-behavioral survey (BBS) conducted among FSWs in the Republic of Tajikistan (n = 2174) in 2017. Using Respondent Driven Sampling Analysis Tool software, we calculated the prevalence of HIV, diagnosed cases, linkage to antiretroviral therapy (ART), and the prevalence of syphilis for FSWs in Tajikistan. Prevalence data were adjusted for network size and any clustering effects in the network. Further, using univariate and multivariable logistic regression, we determined correlates of HIV-positive status. Results were as follows: Of all FSWs in Tajikistan, 2.6% (95% CI: 1.7-3.8%) are HIV positive, 2.3% (95% CI: 1.4-3.5%) are diagnosed and aware of their status, and 2.0% (95% CI: 1.2-3.1%) are on ART. About 5.7% (95% CI: 4.5-7.4%) of FSWs in Tajikistan have ever had syphilis, and 0.8% (95% CI: 0.4-1.3%) have active syphilis infections. The epidemic of injection drug use was found to be strongly synergistic with HIV infection as having had sex with a person who injects drugs was shown to be strongly associated with HIV-positive status (OR: 5.2; 95% CI: 2.6-10.2) in the multivariable model. While this study estimates that HIV prevalence among Tajikistani FSWs is relatively low, it is likely an underestimated due to selection and social desirability biases. To curb the small, but potentially volatile, HIV epidemic among FSWs, the government should consider targeted testing and linkage-to-care efforts for FSWs who inject drugs or who have people who inject drugs partners. Services should also be prioritized in Gorno-Badakhshan, which has a higher number of FSWs per capita relative to other regions. Additionally, the link between HIV and experiences of stigma, violence, and discrimination against FSWs should motivate advocates to protect Tajikistani FSWs from these experiences.

Confirmatory Factor Analysis and Construct Validity of the Internalized Sex Work Stigma Scale among a Cohort of Cisgender Female Sex Workers in Baltimore, Maryland, United States

Internalized sex work stigma among cisgender female sex workers (FSW) is produced within contexts of social marginalization and associated with a range of ill-effects, including psychological distress, and lower rates of healthcare-seeking. This study seeks to uncover latent domains of the new Internalized Sex Work Stigma Scale (ISWSS) using data from 367 FSW in Baltimore, Maryland, USA. The sample was 56% white with high substance use (82% smoked crack cocaine, 58% injected any drug). The average ISWSS score was 34.8 (s.d. = 5.8, possible range: 12-48) and internal consistency was high (0.82). Confirmatory factor analysis revealed four subscales: worthlessness, guilt and shame, stigma acceptance, and sex work illegitimacy. Internal consistency of subscales was high (0.69-0.90); the scale also demonstrated construct validity with depression and agency. In bivariate logistic regressions, higher ISWSS, worthlessness, shame and guilt, and acceptance scores predicted higher odds of rushing client negotiations due to police. In unadjusted multinomial regressions, feeling respected by police predicted lower ISWSS, worthlessness, guilt and shame, acceptance, and illegitimacy scores. Identified factors are congruent with existing literature about how FSW manage sex work-specific stigma. Understanding the unique dimensions and impacts of internalized sex work stigma can inform interventions and policy to reduce morbidities experienced by FSW.

Conceptualizing overdose trauma: The relationships between experiencing and witnessing overdoses with PTSD symptoms among street-recruited female sex workers in Baltimore, Maryland

BACKGROUND

The opioid crisis has rendered witnessing and experiencing overdoses a common occurrence, especially among marginalized and drug using populations, including female sex workers (FSW). Such exposures may confer psychological trauma that has gone unrecognized. We explored relationships between experiencing and witnessing overdoses and PTSD symptomology to understand the traumatic nature of these experiences.

METHODS

Data were from FSW (N = 380) in Baltimore City, Maryland, who reported whether they had witnessed/experienced any overdoses in the past 6 months ("overdose traumas") and PTSD symptoms (PCL-5). We tested for associations between overdose traumas and PTSD diagnoses/symptomology in bivariate logistic regression models and multivariate models, adjusting for sociodemographic, experiences of violence, and drug use characteristics.

RESULTS

In our sample, 35.3% witnessed a fatal overdose, 51.9% witnessed a non-fatal overdose, and 28.3% experienced an overdose in the past 6 months. More than half (52.4%) met criteria for PTSD. Most endorsed symptoms within each PTSD domain: 63.2% for intrusive, 58.4% for avoidance, 66.1% for cognition/mood, and 64.7% for arousal/reactivity symptoms. Experiencing an overdose was associated with meeting PTSD criteria and symptoms in all domains in bivariate models. Witnessing an overdose was associated with PTSD diagnoses and intrusive and arousal/reactivity symptoms in bivariate models. Adjusting for sociodemographic characteristics and drug use, experiencing an overdose was associated with intrusive and cognition/mood symptoms, while neither trauma remained associated with PTSD diagnoses.

