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Background: Female sex workers (FSWs) are vulnerable to a number of health issues, but often delay seeking health care due to structural barriers. Multiservice drop-in centers have been shown to increase FSW access to health services globally, but their impact on FSW in the United States is lacking. This study seeks to evaluate the effect of a community-level empowerment intervention (the multiservice drop-in SPARC center) on cumulative sexually transmitted infections (STIs) among FSW in a city in the United States. Methods: Between September 2017 and January 2019, 385 FSWs were recruited in Baltimore. Participants from areas served by SPARC were recruited to the intervention; other areas of Baltimore were the control. Follow-up occurred at 6, 12, and 18 months. The primary outcome is cumulative STI (ie, positive gonorrhea or chlamydia test at any follow-up). We tested effect modification by condomless sex with paying clients reported at baseline. Logistic regressions with propensity score weighting were used to estimate intervention effect, accounting for loss to follow-up, with bootstrap confidence intervals. Results: Participants completed 713 follow-up study visits (73%, 70%, 64% retention at 6, 12, and 18 months, respectively). Baseline STI prevalence was 28% and cumulative STI prevalence across follow-ups was 26%; these both did not differ between control and intervention communities in bivariate analyses. After adjusting for covariates, FSW in the intervention had a borderline-significant decrease in odds of cumulative STI compared with control (odds ratio, 0.61, P = 0.09). There was evidence of effect modification by baseline condomless sex, such that FSW in the intervention who reported condomless sex had lower odds of cumulative STI compared with FSW in the control community who also reported baseline condomless sex (odds ratio, 0.29; P = 0.04). Conclusions: Results demonstrate the value of a low-barrier, multiservice model on reducing STIs among the highest-risk FSW. Clinical Trial Number: NCT04413591 [ABSTRACT FROM AUTHOR]

Women who use drugs (WWUD) experience structural vulnerabilities (e.g., housing, food insecurities) and comorbidities that elevate their susceptibility to more severe COVID-19 symptoms or fatality compared to similarly-aged women who do not use illicit drugs. Testing is a cornerstone of effective COVID prevention, however, entrenched barriers to healthcare utilization means that WWUD may have diminished accessing to COVID testing. The CARE (COVID Action Research Engagement) study first examines predisposing and enabling factors that predict COVID testing uptake over six months (baseline, 3-, and 6-month follow-up) among a cohort of WWUD (N = 250) in Baltimore, Maryland, providing a nuanced and holistic understanding of how to meaningfully engage WWUD in COVID testing. Then, point-of-care COVID testing will be implemented on a mobile outreach van affiliated with a local community-based organization primarily serving WWUD; anonymous surveys of mobile outreach guests (N = 100) will assess feasibility and acceptability of this integrated testing. The study is grounded in the Behavioral Model for Vulnerable Populations and the Theoretical Framework of Acceptability. We hypothesize that point-of-care COVID testing integrated into a low-barrier harm reduction service, such as a mobile outreach program, will be an enabling environment for COVID testing uptake in part by reducing structural impediments to testing and will be highly feasible and acceptable to participants. Strengths, limitations, and plans for results dissemination are discussed. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Female sex workers (FSWs) have elevated rates of sexually transmitted infections (STIs) including HIV, yet few studies in the United States have characterized the STI burden in this population.Methods: Data were derived from the EMERALD study, a structural community-based intervention with FSWs in Baltimore, MD. Participants (n = 385) were recruited through targeted sampling on a mobile van. Prevalent positive chlamydia or gonorrhea infections were determined by biological samples. Multivariable logistic regressions modeled correlates of confirmed positive STI (gonorrhea or chlamydia).Results: Confirmed STI positive prevalence was 28%, 15% chlamydia and 18% gonorrhea. Approximately two-thirds of the sample (64%) was younger than 40 years, one-third (36%) were Black, and 10% entered sex work in the past year. The sample was characterized by high levels of structural vulnerabilities (e.g., housing instability and food insecurity) and illicit substance use. Female sex workers were more likely to have a positive STI if they had financial dependent(s) (P = 0.04), experienced food insecurity at least weekly (P = 0.01), entered sex work in the past year (P = 0.002), and had 6 or more clients in the past week (P = 0.01). Female sex workers were less likely to have a positive STI test result if they were 40 years or older compared with FSW 18 to 29 years old (P = 0.02), and marginally (P = 0.08) less likely with high (vs. low) social cohesion.Conclusions: More than a quarter of FSWs had confirmed chlamydia or gonorrhea. In addition to STI risks at the individual level, STIs are driven by structural vulnerabilities. Results point to a number of salient factors to be targeted in STI prevention among FSWs. [ABSTRACT FROM AUTHOR]

