Search

Objective Given stark health inequities among precarious and criminalized workers, we aimed to apply a structural determinants framework to systematically review evidence on HIV/sexually transmitted infection (STI) prevalence, access to HIV/STI/SRH services, and condom use among im/migrant sex workers (ISWs) globally. Methods Systematic search of peer-reviewed studies published in English (2009-2019). Eligible studies reported HIV/STI, access to HIV/STI/SRH services, and/or condom use outcomes and/or lived experiences among ISWs. Quantitative and qualitative data were synthesized using a structural determinants framework. Results Of 425 studies screened, 29 studies from 15 countries were included. HIV prevalence ranged from 0.3 to 13.6% and varied across settings, with highest prevalence among undocumented ISWs in a high-income country (Portugal). Precarious immigration status was a structural factor associated with poorer HIV/STI outcomes, whereas qualitative narratives showed ISWs' lived experiences as strongly shaped by policing and stigma. Despite disparities, in some settings, HIV and STI prevalence were lower and odds of condom use with clients were higher among ISWs relative to non-im/migrant sex workers. This review identified a paucity of research on SRH and male and gender-diverse ISWs. Across legislative settings, criminalization of SW and im/migrant status, policing, and migration-related marginalization were prominent structural barriers to ISWs' HIV/STI/SRH access. Conclusion This review identified important inequities and variation in HIV/STI prevalence among ISWs globally. Our findings highlight impacts of the intersections of migration and criminalization, and suggest a need to reform criminalized sex work laws; address punitive policing and immigration enforcement; enable safer indoor work environments; and expand community-based interventions towards promoting HIV/STI/SRH access and health equity among ISWs.

Given growing concerns of im/migrant women’s access to sexual and reproductive health (SRH) services, we aimed to (1) describe inequities and determinants of their engagement with SRH services in Canada; and (2) understand their lived experiences of barriers and facilitators to healthcare. Using a comprehensive review methodology, we searched the quantitative and qualitative peer-reviewed literature of im/migrant women’s access to SRH care in Canada from 2008 to 2018. Of 782 studies, 38 met inclusion criteria. Ontario (n = 18), British Columbia (n = 6), and Alberta (n = 6) were primary settings represented. Studies focused primarily on maternity care (n = 20) and sexual health screenings (n = 12). Determinants included health system navigation and service information; experiences with health personnel; culturally safe and language-specific care; social isolation and support; immigration-specific factors; discrimination and racialization; and gender and power relations. There is a need for research that compares experiences across diverse groups of racialized im/migrants and a broader range of SRH services to inform responsive, equity-focused programs and policies.

After Canada’s laws criminalising sex work were struck down by the Supreme Court for violating sex workers’ rights, new end-demand legislation was passed in 2014. These new laws however continue to criminalise sex work third parties (i.e. venue owners/managers) who gain material benefits, despite evidence that managed in-call venues can provide important protections for sex workers. As part of a longstanding community-based study (AESHA) in Vancouver, this analysis drew on 25 in-depth interviews with third parties who provide services for indoor sex workers. We explored how end-demand third party criminalisation shapes indoor sex workers’ working conditions, health and safety. We found that most third parties were women and current/former sex workers, problematising assumptions of third parties as exploitative male “pimps”. Third parties provided client screening, security and sexual health resources for sex workers, yet end-demand laws restricted condom availability and access to police protections in case of violence, thereby undermining sex workers’ health and safety. Our findings highlight that third party criminalisation under end-demand legislation reproduces the unsafe working conditions under the previous laws deemed unconstitutional by Canada’s highest court. Legislative reforms to decriminalise all aspects of the sex industry, including sex workers’ right to work with third parties, are urgently needed.