CONCLUSIONS

Traumas related to overdose, coined "overdose traumas" appear to be extremely psychologically traumatic, though the relationships vary by type and symptom. Programs should be cognizant of psychological trauma to address the full spectrum of overdose harms. Existing measures of PTSD do not accurately represent the effects of overdose traumas in populations like FSW due to the structural barriers to avoiding locations/situations where overdoses may occur and the overlap between symptoms, drug effects, and adaptive responses to homelessness.

Correlates of newly diagnosed HIV infection among cisgender women sex workers and transgender women sex workers in Greater Kuala Lumpur, Malaysia

Globally, cisgender women sex workers (CWSWs) and transgender women sex workers (TWSWs) experience increased vulnerabilities to HIV infection. Unfortunately, there is limited data on the drivers of HIV infection in these two understudied populations, particularly in Southeast Asia. To better understand factors associated with HIV infection, we evaluated correlates of newly diagnosed HIV infection in these two populations in Greater Kuala Lumpur, Malaysia. A total of 469 women (CWSW: n = 283; TWSW: n = 186) were included in this study. Most participants who tested HIV+ were unaware of their infection (59.6%; n = 34/57). Separate binary and multivariable logistic regressions were conducted to identify correlates of newly diagnosed HIV in CWSWs and TWSWs. Among CWSWs, Chlamydia trachomatis (aOR = 5.66; p = 0.007) and lifetime use of ecstasy/MDMA (aOR = 5.34; p = 0.03) were associated with newly diagnosed HIV, while condomless vaginal sex with clients was associated with lower likelihood of HIV infection (aOR = 0.98; p = 0.01). Among TWSWs, being single (aOR = 6.76; p = 0.03), using mobile application to solicit clients (aOR = 25.33; p = 0.006), and having C. trachomatis infection (aOR = 88.22, p = 0.02) were associated with newly diagnosed HIV. Expansion of HIV/sexually transmitted infection screening is needed to increase detection of HIV and linkage to care for sex workers. Interventions to reduce HIV infection among CWSWs and TWSWs should be tailored to these populations' unique vulnerabilities.

Working with economically vulnerable women engaged in sex work: Collaborating with community stakeholders in Southern Uganda

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03583541.

Resilience among Cisgender and Transgender Women in Street-Based Sex Work in Baltimore, Maryland

INTRODUCTION

Resilience represents adaptability and empowerment and can buffer against the consequences of traumatic events. Cisgender and transgender women in street-based sex work are at high risk for trauma, yet data on their resilience are sparse. A clearer understanding of resilience and its correlates is useful for informing sex worker-centered interventions.

METHODS

Using the Connor-Davidson 10-item Resilience Scale (range, 0-40), we describe resilience among 165 cisgender and 42 transgender street-based women sex workers in Baltimore, Maryland. Longitudinal cohort data were used to examine correlates of resilience in each population. Analyses are conducted using multiple linear regression.

RESULTS

The mean resilience score was 24.2 (95% confidence interval, 23.6-24.8) among cisgender women sex workers and 32.2 among transgender women sex workers (95% confidence interval, 30.8-32.7). Among cisgender participants, positive correlates of resilience were being Black, Hispanic, or other race (ß = 2.7; p = .004), having housing (ß = 1.9; p = .034), social cohesion score (ß = 0.18; p = .047), and daily drug injection (ß = 3.7; p < .001); negative correlates of resilience were sexual violence (ß = -4.8; p = .006) and exposure to egregious police acts (ß = -0.6; p = .015). Among transgender participants, higher education level (ß = 8.8; p < .001), food security (ß = 3.5; p = .005), and housing stability (ß = 2.0; p < .001) were associated with increased resilience, and daily noninjection drug use (excluding marijuana; ß = -3.3; p < .001) and physical violence (ß = -2.9; p < .001) were associated with reduced resilience.

CONCLUSIONS

This study is the first to characterize factors that may influence resilience among cisgender and transgender women sex workers. Results highlight tangible intervention targets for promoting mental health and safety among a uniquely vulnerable population of women.