Background: Female sex workers (FSWs) are an important population for HIV acquisition and transmission. Their risks are shaped by behavioral, sexual network, and structural level factors. Violence is pervasive and associated with HIV risk behavior and infection, yet interventions to address the dual epidemics of violence and HIV among FSWs are limited.Methods: We used participatory methods to develop a brief, trauma-informed intervention, INSPIRE (Integrating Safety Promotion with HIV Risk Reduction), to improve safety and reduce HIV risk for FSWs. A quasi-experimental, single group pretest-posttest study evaluated intervention feasibility, acceptability and efficacy among FSWs in Baltimore, MD, most of whom were drug-involved (baseline n = 60; follow-up n = 39 [65%]; non-differential by demographics or outcomes). Qualitative data collected at follow-up contextualizes findings.Results: Based on community partnership and FSW input, emergent goals included violence-related support, connection with services, and buffering against structural forces that blame FSWs for violence. Qualitative and quantitative results demonstrate feasibility and acceptability. At follow-up, improvements were seen in avoidance of client condom negotiation (p = 0.04), and frequency of sex trade under the influence of drugs or alcohol (p = 0.04). Women's safety behavior increased (p < 0.001). Participants improved knowledge and use of sexual violence support (p < 0.01) and use of intimate partner violence support (p < 0.01). By follow-up, most respondents (68.4%) knew at least one program to obtain assistance reporting violence to police. Over the short follow-up period, client violence increased. In reflecting on intervention acceptability, participants emphasized the value of a safe and supportive space to discuss violence.Discussion: This brief, trauma-informed intervention was feasible and highly acceptable to FSWs. It prompted safety behavior, mitigated sex trade under the influence, and bolstered confidence in condom negotiation. INSPIRE influenced endpoints deemed valuable by community partners, specifically improving connection to support services and building confidence in the face of myths that falsely blame sex workers for violence. Violence persisted; prevention also requires targeting perpetrators, and longer follow-up durations as women acquire safety skills. This pilot study informs scalable interventions that address trauma and its impact on HIV acquisition and care trajectories for FSWs.Conclusion: Addressing violence in the context of HIV prevention is feasible, acceptable to FSWs, and can improve safety and reduce HIV risk, thus supporting FSW health and human rights. [ABSTRACT FROM AUTHOR]

BACKGROUND: Patient decision aids facilitate informed decision making for medical tests and procedures that have uncertain benefits. OBJECTIVE: To describe participants' evaluation and utilization of print-based and web-based prostate cancer screening decision aids that were found to improve decisional outcomes in a prior randomized controlled trial. DESIGN: Men completed brief telephone interviews at baseline, one month, and 13 months post-randomization. PARTICIPANTS: Participants were primary care patients, 45-70 years old, who received the print-based ( N = 628) or web-based decision aid ( N = 625) and completed the follow-up assessments. MAIN MEASURES: We assessed men's baseline preference for web-based or print-based materials, time spent using the decision aids, comprehension of the overall message, and ratings of the content. KEY RESULTS: Decision aid use was self-reported by 64.3 % (web) and 81.8 % (print) of participants. Significant predictors of decision aid use were race (white vs. non-white, OR = 2.43, 95 % CI: 1.77, 3.35), higher education (OR = 1.68, 95 % CI: 1.06, 2.70) and trial arm (print vs. web, OR = 2.78, 95 % CI: 2.03, 3.83). Multivariable analyses indicated that web-arm participants were more likely to use the website when they preferred web-based materials (OR: 1.91, CI: 1.17, 3.12), whereas use of the print materials was not significantly impacted by a preference for print-based materials (OR: 0.69, CI: 0.38, 1.25). Comprehension of the decision aid message (i.e., screening is an individual decision) did not significantly differ between arms in adjusted analyses (print: 61.9 % and web: 68.2 %, p = 0.42). CONCLUSIONS: Decision aid use was independently influenced by race, education, and the decision aid medium, findings consistent with the 'digital divide.' These results suggest that when it is not possible to provide this age cohort with their preferred decision aid medium, print materials will be more highly used than web-based materials. Although there are many advantages to web-based decision aids, providing an option for print-based decision aids should be considered. [ABSTRACT FROM AUTHOR]