Objectives: Sex workers (SWs) face an increased burden of sexually transmitted and blood-borne infections, yet little is known regarding hepatitis B virus (HBV) prevention and care. This study was performed to characterize cross-sectional and prospective correlates of HBV vaccination among SWs in Vancouver. Methods: Questionnaire data were drawn from a community-based cohort of SWs (2010–2017). Multivariable logistic regression was used to examine correlates of lifetime self-reported HBV vaccination. Multivariable generalized estimating equation (GEE) regression was used to assess correlates of recent vaccination. Results: Among 855 participants, 68.3% reported lifetime HBV vaccination. Multivariable logistic regression showed that im/migrants (adjusted odds ratio (AOR) 0.50, 95% confidence interval (CI) 0.32–0.78) had lower odds of vaccination and that those using injection drugs (AOR 1.88, 95% CI 1.27– 2.78) and those who had undergone HIV testing (AOR 1.94, 95% CI 1.14–3.29) had higher odds of vaccination. In the multivariable GEE analysis, HIV seropositivity (AOR 1.93, 95% CI 1.26–2.97) and recent STI testing (AOR 2.95, 95% CI 1.99–4.39) correlated with recent HBV vaccination. Conclusions: Im/migrant SWs from HBV-endemic settings appear to face gaps in HBV prevention. Evidence-based interventions addressing gaps in voluntary HBV prevention and care are needed, including community-based and culturally safe services. Injection drug use and HIV testing were linked to enhanced vaccination, suggesting that harm reduction and HIV programmes may facilitate linkage to HBV prevention. Keywords: Hepatitis B, Vaccination, Sex work, Immigrants

Given the disproportionate HIV burden faced by female sex workers FSWs and limited data regarding their engagement in the HIV cascade of care in conflict-affected settings, we characterized the cascade of care and examined associations with new HIV diagnoses and antiretroviral therapy (ART) use in a community-based cohort of FSWs in conflict-affected Northern Uganda. Data were collected via FSW/peer-led time-location sampling and outreach, interview-administered questionnaires, and voluntary HIV testing. Of 400 FSWs, 33.5% were living with HIV, of whom 33.6% were new/previously undiagnosed infections and 32.8% were on ART. Unstable housing and heavy alcohol/drug use were independently associated with increased odds of new HIV diagnoses, whereas exposure to condom demonstrations and number of lifetime pregnancies were negatively associated. In subanalysis among known HIV-positive women, age and time since diagnosis were associated with ART use, whereas sexually transmitted infections were negatively associated. Findings suggest the need for FSW-tailored, peer-based, and integrated HIV and sexual and reproductive health programs to address gaps in HIV testing and treatment for FSWs in conflict-affected communities.

Background Differential impacts of the COVID-19 pandemic have brought deeply rooted inequities to the forefront, where increasing evidence has shown that racialized immigrant and migrant (im/migrant) populations face a disproportionate burden of COVID-19. Im/migrant communities may be worst affected by lockdowns and restrictive measures, face less opportunity to physically distance or stay home sick within ‘essential’ jobs, and experience severe barriers to healthcare. Insufficient attention to experiences of racialized im/migrants in current pandemic responses globally highlights an urgent need to more fulsomely address unmet health needs through an anti-racist, equity-oriented lens. This commentary aims to highlight the need for public health and clinical training, research, and policy to thoughtfully prioritize im/migrant health equity during and beyond the COVID-19 pandemic. Main text Global pandemic responses have neglected im/migrants by continuing to ignore or insufficiently address inequities, exacerbating COVID transmission, xenophobia, and occupational injustice. Deaths, illness, stress, and other negative outcomes of the overlapping epidemics of COVID-19 and structural racism disproportionately borne by racialized im/migrants suggest the urgent need for action. As evidence mounts about how im/migrants have been left behind in times of crises, we need enhanced focus on health equity within COVID-19 research and interventions, including research that examines and pursues structural interventions necessary to mitigate these impacts, and that identifies patterns and harms of xenophobic policy, structural racism, and white supremacy in shaping im/migrant health outcomes. We must also strengthen anti-racist and equity-oriented curriculum within health education, and ensure sufficient attention to the needs of im/migrant communities within public health, clinical, and research training. Conclusion The COVID-19 pandemic has exacerbated and rendered more visible the deeply rooted health and social inequities faced by racialized im/migrants across diverse settings. We argue for a greater emphasis on equity-focused and anti-racist im/migrant health research, interventions, and training. Policymakers and practitioners must ensure that healthcare policies and practices do not exacerbate inequities, and instead meaningfully address unmet needs of communities, including racialized im/migrants. Ethical and respectful community engagement, commitment and collaboration with global, national, and local communities, policymakers, academics, and educators, as well as accountability across sectors, is critical.

This volume uses community case studies and data from around the world to highlight the sustained health and social inequities that sex workers in all of their diversity experience in 2020. Guided by a balanced community–academic partnership, this volume aims to ensure that sex workers’ voices are amplified in describing both challenges and the ways forward. Collectively, the chapters describe an elevated burden of HIV, sexually transmitted infections, drug-related harms, violence and other human rights violations, and significant unmet sexual and reproductive health needs. They also demonstrate that sex workers are not passive recipients of such inequity, but rather actively resist and continue to mobilise to advocate for improved health, safety, and human rights conditions and policy changes. Evidence-based recommendations include sex work decriminalisation, ensuring accessible and sex worker-friendly services, removal of punitive policing and surveillance, community empowerment, and strengthening capacity for community engagement in research, policy, and programmes.