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

BACKGROUND

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

SETTING

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

METHODS

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

RESULTS

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

CONCLUSION

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

Disparities in HIV-related risk and socio-economic outcomes among trans women in the sex trade and effects of a targeted, anti-sex-trafficking policy

INTRODUCTION

Marginalization of sex work presents numerous risks for trans women (TW) engaged in the sex trade, including criminalization, traumatization, and contracting HIV. We identified socio-economic and HIV risk disparities among trans women sex workers and others who do sex work (TWSW/OWSW), and evaluated these disparities for TWSW/OWSW compared to TW not engaged in sex work from pre- and post-implementation of the US 2018 "Allow States and Victims to Fight Online Sex Trafficking Act" and "Stop Enabling Sex Traffickers Act" (FOSTA-SESTA).

METHODS

We analyzed 429 trans women (TW) from the Trans*National cohort study (2016-2019). Generalized estimating equations (GEE) characterized differences in socio-economic and HIV risk outcomes for TWSW/OWSW compared to TW not engaged in sex work over the study period. Adjusted, pre-to-post law changes in these outcomes for TWSW/OWSW versus TW not engaged in sex work were compared using difference-in-differences GEE regression analyses.

RESULTS

Over 18 months, TWSW/OWSW had higher adjusted odds of being unstably housed, having income from criminalized sources, experiencing transphobic hate crimes, experiencing discrimination from police/courts, being incarcerated, meeting sex partners in the street/public settings, meeting sex partners on Craigslist or other online forums (except dating apps), or engaging in condomless anal intercourse, (p < 0.01 for all comparisons); TWSW/OWSW also had a higher mean number of income sources (p = 0.03). One difference-in-differences analysis showed additive interaction: the adjusted mean number of income sources reported by TWSW/OWSW compared to those not engaged in sex work decreased from pre-to post-FOSTA-SESTA (from 1.79 to 1.48 for TWSW/OWSW and from 1.52 to 1.47 for TW not engaged in sex work; p = 0.01).

CONCLUSIONS

Disparities in socio-economic and HIV-related risk outcomes exist for TWSW/OWSW in San Francisco. There is an urgent need for comprehensive, long-term follow-up data of TW to accurately analyze policy effects, especially given the recent enactment of a number of other policies targeting TW.

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.

Age Matters: Determinants of sexual and reproductive health vulnerabilities amongst young women who sell sex (16-24 years) in Zimbabwe

INTRODUCTION

Female sex workers bear a disproportionate burden of HIV and other poor sexual and reproductive health (SRH) outcomes which has led to the tailoring of SRH interventions to mitigate risk. Understanding of the SRH vulnerabilities of young women who sell sex (YWSS) (16-24 years) in Southern Africa is under-represented in research which may result in a mismatch in current SRH interventions and service design.

OBJECTIVE

This paper is based on a sub-analysis of a qualitative study investigating the SRH of young women who sell sex (16-24 years) in Zimbabwe. We explored the differences in dynamics of SRH vulnerability amongst YWSS within the 16-24 year age band.

METHODS

In-depth interviews (IDIs) were conducted amongst key informants (n = 4), health care providers (n = 5), and peer educators (n = 16). Amongst YWSS, we conducted IDIs (n = 42) and focus group discussions (n = 30). Transcripts were inductively coded for emergent themes and categories.

RESULTS

Age and life stage determinants led to key differences in SRH vulnerabilities between younger (16-19 years) and older YWSS (20-24 years). These determinants emerged in the following ways: 1) distancing of younger participants from a "sex worker" identity leading to difficulties in identification and limiting intervention reach, 2) inexperience in dealing with clients and immature cognitive development leading to greater exposure to risk, and 3) the subordinate social position and exploitation of young participants within sex worker hierarchies or networks and lack of protective networks.

CONCLUSIONS

We highlight the presence of a diverse group of vulnerable young women who may be missed by sex worker programme responses. In future intervention planning, there is need to consider the age-related needs and vulnerabilities within a spectrum of young women involved in a wide range of transactional relationships to ensure that services reach those most vulnerable to poor SRH outcomes.

Incidence and Predictors of Chlamydia, Gonorrhea and Trichomonas Among a Prospective Cohort of Cisgender Female Sex Workers in Baltimore, Maryland

BACKGROUND

Cisgender female sex workers (CFSWs) have elevated rates of sexually transmitted infections (STI) yet are underrepresented in targeted programming and research in the United States. We examined the prevalence, incidence and predictors of chlamydia, gonorrhea, and trichomonas infection among CFSW.

METHODS

Two hundred fifty street-based CFSWs were recruited into a prospective observational cohort in Baltimore, Maryland using targeted sampling in 2016 to 2017 and completed surveys and STI testing at baseline, 3, 6, 9, and 12 months. Cox proportional hazards regression was used to model the predictors of STI.