Background: The criminalization of sex work and drug use creates unequal power dynamics easily exploited by police. Women who exchange sex (WES) in settings around the globe have reported coerced sex and sexual assault by police, and some have reported police as paying clients. Little research has examined nuances underlying WES's sexual interactions with police. Methods: A cohort of cisgender WES (N = 308) was recruited through targeted sampling in Baltimore, Maryland and completed a structured survey every 6 months for 18 months. Follow-up surveys included detailed questions about recent sexual encounters with police. In bivariate and multivariate models using generalized estimating equations to account for intra-person correlation, we examined correlates of reporting recent sex with police over time. Results: One-third reported recent sex with police at any study visit. At each time point, about 90% of women who reported sex with police reported any uniformed or non-uniformed police had paid for sex. Between 72 and 85% had been solicited for paid sex by uniformed police. Between 41 and 50% of women who reported recent sex with police indicated they had done so because they feared arrest otherwise; one-third were directly pressured for sex by police to avoid arrest or trouble. In the final adjusted model, severe food insecurity [adjusted odds ratio (aOR) = 2.05; 95% confidence interval (CI) 1.13–3.71], Black race (vs. white, non-Hispanic; aOR = 1.90; 95% CI 1.13–3.17), recent arrest (aOR = 1.51; 95% CI 1.01–2.27), nonfatal overdose (aOR = 1.94; 95% CI 1.24–3.01), and client- or non-paying intimate partner-perpetrated violence (aOR = 2.46; 95% CI 1.63–3.71) were significantly independently associated with recent sex with police. Conclusions: Sexual encounters between WES and police in Baltimore are common and often coerced to avoid arrest in a setting where both drug use and sex work are criminalized. Recent sex with police was more prevalent among WES who were racially marginalized, highly structurally vulnerable, and/or at high risk for drug overdose—and therefore subject to the dual-criminalization of sex work and drug use. This indicates deep power imbalances and their exploitation by police as the root of such sexual encounters and adds to the evidence regarding the need for decriminalization to support the health and wellbeing of WES. [ABSTRACT FROM AUTHOR]

Background: Existing research in urban areas has documented a multitude of ways in which law enforcement may affect risks for bloodborne infectious disease acquisition among people who inject drugs (PWID), such as via syringe confiscation and engaging in practices that deter persons from accessing syringe services programs (SSPs). However, limited work has been conducted to explore how law enforcement may impact SSP implementation and operations in rural counties in the United States. This creates a significant gap in the HIV prevention literature given the volume of non-urban counties in the United States that are vulnerable to injection drug use-associated morbidity and mortality. Objective: This study explores the influence of law enforcement during processes to acquire approvals for SSP implementation and subsequent program operations in rural Kentucky counties. Methods: From August 2020 to October 2020, we conducted eighteen in-depth qualitative interviews among persons involved with SSP implementation in rural counties in Kentucky (USA). Interviews explored the factors that served as barriers and facilitators to SSP implementation and operations, including the role of law enforcement. Results: Participants described scenarios in which rural law enforcement advocated for SSP implementation; however, they also reported police opposing rural SSP implementation and engaging in adverse behaviors (e.g., targeting SSP clients) that may jeopardize the public health of PWID. Participants reported that efforts to educate rural law enforcement about SSPs were particularly impactful when they discussed how SSP implementation may prevent needlestick injuries. Conclusions: The results of this study suggest that there are multiple ways in which rural SSP implementation and subsequent operations in rural Kentucky counties are affected by law enforcement. Future work is needed to explore how to expeditiously engage rural law enforcement, and communities more broadly, about SSPs, their benefits, and public health necessity. [ABSTRACT FROM AUTHOR]

Introduction: The sex work environment influences sex workers' control over enforcing condom use. Sex work in outdoor and public spaces, compared with indoor spaces, may inhibit condom negotiation. We examined longitudinal associations between public place of sex work and condom coercion among female sex workers. Methods: This cohort study involved 5 data collection points over 1 year among female sex workers (N = 246) in Baltimore, Maryland, recruited by targeted sampling. We conducted bivariate analyses to examine associations between currently conducting any sex work in a public place (PPSW, eg, car, abandoned house, street, park/forest, and public bathroom) vs. exclusively indoor sex work (eg, house, motel, and dance club) with sociodemographic, substance use (eg, injection drug use, crack use), and past 3-month condom coercion (eg, client condom refusal/removal). We used logistic regressions with generalized estimating equations and exchangeable correlation structure to examine longitudinal associations between PPSW and subsequent condom coercion, adjusting for sociodemographic and substance use variables. Findings: Among participants (race/ethnicity: White: 67.5%; Black/African American: 22.8%; Latina/other ethnicity: n = 9.8%; age range: 18--61), most reported daily injection drug use (58.5%), daily crack use (62.2%), and homelessness (62.2%). Most (88.6%) reported any PPSW at baseline. Current PPSW was associated with increased odds of past 3-month condom coercion (adjusted odds ratio [aOR]: 1.85, 95% confidence interval: 1.16 to 2.94, P = 0.01) compared with indoor sex work, as was daily crack use (aOR 1.67, 95% confidence interval: 1.18 to 2.37). Conclusions: Public sex work environments were associated with client condom coercion and confer additional sexual health risks in contexts of illegality. Interventions should address risk disparities in social geographies of sex work. [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]