Female sex workers (FSWs) who use drugs face increased risk of intimate partner violence (IPV) and nonpartner violence (NPV). The association between violence and drug overdose is unknown.To examine the association between IPV, NPV, and nonfatal drug overdose among FSWs who use drugs in Kazakhstan.This cross-sectional study included 400 adult FSWs in Kazakhstan who reported illicit drug use in the past year, exchanged sex for money or drugs, and reported having unprotected sex in the past 90 days. Baseline data were collected from February 2015 to May 2017 from Project Nova, an HIV prevention study among FSWs who use drugs in Kazakhstan. Data analysis was conducted from April 2019 to March 2020.Lifetime and recent (past 90 day) experiences of physical, sexual, and psychological IPV and NPV using the Revised Conflict Tactics Scale. Subtypes of violence were identified using exploratory factor analysis.Lifetime and recent incidence of nonfatal overdose; sociodemographic characteristics as well as lifetime and recent sex work and drug use behaviors were also collected.The 400 participants had a mean (SD) age of 34.1 (8.4) years. Most experienced food insecurity (358 [89.5%]) and homelessness (232 [58.0%]) in the past 90 days; one-third (130 [32.5%]) reported a history of incarceration. Most (359 [89.7%]) experienced some form of violence; 150 (37.5%) reported a lifetime nonfatal overdose, of whom 27 (18.0%) reported nonfatal overdose in the past 90 days. Lifetime severe physical violence (adjusted odds ratio [aOR], 1.27; 95% CI, 1.02-1.59; P = .03), engagement in sex work for more than 10 years (aOR, 2.54; 95% CI, 1.50-4.28; P .001), and a history of incarceration (aOR, 4.34; 95% CI, 2.58-7.32; P .001) were associated with greater odds of nonfatal overdose. Engaging in sex work for more than 10 years (aOR, 3.97; 95% CI, 1.36-11.61; P = .01) and a history of incarceration (aOR, 3.63; 95% CI, 1.39-9.48; P = .008) were associated with greater odds of recent nonfatal overdose.In this study, violence against FSWs who use drugs in Kazakhstan was associated with increased odds of nonfatal overdose. Harm reduction programs for women should consider including services to address gender-based violence and the needs of women after incarceration.

BACKGROUND: Given shifting sex work criminalization and enforcement in Canada, this study examined worrying about workplace inspections by authorities amongst indoor sex workers in Vancouver (2014–2017). METHODS: Community-based prospective cohort of sex workers (AESHA). Bivariate and multivariable logistic regression were used to investigate factors associated with worry about inspections. RESULTS: 23.9% of participants experienced workplace inspections; 51.6% worried about inspections. In multivariable analyses, worrying about inspections was associated with recent im/migration (adjusted odds ratio[AOR] 3.13; 95% confidence interval[CI] 1.77–5.53), police harassment (AOR3.49; 95%CI 1.92–6.34), and workplace violence (AOR1.66, 95%CI 1.09–2.51). In a multivariable confounder model, worry was independently associated with barriers to health access (AOR1.45, 95%CI 1.06–1.98). DISCUSSION: Im/migrant indoor workers are disproportionately impacted by concerns about workplace inspections, which was independently linked to enhanced barriers to health access. Current criminalization measures may exacerbate health inequities among im/migrant sex workers.