RESULTS

Mean age was 36 years, and 66.5% of respondents were white. Baseline prevalence of chlamydia, gonorrhea, trichomonas was 10.5%, 12.6%, and 48.5%, respectively. The incidence of chlamydia, gonorrhea, and trichomonas was 14.3, 19.3, 69.1 per 100 person-years. Over one year of observation, past year sex work initiation predicted both chlamydia incidence (adjusted hazard ratio [aHR], 2.7; 95% confidence interval [CI], 1.3-6.0) and gonorrhea incidence (aHR, 1.7; 95% CI, 1.0-2.8). Client sexual violence predicted gonorrhea incidence (aHR, 2.9; 95% CI, 1.2-7.1) and having female sexual partners predicted trichomonas incidence (aHR, 3.4; 95% CI, 1.3-8.5). Having a usual health care provider (aHR, 0.6; 95% CI, 0.5-0.7) was inversely associated with trichomonas.

CONCLUSIONS

In this study of urban US street-based CFSW, interpersonal and structural factors differentially predicted STIs, and infection rates remained elevated through follow-up despite regular testing, notification, and treatment referral. Focused and multifaceted interventions for sex workers and their sexual partners are urgently needed.

Exposure to Police and Client Violence Among Incarcerated Female Sex Workers in Baltimore City, Maryland

Objectives. To determine the rate and correlates of incarceration among street-based female sex workers (FSWs).Methods. From April 2016 to January 2017, FSWs (n = 250) in Baltimore City, Maryland, were enrolled in a 12-month prospective cohort study. We analyzed baseline data and used zero-inflated negative binomial regression to model the incarceration rate.Results. Overall, 70% of FSWs had ever been incarcerated (mean = 15 times). In the multivariable analysis, incarceration rate was higher for FSWs exposed to police violence, non-Hispanic White FSWs, and women who used injection drugs daily. Risk for ever being incarcerated was higher for FSWs exposed to police or client violence, non-Hispanic Black FSWs, women who used injection or noninjection drugs daily, and those with longer time in sex work.Conclusions. Incarceration was associated with exposure to violence from both police and clients. Daily drug use and time in sex work appeared to amplify these risks. Although non-Hispanic Black women were at greater risk for ever being incarcerated, non-Hispanic White women were incarcerated more frequently.Public Health Implications. Decriminalization of sex work and drug use should be prioritized to reduce violence against FSWs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

"An ethnographic exploration of factors that drive policing of street-based female sex workers in a U.S. setting - identifying opportunities for intervention"

Background

Building on a broader sociological discourse around policing approaches towards vulnerable populations, increasing public health and human rights evidence points to policing practices as a key health determinant, particularly among street-based sex workers. Despite the importance of policing as a structural health determinant, few studies have sought to understand the factors that underlie and shape harmful policing practices towards sex workers. This study therefore aimed to explore the drivers for policing attitudes and practices towards street-based cisgender female sex workers.

Methods

Drawing on ethnographic methods, 280 h of observations with police patrol and 10 stakeholder interviews with senior police leadership in Baltimore City, USA were carried out to better understand the drivers for policing strategies towards cisgender female sex workers. Analysis was data- and theory-driven, drawing on the concepts of police culture and complementary criminological and sociological literature that aided exploration of the influence of the ecological and structural environment on policing practices.

Results

Ecological factors at the structural (e.g., criminalization), organizational (e.g., violent crime control), community and individual level (e.g., stigmatizing attitudes) emerged as key to shaping individual police practices and attitudes towards cisgender female sex workers in this setting. Findings indicate senior police support for increased alignment with public health and human rights goals. However, the study highlights that interventions need to move beyond individual officer training and address the broader structural and organizational setting in which harmful police practices towards sex work operate.

Conclusions

A more in-depth understanding of the circumstances that drive law enforcement approaches to street-based sex work is critical to the collaborative design of interventions with police in different settings. In considering public health-police partnerships to address the rights and health of sex worker populations in the U.S. and elsewhere, this study supports existing calls for decriminalization of sex work, supported by institutional and policy reforms, neighborhood-level dialogues that shift the cultural landscape around sex work within both the police and larger community, and innovative individual-level police trainings.

The PrEP Care Continuum Among Cisgender Women Who Sell Sex and/or Use Drugs Globally: A Systematic Review

HIV prevalence among cisgender female sex workers (FSW) and/or women who use drugs (WWUD) is substantially higher compared to similarly aged women. Consistent with PRISMA guidelines, we conducted the first systematic review on the pre-exposure prophylaxis (PrEP) continuum among FSW and/or WWUD, searching PubMed, Embase, CINAHL, PsycInfo, and Sociological Abstracts. Eligibility criteria included: reporting a PrEP related result among FSW and/or WWUD aged 18 + ; peer-reviewed; and published in English between 2012 and 2018. Our search identified 1365 studies; 26 met eligibility requirements, across the following groups: FSW (n = 14), WWUD (n = 9) and FSW-WWUD (n = 3). Studies report on at least one PrEP outcome: awareness (n = 12), acceptability (n = 16), uptake (n = 4), and adherence (n = 8). Specific barriers span individual and structural levels and include challenges to daily adherence, cost, and stigma. Combining health services and long-acting PrEP formulas may facilitate better PrEP uptake and adherence. The limited number of studies indicates a need for more research.

