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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. [ABSTRACT FROM AUTHOR]

Aims: To determine the interpersonal and structural factors associated with receptive syringe sharing (RSS) among female sex workers who inject drugs (FSW‐IDU), a group at high risk of HIV/hepatitis C virus (HCV) acquisition. Design Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) study, a prospective cohort study. Setting: Baltimore, MD, USA Participants: One hundred and eighty FSW‐IDU; mean age = 33 years, 77.1% white and 62.9% in a relationship/married. Measurements Surveys were conducted between April 2016 and February 2018. The main outcome was recent RSS (past 3 months). In addition to socio‐demographic characteristics and drug use behaviors, we assessed factors at the interpersonal level, including injection practices, intimate partner and client drug use and exposure to violence. Structural‐level factors included methods of syringe access. Findings Nearly all FSW‐IDU used heroin (97.1%) or crack cocaine (89.7%). Recent RSS was reported by 18.3%. Syringes were accessed from needle exchange programs (64.6%), pharmacies (29.7%), street sellers (30.3%) or personal networks (29.1%). Some FSW‐IDU had clients or intimate partners who injected drugs (26.3 and 26.9%, respectively). Longitudinal factors independently associated with RSS in the multi‐level mixed‐effects model were recent client violence [adjusted odds ratio (aOR) = 2.17, 95% confidence interval (CI) = 1.09–4.33], having an intimate partner who injected drugs (aOR = 2.18, 95% CI = 0.98–4.85), being injected by others (aOR = 4.95, 95% CI = 2.42–10.10) and obtaining syringes from a street seller (aOR = 1.88, 95% CI = 0.94–3.78) or from a member of their personal network (aOR = 4.43, 95% CI = 2.21–8.90). Conclusions: Client violence, intimate partner injection drug use, being injected by others and obtaining syringes from personal connections appear to increase parenteral HIV/HCV risk among female sex workers who inject drugs. [ABSTRACT FROM AUTHOR]

Background: In 2018, there were over 67,000 drug overdose deaths in the United States, with almost half involving illicit fentanyl and other synthetic opioids. While overall age-adjusted drug overdose deaths decreased by 4.6% from 2017 to 2018, synthetic opioid deaths increased 10.0%. This pilot study evaluates the impact of a brief fentanyl test strip (FTS) intervention to increase fentanyl awareness and reduce overdose risk.Methods: Female sex workers (FSW) reporting past month illicit opioid use were recruited between April 2018 through February 2019 in Baltimore City, Maryland. At baseline, they completed a baseline survey, and received tailored harm reduction messaging, 5 FTS and training, and a naloxone kit, then completed a survey after one month. McNemar's test was used to compare repeated measures.Results: Among N = 103, 54% were <40 years, 59% were white, and 24% had overdosed in the past year. Among 68 who completed follow-up, most (84%) used ≥1 FTS to test their drugs, 86% had ≥1 fentanyl-positive result, 57% were surprised by the result, and 69% engaged in harm reduction behaviors following the result (e.g., asked someone to check on them, did a tester shot, used a smaller amount). Significant pretest-posttest reductions in daily illicit opioid use (77% to 56%; p = 0.003), injection frequency (40% to 25%; p = 0.004), benzodiazepine use (22% to 7%; p = 0.008), and solitary drug use (96% vs. 68%; p < 0.001) were observed. No change in preferring drugs containing fentanyl was found. Some (18%) gave their FTS to others. All but three (96%) reported being likely to use FTS in the future.Conclusions: We found high FTS acceptability and reductions in drug use frequency and solitary drug use following FTS use among FSW who use drugs in Baltimore. These findings demonstrate that FTS-based interventions hold potential in reducing overdose risk. [ABSTRACT FROM AUTHOR]