Background Despite rapid increases in crystal methamphetamine (CM) use worldwide and established gendered patterns of use, empirical research on CM injection initiation among sex workers is limited. Given the wide range of harms associated with CM, alongside stimulant effects including sexual dis-inhibition and prolonged awake-ness, this study aimed to longitudinally investigate socio-structural predictors of initiating CM injection among sex workers in Vancouver, Canada. Methods Data (2010–2014) were drawn from a community-based cohort of women sex workers: AESHA (An Evaluation of Sex Workers Health Access). Participants completed bi-annual interviewer-administered questionnaires and HIV/STI testing. Kaplan Meier methods and Cox proportional hazards regression were used to model predictors of CM injection initiation among CM injection-naive participants. Results Of 455 participants eligible at baseline, 14.3% (n = 65) injected CM for the first time over follow-up, with an incidence density of 6.79 per 100 person-years (95% Confidence Interval [CI] 5.30–8.69). In multivariable analysis, injection heroin use (Adjusted Hazard Ratio [AHR] 6.11; 95%CI 3.24–11.52), having an intimate partner who injects drugs (AHR 2.93; 95%CI 1.57–5.46), workplace violence (AHR 2.85; 95%CI 1.74–4.67), HIV seropositivity (AHR 2.69; 95%CI 1.45–5.00), and childhood abuse (AHR 1.86; 95%CI 0.99–3.49) were independently associated with initiating CM injection. Conclusions Findings underscore the gendered and social risk environment of CM injection initiation among sex workers. The strong influences of historical/workplace violence, coupled with heroin injection (known to be self-medicating for post-traumatic stress) as a primary risk pathway, emphasize the urgency of increasing access to integrated, trauma-informed addiction treatment and HIV care for marginalized women.

BackgroundWhile female sex workers (FSWs) face a high burden of violence and criminalisation, coupled with low access to safe, non-coercive care, little is known about such experiences among FSWs in conflict-affected settings, particularly as they relate to sexual and reproductive health (SRH) and rights. We explored factors associated with lifetime abortions among FSWs in northern Uganda; and separately modelled the independent effect of lifetime exposures to incarceration and living in internally displaced persons (IDP) camps on coerced and unsafe abortions.MethodsAnalyses are based on a community-based cross-sectional research project in Gulu District, northern Uganda (2011–2012) with The AIDS Support Organization (TASO) Gulu, FSWs, and other community organisations. We conducted questionnaires, sex worker/community-led outreach to sex work venues, and voluntary HIV testing by TASO.ResultsOf 400 FSWs, 62 had ever accessed an abortion. In a multivariable model, gendered violence, both childhood mistreatment/or abuse at home [adjusted odds ratio (AOR) 1.96; 95% confidence interval (95% CI) 0.99–3.90] and workplace violence by clients (AOR 3.57; 95% CI 1.31–9.72) were linked to increased experiences of abortion. Lifetime exposure to incarceration retained an independent effect on increased odds of coerced abortion (AOR 5.16; 95% CI 1.39–19.11), and living in IDP camps was positively associated with unsafe abortion (AOR 4.71; 95% CI 1.42–15.61).Discussion and conclusionsThese results suggest a critical need for removal of legal and social barriers to realising the SRH rights of all women, and ensuring safe, voluntary access to reproductive choice for marginalised and criminalised populations of FSWs.

Background Hepatitis C virus (HCV) represents a significant cause of morbidity and mortality globally. While sex workers may face elevated HCV risks through both drug and sexual pathways, incidence data among sex workers are severely lacking. HCV incidence and predictors of HCV seroconversion among women sex workers in Vancouver, BC were characterized in this study. Methods Questionnaire and serological data were drawn from a community-based cohort of women sex workers (2010–2014). Kaplan–Meier methods and Cox regression were used to model HCV incidence and predictors of time to HCV seroconversion. Results Among 759 sex workers, HCV prevalence was 42.7%. Among 292 baseline-seronegative sex workers, HCV incidence density was 3.84/100 person-years (PY), with higher rates among women using injection drugs (23.30/100 PY) and non-injection crack (6.27/100 PY), and those living with HIV (13.27/100 PY) or acute sexually transmitted infections (STIs) (5.10/100 PY). In Cox analyses adjusted for injection drug use, age (hazard ratio (HR) 0.94, 95% confidence interval (CI) 0.86–1.01), acute STI (HR 2.49, 95% CI 1.02–6.06), and non-injection crack use (HR 2.71, 95% CI 1.18–6.25) predicted time to HCV seroconversion. Discussion While HCV incidence was highest among women who inject drugs, STIs and the use of non-injection stimulants appear to be pathways to HCV infection, suggesting potential dual sexual/drug transmission. Integrated HCV services within sexual health and HIV/STI programs are recommended.