Barriers and facilitators to retaining a cohort of street-based cisgender female sex workers recruited in Baltimore, Maryland, USA: results from the SAPPHIRE study

BACKGROUND

Despite experiencing HIV/STIs, violence, and other morbidities at higher rates than the general public, street-based female sex workers are often absent from public health research and surveillance due to the difficulty and high costs associated with engagement and retention. The current study builds on existing literature by examining barriers and facilitators of retaining a street-based cohort of cisgender female sex workers recruited in a mobile setting in Baltimore, Maryland who participated in the SAPPHIRE study. Participants completed interviews and sexual health testing at baseline, 3-, 6-, 9-, and 12-months.

METHODS

Retention strategies are described and discussed in light of their benefits and challenges. Strategies included collecting several forms of participant contact information, maintaining an extensive field presence by data collectors, conducting social media outreach and public record searches, and providing cash and non-cash incentives. We also calculated raw and adjusted retention proportions at each follow-up period. Lastly, baseline sample characteristics were compared by number of completed visits across demographic, structural vulnerabilities, work environment, and substance use variables using F-tests and Pearson's chi-square tests.

RESULTS

Although there were drawbacks to each retention strategy, each method was useful in tandem in achieving a successful follow-up rate. While direct forms of contact such as phone calls, social media outreach, and email were useful for retaining more stable participants, less stable participants required extensive field-based efforts such as home and site visits that increase the likelihood of random encounters. Overall, adjusted retention exceeded 70% for the duration of the 12-month study. Participants who were younger, recently experienced homelessness, and injected drugs daily were less likely to have completed all or most follow-up visits.

CONCLUSION

Retention of street-based female sex workers required the simultaneous use of diverse retention strategies that were tailored to participant characteristics. With familiarity of the dynamic nature of the study population characteristics, resources can be appropriately allocated to strategies most likely to result in successful retention.

Enhancing national prevention and treatment services for sex workers in Zimbabwe: a process evaluation of the SAPPH-IRe trial

Targeted HIV interventions for female sex workers (FSW) combine biomedical technologies, behavioural change and community mobilization with the aim of empowering FSW and improving prevention and treatment. Understanding how to deliver combined interventions most effectively in sub-Saharan Africa is critical to the HIV response. The Sisters' Antiretroviral Programme for Prevention of HIV: an Integrated Response (SAPPH-Ire) randomized controlled trial in Zimbabwe tested an intervention to improve FSW engagement with HIV services. After 2 years, results of the trial showed no significant difference between study arms in proportion of FSW with HIV viral load ≥1000 copies/ml as steep declines occurred in both. We present the results of a process evaluation aiming to track the intervention's implementation, assess its feasibility and accessibility, and situate trial results within the national HIV policy context. We conducted a mixed methods study using data from routine programme statistics, qualitative interviews with participants and respondent driven surveys. The intervention proved feasible to deliver and was acceptable to FSW and providers. Intervention clinics saw more new FSW (4082 vs 2754), performed over twice as many HIV tests (2606 vs 1151) and nearly double the number of women were diagnosed with HIV (1042 vs 546). Community mobilization meetings in intervention sites also attracted higher numbers. We identified some gaps in programme fidelity: offering pre-exposure prophylaxis took time to engage FSW, viral load monitoring was not performed, and ratio of peer educators to FSW was lower than intended. During the trial, reaching FSW with HIV testing and treatment became a national priority, leading to increasing attendance at both intervention and control clinics. Throughout Zimbabwe, antiretroviral therapy coverage improved and HIV-stigma declined. Zimbabwe's changing HIV policy context appeared to contribute to positive improvements across the HIV care continuum for all FSW over the course of the trial. More intense community-based interventions for FSW may be needed to make further gains.