Background: Street-based female sex workers (FSW) often cycle in and out of sex work engagement. For many FSW, substance use plays a critical role in sex work entry, continuation, and interruptions. We examined individual, interpersonal, and structural correlates of short-term interruptions of sex work among street-based FSW in an urban environment.Methods: Data were from 205 FSW in Baltimore, MD, USA followed as part of an observational prospective cohort study between April 2016-Februrary 2018. The primary outcome was short-term interruptions of sex work (stopping sex work) over the past 3 months, asked every 3 months over a 12-month follow-up. We assessed the relationship between individual, structural, and interpersonal factors for each woman's prior visit and current visit with short-term sex work interruptions. We employed modified Poisson regression with Generalized Estimating Equations to identify correlates of short-term interruptions of sex work.Results: Eighty-two women (40%) reported stopping sex work over the past 3 months at least once during follow-up. Past drug treatment (adjusted incidence rate ratio [aIRR] 1.40; 95% CI: 1.06-1.86) and not having used drugs in the past 3 months (aIRR 2.70; 95% CI: 1.96-3.71) were positively associated with short-term interruption to sex work. Past intimate partner violence (IPV) (aIRR 0.52; 95% CI: 0.31-0.86) and current homelessness (aIRR 0.61; 95% CI: 0.41-0.91) were negatively associated with short-term interruption. Results were inconclusive for the association between recent prostitution arrest and short-term interruptions to sex work (IRR 0.86; 95% CI: 0.40-1.86).Conclusion: The study suggests that similar to other professions, women leave sex work for numerous reasons. Substance use cessation and participation in drug treatment programs may contribute to short-term interruptions of sex work by reducing reliance on sex work for income among street-based FSW. Structural vulnerabilities including homelessness and IPV are driving continued street-based sex work, speaking to the need for holistic structural interventions. [ABSTRACT FROM AUTHOR]

Female sex workers are a structurally vulnerable population, including critical insecurity such as having access to food and shelter. This risk may be heightened among individuals who enter sex work as minors. However, the reasons for entering sex work as a minor and the long-term structural risk implications are poorly understood. Here, we investigated the reasons for and long-term impact of trading sex before the age of eighteen on women's structural vulnerability among a cohort of 250 cisgender women involved in street-based sex work in Baltimore City, Maryland, USA. We used logistic regression to explore the role of age of entry on two structural vulnerability outcomes of interest (homelessness and recent food insecurity in the past 3 months). Overall, 73% of women entered the sex trade to get drugs, 36% of women entered to get basic necessities such as food or housing, and 17% of women entered to support their children or family. Of significance, 21% of those aged < 18 years at entry reported being either coerced, threatened, pressured, misled, tricked, or physically forced into trading sex compared to 5% in those who entered at an older age group (p value < 0.001). In adjusted analysis, women who first trade sex before the age of 18 had 4.54 increased odds of experiencing recent homelessness (95% CI 1.92-10.70) and had 3.14 times increased odds of experiencing recent food insecurity (95% CI 1.42-6.94). Those who entered as minors were also more likely to be HIV positive (11.3% vs 3.6%, p value = 0.02). This study highlights that those who trade sex at a younger age experience an ongoing cumulative vulnerability in comparison to those entering over the age of 18. These findings call for additional research into a more detailed understanding of young women's entry into the sex trade and trajectory. A focus on the importance of policy changes and structural interventions that directly alleviate young people's socio-economic disadvantage is needed. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Overdose Prevention Sites (OPS) operate worldwide as spaces where people can consume previously purchased drugs under supervision, and are linked to reductions in HIV/HCV transmission and fatal overdoses. As the United States weighs their merits and legality, research is needed to estimate acceptability and use among populations at high risk for overdose. We examine willingness to use OPS among street-based female sex workers (FSW) with prevalent drug use and associated morbidities.Methods: We describe self-reported willingness, barriers and conditions around use of a hypothetical OPS among 141 FSW engaged in active drug use in Baltimore City, and describe trends using Pearson's χ2 and Fisher's exact tests.Results: Most women had history of overdose (55 %) and were likely to use OPS (77 %). Willingness was higher among women who: were sexual minorities (97 %;P=0.002),experienced homelessness (82 %;P=0.019), injected drugs (82 %;P=0.013), shared syringes (82 %;P=0.007), experienced sexual violence (92 %;P=0.045) or reported heroin use (83 %;P=0.039) in the past 3 months. Common anticipated barriers included transportation (45 %) and fear of arrest (41 %).Conclusions: This study highlights a population of uniquely high-risk women who would benefit from an OPS integrated with other services. Conditions and barriers discussed are informative for planning and implementation. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Globally, HIV prevention interventions have proven efficacious among street-based female sex workers (FSWs); yet, there is a dearth of US-based HIV prevention research among this group. The lack of research among FSWs in the USA is partially driven by challenges in recruiting members of this population. The purpose of this research is to describe how targeted sampling was employed to recruit a cohort of street-based FSWs for a study that examined the role of police in shaping the HIV risk environments of street-based FSWs in Baltimore, MD. Our research demonstrates that targeted sampling can be an advantageous strategy for recruiting hidden populations that are mobile and geographically dispersed. [ABSTRACT FROM AUTHOR]