Background Under new Canadian sex work laws (PCEPA) passed in 2014, sex workers with precarious legal status face exacerbated criminalization, yet little quantitative evidence exists on how legal immigration status shapes HIV/STI risk. This study aimed to model the effect of precarious status on client condom refusal; and the potential moderating effect of precarious status on the relationship between condom refusal and the post-PCEPA law reform period. Methods Longitudinal data were drawn from AESHA, a community-based cohort of 900+ sex workers in Vancouver (2010–2018). A multivariable confounder model using logistic regression with generalized estimating equations was developed to model the independent effect of precarious status (any immigration status that is revocable under criminal charges: permanent residency, temporary residency, and undocumented) on recent client condom refusal (forcing unprotected sex or intentionally breaking the condom) over the study period. A second multivariable confounder model examined the moderating effect of precarious status on the relationship between condom refusal and the post-PCEPA law reform period (2015-present). Results Over the 8-year study (n=758), 9.1% of participants had precarious status and 16.5% experienced condom refusal, with a total 196 events of condom refusal reported. In multivariable analysis adjusted for confounders, precarious status was independently associated with increased odds of facing condom refusal (adjusted odds ratio [AOR] 2.53, 95% confidence interval[CI] 1.37–4.68). In a second multivariable confounder model, legal status moderated the relationship between condom refusal and the post-PCEPA law reform period: among women with non-precarious status, odds of condom refusal were not significantly different post-PCEPA (AOR 1.17, 95%CI 0.77–1.78), whereas women with precarious status faced 4-fold increased odds of condom refusal post-PCEPA (4.35, 95%CI 1.21–15.66). Conclusion Laws criminalizing sex work among im/migrants in Canada enhance vulnerability among those with precarious status through presenting barriers to safer sex and increasing HIV/STI risk, highlighting urgent need for sex work and immigration policy reforms. Disclosure No significant relationships.

This research aimed to determine the effect of food insecurity on sexual HIV risk with clients among youth sex workers (YSWs)

Despite increasing gentrification across North American cities, little is known about impacts on work and living environments and health access for marginalized women. Drawing upon prospective cohort and external spatial data, we examined changes in land use and sex workers’ work/living environments in relation to gentrification exposure in Metro Vancouver (2010–2014), and modeled independent effects of gentrification exposure on reduced utilization of HIV/STI testing, sexual health, and sex worker support services. These decreases occurred despite efforts to scale-up HIV services for marginalized populations. Planning of healthcare, housing, and other support services should be responsive to shifting urban landscapes for marginalized women.

Background High rates of overdose and overdose-related mortality in North America represent a pressing health and social concern. Women sex workers face severe health and social inequities, which have been linked to structural factors including negative police interactions; however, little is known regarding the burden of overdose or how policing impacts overdose risk amongst sex workers who use drugs. Given this, we aimed to explore the independent effects of experiencing police-related barriers to harm reduction on non-fatal overdose amongst women sex workers who use drugs in Metro Vancouver, Canada over a 7.5-year period. Methods Data were drawn from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women sex workers in Metro Vancouver, from 2010 to 2017. Using multivariate logistic regression with generalized estimating equations (GEE), we used a confounder modeling approach to identify the independent effect of experiencing police-related barriers to harm reduction strategies on non-fatal overdose amongst sex workers using drugs within the last six months at each study visit. Results Amongst 624 participants, 7.7% overdosed within the last six months at baseline and 27.6% overdosed during the study period, contributing 287 non-fatal overdose events over the 7.5-year period. 68.6% reported police-related barriers to harm reduction strategies during the study. In a multivariate confounder model, exposure to police-related barriers to harm reduction strategies [AOR: 2.15, CI: 1.60–2.90] was independently associated with higher odds of non-fatal overdose after adjustment for key confounders. Conclusions Our findings suggest that in the context of the current overdose crisis, adversarial policing practices may undermine access to lifesaving overdose prevention services and exacerbate overdose risks for marginalized women. Findings underscore the urgent need to scale-up access and remove barriers to progressive harm reduction strategies for women sex workers.