The health impacts of violence perpetrated by police, military and other public security forces on gay, bisexual and other men who have sex with men in El Salvador

Gay, bisexual and other men who have sex with men face both high levels of violence and a disproportionate burden of poor health outcomes. We explored violence perpetrated against Salvadoran gay, bisexual and other men who have sex with men by public security forces; perceived motivations of violence; and impacts on health. We conducted structured qualitative interviews with 20 participants and used systematic coding and narrative analysis to identify emergent themes. Nearly all participants described the physical, emotional, sexual and/or economic violence by public security forces. Most attributed being targeted to their gender expression and/or perceived sexual orientation. The most common impact was emotional distress, including humiliation, fear and depression; lasting physical injuries were also widely reported. Study participants felt unable to report these incidents for fear of retribution or inaction. Men reported feelings of helplessness and distrust, avoidance of authorities and altering when, where or how often they appeared in public spaces. Programmes and interventions should focus on providing mental health services for LGBTI (lesbian, gay, bisexual, transgender and intersex) victims of violence, educating public security forces on the legal rights of Salvadorans and expanding current LGBTI-inclusive policies to all public security forces.

Policing Practices and Risk of HIV Infection Among People Who Inject Drugs

Drug-law enforcement constitutes a structural determinant of health among people who inject drugs (PWID). Street encounters between police and PWID (e.g., syringe confiscation, physical assault) have been associated with health harms, but these relationships have not been systematically assessed. We conducted a systematic literature review to evaluate the contribution of policing to risk of human immunodeficiency virus (HIV) infection among PWID. We screened MEDLINE, sociological databases, and gray literature for studies published from 1981 to November 2018 that included estimates of HIV infection/risk behaviors and street policing encounters. We extracted and summarized quantitative findings from all eligible studies. We screened 8,201 abstracts, reviewed 175 full-text articles, and included 27 eligible analyses from 9 countries (Canada, China, India, Malaysia, Mexico, Russia, Thailand, Ukraine, and the United States). Heterogeneity in variable and endpoint selection precluded meta-analyses. In 5 (19%) studies, HIV infection among PWID was significantly associated with syringe confiscation, reluctance to buy/carry syringes for fear of police, rushed injection due to a police presence, fear of arrest, being arrested for planted drugs, and physical abuse. Twenty-one (78%) studies identified policing practices to be associated with HIV risk behaviors related to injection drug use (e.g., syringe-sharing, using a "shooting gallery"). In 9 (33%) studies, policing was associated with PWID avoidance of harm reduction services, including syringe exchange, methadone maintenance, and safe consumption facilities. Evidence suggests that policing shapes HIV risk among PWID, but lower-income settings are underrepresented. Curbing injection-related HIV risk necessitates additional structural interventions. Methodological harmonization could facilitate knowledge generation on the role of police as a determinant of population health.

The development of the Police Practices Scale: Understanding policing approaches towards street-based female sex workers in a U.S. City

Policing is an important structural determinant of HIV and other health risks faced by vulnerable populations, including people who sell sex and use drugs, though the role of routine police encounters is not well understood. Given the influence of policing on the risk environment of these groups, methods of measuring the aggregate impact of routine policing practices are urgently required. We developed and validated a novel, brief scale to measure police patrol practices (Police Practices Scale, PPS) among 250 street-based female sex workers (FSW) in Baltimore, Maryland, an urban setting with high levels of illegal drug activity. PPS items were developed from existing theory and ethnography with police and their encounters with FSW, and measured frequency of recent (past 3 months) police encounters. The 6-item scale was developed using exploratory factor analysis after examining the properties of the original 11 items. Confirmatory factor analysis was used to model the factor structure. A 2-factor model emerged, with law enforcement PPS items and police assistance PPS items loading on separate factors. Linear regression models were used to explore the relative distribution of these police encounters among FSW by modeling association with key socio-demographic and behavioral characteristics of the sample. Higher exposure to policing was observed among FSW who were homeless (β = 0.71, p = 0.037), in daily sex work (β = 1.32, p = 0.026), arrested in the past 12 months (β = 1.44, p<0.001) or injecting drugs in the past 3 months (β = 1.04, p<0.001). The PPS provides an important and novel contribution in measuring aggregate exposure to routine policing, though further validation is required. This scale could be used to evaluate the impact of policing on vulnerable populations’ health outcomes, including HIV risk.

Community-Based Responses to Negative Health Impacts of Sexual Humanitarian Anti-Trafficking Policies and the Criminalization of Sex Work and Migration in the US