Background Women involved in both street-level and off-street sex work face disproportionate health and social inequities compared to the general population. While much research has focused on HIV and sexually transmitted infections (STIs) among sex workers, there remains a gap in evidence regarding the broader health issues faced by this population, including mental health. Given limited evidence describing the mental health of women in sex work, our objective was to evaluate the burden and correlates of mental health diagnoses among this population in Vancouver, Canada. Methods An Evaluation of Sex Workers Health Access (AESHA) is a prospective, community-based cohort of on- and off-street women in sex work in Vancouver, Canada. Participants complete interviewer-administered questionnaires semi-annually. We analyzed the lifetime burden and correlates of self-reported mental health diagnoses using bivariate and multivariable logistic regression. Results Among 692 sex workers enrolled between January 2010 and February 2013, 338 (48.8%) reported ever being diagnosed with a mental health issue, with the most common diagnoses being depression (35.1%) and anxiety (19.9%). In multivariable analysis, women with mental health diagnoses were more likely to identify as a sexual/gender minority (LGBTQ) [AOR=2.56, 95% CI: 1.72—3.81], to use non-injection drugs [AOR=1.85, 95% CI: 1.12—3.08], to have experienced childhood physical/sexual trauma [AOR=2.90, 95% CI: 1.89—4.45], and work in informal indoor [AOR=1.94, 95% CI: 1.12 – 3.40] or street/public spaces [AOR=1.76, 95% CI: 1.03–2.99]. Conclusions This analysis highlights the disproportionate mental health burden experienced by women in sex work, particularly among those identifying as a sexual/gender minority, those who use drugs, and those who work in informal indoor venues and street/public spaces. Evidence-informed interventions tailored to sex workers that address intersections between trauma and mental health should be further explored, alongside policies to foster access to safer workspaces and health services.

OBJECTIVE: To describe the characteristics of female sex workers (FSWs) who do and do not use dual contraceptives (i.e. male condoms plus a non-barrier method) in Gulu northern Uganda. METHODS: The present analysis was based on data gathered as part of a questionnaire-based cross-sectional study conducted between May 2011 and January 2012. FSWs aged 14 years or older were recruited through peer-led or sex worker-led outreach and community-based services. Logistic regression was used to identify correlates of dual contraceptive use. RESULTS: Among the 400 FSWs who participated 180 (45.0%) had ever used dual contraceptives. In the multivariate model dual contraceptive use was positively associated with older age (adjusted odds ratio [AOR] 1.09 95% confidence interval [CI] 1.04-1.15; P=0.001) prior unintended pregnancy (AOR 1.53 95% CI 1.01-2.34; P=0.046) and HIV testing (AOR 5.22 95% CI 1.75-15.57; P=0.003). Having to rush sexual negotiations owing to police presence was negatively associated with dual contraceptive use (AOR 0.65 95% CI 0.42-1.00; P=0.050). CONCLUSION: Although a history of unintended pregnancy and accessing HIV testing might promote contraceptive use criminalized work environments continue to pose barriers to uptake of sexual and reproductive health services among FSWs in post-conflict northern Uganda. Integrated links between HIV and sexual health programs could support contraceptive uptake among FSWs. Copyright (c) 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Coerced and adolescent sex industry involvement are linked to serious health and social consequences, including enhanced risk of HIV infection. Using ethnographic fieldwork, including interviews with 30 female sex workers with a history of coerced or adolescent sex industry involvement, we describe contextual factors influencing vulnerability to coerced and adolescent sex industry entry and their impacts on HIV risk and prevention. Early gender-based violence and economic vulnerability perpetuated vulnerability to coercion and adolescent sex exchange, while HIV risk mitigation capacities improved with increased age, control over working conditions, and experience. Structural interventions addressing gender-based violence, economic factors, and HIV prevention among all females who exchange sex are needed.

© 2015 Elsevier Ltd. Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1-31) and 20% in Canada (95% UI 3-39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per μL could avert 34% (95% UI 25-42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8-36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33-46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.

BACKGROUND: Hepatitis C virus (HCV) eradication leads to reduced morbidity, mortality and transmission. Despite the disproportionate burden of HCV among sex workers, data regarding the HCV care continuum in this population remain negligible.METHODS: Using baseline data from an ongoing cohort of women sex workers in Vancouver (An Evaluation of Sex Workers’ Health Access, January 2010 to August 2013), the authors assessed HCV prevalence and engagement in the HCV care continuum within the past year. Multivariable logistic regression analyses were used to evaluate associations with recent (ie, in the past year) HCV testing.RESULTS: Among 705 sex workers, 302 (42.8%) were HCV seropositive. Of these, 22.5% were previously unaware of their HCV status, 41.7% had accessed HCV-related care, 13.9% were offered treatment and only 1.0% received treatment. Among 552 HCV-seronegative sex workers, only one-half (52.9%) reported a recent HCV test. In multivariable analysis, women who self-identified as a sexual/gender minority (adjusted OR [aOR] 1.89 [95% CI 1.11 to 3.24]), resided in the inner city drug use epicentre (aOR 3.19 [95%CI 1.78 to 5.73]) and used injection (aOR 2.00 [95% CI 1.19 to 3.34]) or noninjection drugs (aOR 1.95 [95% CI 1.00 to 3.78]) had increased odds of undergoing a recent HCV test, while immigrant participants (aOR 0.24 [95% CI 0.12 to 0.48]) had decreased odds.CONCLUSIONS: Despite a high burden of HCV among sex workers, large gaps in the HCV care continuum remain. Particularly concerning are the low access to HCV testing, with one-fifth of women living with HCV being previously unaware of their status, and the exceptionally low prevalence of HCV treatment. There is a critical need for further research to better understand and address barriers to engage in the HCV continuum for sex workers.

Background Across diverse regions globally, sex workers continue to face a disproportionate burden of HIV and other sexually transmitted and blood borne infections (STBBIs). Evidence suggests that behavioural and biomedical interventions are only moderately successful in reducing STBBIs at the population level, leading to calls for increased structural and community-led interventions. Given that structural approaches to mitigating STBBI risk beyond HIV among sex workers in high-income settings remain poorly understood, this critical review aimed to provide a comprehensive synthesis of the global research and literature on determinants of HIV and other STBBIs and promising intervention practices for sex workers of all genders in high-income countries. Methods We searched for publications over the last decade (January 2005–March 2016) among sex workers (cis women, cis men, and trans individuals). Data obtained from quantitative peer-reviewed studies were triangulated with publicly available reports and qualitative/ethnographic research where quantitative evidence was limited. Results Research demonstrates consistent evidence of the direct and indirect impacts of structural factors (e.g., violence, stigma, criminalization, poor working conditions) on increasing risk for STBBIs among sex workers, further compounded by individual and interpersonal factors (e.g., mental health, substance use, unprotected sex). Sub-optimal access to health and STBBI prevention services remains concerning. Full decriminalization of sex work has been shown to have the largest potential to avert new infections in sex work, through reducing workplace violence and increasing access to safer workspaces. Promising practices and strategies that should be scaled-up and evaluated to prevent STBBIs are highlighted. Conclusions The high burden of STBBIs among sex workers across high-income settings is of major concern. This review uniquely contributes to our understanding of multilevel factors that potentiate and mitigate STBBI risk for sex workers of all genders. Research suggests that multipronged structural and community-led approaches are paramount to addressing STBBI burden, and are necessary to realizing health and human rights for sex workers. Given the heterogeneity of sex worker populations, and distinct vulnerabilities faced by cis men and trans sex workers, further research utilizing mixed-methods should be implemented to delineate the intersections of risk and ameliorate critical health inequalities.

Despite universal health care in Canada, sex workers (SWs) and im/migrants experience suboptimal health care access. In this analysis, we examined the correlates of unmet health needs among SWs in Metro Vancouver over time. Data from a longitudinal cohort of women SWs (An Evaluation of Sex Workers Health Access [AESHA]) were used. Of 742 SWs, 25.5% reported unmet health needs at least once over the 4-year study period. In multivariable logistic regression using generalized estimating equations, recent im/migration had the strongest impact on unmet health needs; long-term im/migration, policing, and trauma were also important determinants. Legal and social supports to promote im/migrant SWs’ access to health care are recommended.

Despite the high HIV burden faced by sex workers, data on access and retention in antiretroviral therapy (ART) are limited. Using an innovative spatial epidemiological approach, we explored how the social geography of sex work criminalization and violence impacts HIV treatment interruptions among sex workers living with HIV in Vancouver over a 3.5-year period. Drawing upon data from a community-based cohort (AESHA, 2010–2013) and linked external administrative data on ART dispensation, GIS mapping and multivariable logistic regression with generalized estimating equations to prospectively examine the effects of spatial criminalization and violence near women’s places of residence on 2-day ART interruptions. Analyses were restricted to 66 ART-exposed women who contributed 208 observations and 83 ART interruption events. In adjusted multivariable models, heightened density of displacement due to policing independently correlated with HIV treatment interruptions (AOR: 1.02, 95%CI: 1.00–1.04); density of legal restrictions (AOR: 1.30, 95%CI: 0.97–1.76) and a combined measure of criminalization/violence (AOR: 1.00, 95%CI: 1.00–1.01) were marginally correlated. The social geography of sex work criminalization may undermine access to essential medicines, including HIV treatment. Interventions to promote ‘enabling environments’ (e.g. peer-led models, safer living/working spaces) should be explored, alongside policy reforms to ensure uninterrupted treatment access.