System-involvement resulting from anti-trafficking interventions and the criminalization of sex work and migration results in negative health impacts on sex workers, migrants, and people with trafficking experiences. Due to their stigmatized status, sex workers and people with trafficking experiences often struggle to access affordable, unbiased, and supportive health care. This paper will use thematic analysis of qualitative data from in-depth interviews and ethnographic fieldwork with 50 migrant sex workers and trafficked persons, as well as 20 key informants from legal and social services, in New York and Los Angeles. It will highlight the work of trans-specific and sex worker–led initiatives that are internally addressing gaps in health care and the negative health consequences that result from sexual humanitarian anti-trafficking interventions that include policing, arrest, court-involvement, court-mandated social services, incarceration, and immigration detention. Our analysis focuses on the impact of criminalization on sex workers and their experiences with sexual humanitarian efforts intended to protect and control them. We argue that these grassroots community-based efforts are a survival-oriented reaction to the harms of criminalization and a response to vulnerabilities left unattended by mainstream sexual humanitarian approaches to protection and service provision that frame sex work itself as the problem. Peer-to-peer interventions such as these create solidarity and resiliency within marginalized communities, which act as protective buffers against institutionalized systemic violence and the resulting negative health outcomes. Our results suggest that broader public health support and funding for community-led health initiatives are needed to reduce barriers to health care resulting from stigma, criminalization, and ineffective anti-trafficking and humanitarian efforts. We conclude that the decriminalization of sex work and the reform of institutional practices in the US are urgently needed to reduce the overall negative health outcomes of system-involvement.

Correlates of Sexual Coercion among People Who Inject Drugs (PWID) in Los Angeles and San Francisco, CA

Experiences of coerced or forced sex have been associated with risk for HIV infection for all adults and may be more common for gays, lesbians, bisexuals (GLB) and people who inject drugs (PWID). In this study, we explored factors associated with prior 12-month experiences of forced or coerced sex among a sample of PWID, with a focus on sexual orientation and gender. PWID (N = 772) from Los Angeles and San Francisco were recruited using targeted sampling methods in 2011-2013 and surveyed on a range of items related to demographics, drug use, HIV risk, and violence, including experiences of forced or coerced sex in the prior 12 months. In this racially/ethnically diverse, mostly homeless, and low-income sample of PWID, 25% of participants were female and 15% identified as GLB. Sexual coercion was reported by 9% of gay and bisexual men, 8% of heterosexual females, 5% of lesbians and bisexual women, and less than 1% of heterosexual men. In multivariate analyses, compared to heterosexual males, gay or bisexual males (adjusted odds ratio [AOR] = 10.68; 95% confidence interval [CI] = 2.03, 56.23), and heterosexual females (AOR = 9.69; 95% CI = 2.04, 45.94) had increased odds of coerced sex in the prior 12 months. Having a paying sex partner (AOR = 3.49; 95% CI = 1.42, 8.54) or having had forced sex prior to the age of 16 by someone at least five years older (AOR = 4.74; 95% CI = 1.88, 11.93) also elevated the odds of coercive sex. Sexual coercion is common among PWID, but especially for gay and bisexual men and heterosexual females. Efforts to reduce sexual violence among PWID are urgently needed.

Drivers of HIV Infection Among Cisgender and Transgender Female Sex Worker Populations in Baltimore City: Results From the SAPPHIRE Study

OBJECTIVE

To determine and compare risk factors for HIV infection among cisgender female sex workers (CFSWs) and transgender female sex workers (TFSWs).

DESIGN

Baseline data from a cohort study (SAPPHIRE) of street-based CFSW and TFSW in Baltimore, MD.

METHODS

Women were queried about individual (eg, drug use), interpersonal (eg, sexual abuse), and structural (eg, housing) risk factors and questioned on their sex work risk environment. Women were tested for HIV/sexually transmitted infections. We used logistic regression to identify key risk factors for prevalent HIV in each population.

RESULTS

We recruited 262 CFSW and 62 TFSW between 2016 and 2017. Compared with TFSW, CFSW were more likely to be white (66% vs. 0%), recently homeless (62% vs. 23%, P < 0.001), regularly gone to sleep hungry (54% vs. 16%, P < 0.001), and to inject drugs (71% vs. 4%, P < 0.001). HIV prevalence was 8 times greater in TFSW than in CFSW (40% vs. 5%, P < 0.001). All participants reported high rates of lifetime physical and sexual violence. Cocaine injection [adjusted odds ratio (aOR) = 3.65, 95% confidence interval (CI): 1.12 to 11.88], food insecurity (aOR = 1.92, 95% CI: 1.22 to 3.04), and >5 years in sex work (aOR = 5.40, 95% CI: 2.10 to 13.90) were independently associated with HIV among CFSW. Childhood sexual abuse (aOR = 4.56, 95% CI: 1.20 to 17.32), being in sex work due to lack of opportunities (aOR = 4.81, 95% CI: 1.29 to 17.90), and >5 years in sex work (aOR = 5.62, 95% CI: 1.44 to 21.85) were independently associated with HIV among TFSW.

CONCLUSIONS

Although distinct, both populations share a history of extensive childhood abuse and later life structural vulnerability, which drive their engagement in street-based sex work and their HIV risk profiles.

Reaching key adolescent populations

PURPOSE OF REVIEW

Adolescents and young people who fit within key populations face some of the greatest barriers to HIV care, but are frequently overlooked. We review the recent literature on these young, vulnerable populations including HIV risk factors, barriers to care, and strategies for engagement.

RECENT FINDINGS

Common risk factors include age, risky sexual practices, poor education, and high levels of alcohol and drug abuse. Barriers to care include limited data, criminalization, and high levels of stigma. Strategies to increase engagement include incorporating adolescents into biological and behavioral surveys and the use of social media. Digital innovations for HIV prevention and testing show promise, and pre-exposure prophylaxis may be acceptable. At a policy level, decriminalizing same-sex activity and commercial sex work are priorities. Differentiated models of care including HIV self-testing, after-hour services, community-based delivery, and multimonth dispensing of antiretroviral therapy, should be combined into holistic care.

SUMMARY

There has been limited success in reaching these key adolescent populations largely because of criminalization and stigma. Accurate, generalizable data are needed to inform the development of innovative strategies for holistic care.

Structural determinants of health: a qualitative study on female sex workers in Benin

The objective of this paper is to expose those socio-structural contexts revealing the social injustice and human rights violations that sub-Saharan women face every day when forced into sex work by unemployment or sickness. Results of a qualitative study highlighting some key structural determinants of sex work and HIV infection among FSWs will be presented and examined through the lens of the WHO conceptual framework for action on the social determinants of health. The results showed that most FSWs had lacked the necessary financial support at some point in their lives. Also, both the socioeconomic and political context failed to provide proper support to prevent involvement in sex work and the consequent risks of HIV. The cultural and societal values placed on the health and well-being of FSWs in Benin appear to depend on the degree to which sexual violence and adultery are perceived as a collective social concern. This portrait of FSWs calls for both long-term interventions through a structural determinant approach to HIV prevention, targeting all the women who could face such a financial situation well before their entry into sex work, while maintaining short and medium-term interventions on the intermediary determinants.

Law enforcement and public health: recognition and enhancement of joined-up solutions

Public security and law enforcement have a crucial but often largely unacknowledged role in protecting and promoting public health. Although the security sector is a key partner in many specific public health programmes, its identity as an important part of the public health endeavour is rarely recognised. This absence of recognition has resulted in a generally inadequate approach to research and investigation of ways in which law enforcement, especially police at both operational and strategic levels, can be effectively engaged to actively promote and protect public health as part of a broader multisectoral public health effort. However, the challenge remains to engage police to consider their role as one that serves a public health function. The challenge consists of overcoming the continuous and competitive demand for police to do so-called policing, rather than serve a broader public health function-often derogatively referred to as social work. This Series paper explores the intersect between law enforcement and public health at the global and local levels and argues that public health is an integral aspect of public safety and security. Recognition of this role of public health is the first step towards encouraging a joined-up approach to dealing with entrenched social, security, and health issues.

Police-Related Correlates of Client-Perpetrated Violence Among Female Sex Workers in Baltimore City, Maryland

OBJECTIVES

To characterize interactions that female sex workers (FSWs) have with the police and explore associations with client-perpetrated violence.

METHODS

Baseline data were collected April 2016 to January 2017 from 250 FSWs from the Sex Workers and Police Promoting Health in Risky Environments (SAPPHIRE) study based in Baltimore, Maryland. Interviewer-administered questionnaires captured different patrol or enforcement and abusive police encounters, experiences of client-perpetrated violence, and other risk factors, including drug use. We conducted bivariate and multivariable analysis in Stata/SE version 14.2 (StataCorp LP, College Station, TX).

RESULTS

Of participants, 78% reported lifetime abusive police encounters, 41% reported daily or weekly encounters of any type. In the previous 3 months, 22% experienced client-perpetrated violence. Heroin users (70% of participants) reported more abusive encounters (2.5 vs 1.6; P < .001) and more client-perpetrated violence (26% vs 12%; P = .02) than others. In multivariable analysis, each additional type of abusive interaction was associated with 1.3 times (95% confidence interval [CI] = 1.1, 1.5) increased odds of client-perpetrated violence. For patrol or enforcement encounters, this value was 1.3 (95% CI = 1.0, 1.7).

CONCLUSIONS

Frequent exposures to abusive police practices appear to contribute to an environment where client-perpetrated violence is regularly experienced. For FSWs who inject drugs, police exposure and client-perpetrated violence appear amplified. Public Health Implications. Structural interventions that address police-FSW interactions will help alleviate police's negative impact on FSWs' work environment.

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

BACKGROUND

Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur.

METHODS AND FINDINGS

We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing.

CONCLUSIONS

Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.