In light of limited data on structural determinants of access and retention in antiretroviral therapy (ART) among sex workers, we examined structural correlates of ART use among sex workers living with HIV over time. Longitudinal data were drawn from a cohort of 646 female sex workers in Vancouver, Canada (2010-2012) and linked pharmacy records on ART dispensation. We used logistic regression with generalized estimating equations (GEE) to examine correlates of gaps in ART use (i.e., treatment interruptions or delayed ART initiation), among HIV seropositive participants (n = 74). Over a 2.5-year period, 37.8 % of participants experienced gaps in ART use (i.e., no ART dispensed in a 6-month period). In a multivariable GEE model, younger age, migration/mobility, incarceration, and non-injection drug use independently correlated with gaps in ART use. In spite of successes scaling-up ART in British Columbia, younger, mobile, or incarcerated sex workers face persistent gaps in access and retention irrespective of drug use. Community-based, tailored interventions to scale-up entry and retention in ART for sex workers should be further explored in this setting.

The three studies presented in this Special Topics in Immigrant Health report findings from a novel transnational, mixed-methods study with indigenous Mayans in Yucatán, Mexico, and their satellite communities in Southern California. Indigenous migrants comprise the largest proportion of recent, first-time migrants from Mexico to the United States and are among the migrant populations most vulnerable to discrimination (e.g. work place) and health disparities. The studies presented focus on three topics: perceived discrimination and mental health among indigenous migrants and non-migrants, risky alcohol use behaviors associated with migration to the U.S. and within Mexico, and gendered power dynamics related to sexual health care access and utilization. This transnational research sheds new light on health issues and gender differences affecting indigenous Mexican migrant men, women and their families. Findings can serve to inform intervention research to improve migrant health in the U.S. and Mexico as well as transnational collaboration between countries.

In Tijuana, Mexico, sex work is regulated by the municipal government, through registration cards issued to female sex workers (FSWs) for an annual fee. Registration has been associated with decreased drug use and increase condom use and HIV testing. Previously, it was demonstrated that FSWs operating in bars were more likely than street-based FSWs to be registered. This implies that certain venues may be more accessible to local authorities for the enforcement of this type of programme. Taking a novel multilevel approach, we examined whether venue characteristics of bars reflecting greater organised management and visibility affect registration status of FSWs. In an analysis of venue-level characteristics, predictors of being registered were availability of free condoms at work and distance to the main sex strip; however, these were not independently associated after inclusion of FSWs’ income, illicit drug use and history of HIV testing. Our findings suggest that sex work regulations may inadvertently exclude venues in which the more vulnerable and less visible FSWs, such as injection drug users and those with limited financial resources, are situated. Efforts to revise or reconsider sex work regulations to ensure that they best promote FSWs’ health, human and labour rights are recommended.

OBJECTIVE Despite global evidence that sex workers (SWs) are disproportionately impacted by HIV, data on HIV treatment outcomes among SWs living with HIV remains sparse. This study examined the correlates of undetectable plasma viral load (pVL) among street- and off-street SWs living with HIV and on antiretroviral therapy (ART) in Metro Vancouver, Canada. METHODS Analyses drew on data (2010-2014) from a longitudinal cohort of SWs (An Evaluation of Sex Workers Health Access) and confidential linkages with the Drug Treatment Program (DTP) data on ART dispensation and outcomes. Bivariate and multivariable generalized linear mixed-effects models were used to identify longitudinal correlates of undetectable pVL (

Objectives Surveillance data frequently indicate that young men and women experience high—yet considerably different—reported rates of sexually transmitted infections (STIs), including bacterial infections such as chlamydia. We examined how several sex-based (eg, biological) and gender-based (eg, sociocultural) factors may interact to influence STI surveillance data trends. Methods Employing ethno-epidemiological techniques, we analysed cross-sectional qualitative data collected between 2006 and 2013 about young people9s experiences accessing STI testing services in five communities in British Columbia, Canada. These data included 250 semistructured interviews with young men and women aged 15–24 years, as well as 39 clinicians who provided STI testing services. Results The findings highlight how young women are socially and medically encouraged to regularly test, while young men are rarely offered similar opportunities. Instead, young men tend to seek out testing services: (1) at the beginning or end of a sexual relationship; (2) after a high-risk sexual encounter; (3) after experiencing symptoms; or (4) based on concerns about ‘abnormal’ sexual anatomy. Our results illustrate how institutions and individuals align with stereotypical gender norms regarding sexual health responsibilities, STI testing and STI treatments. While these patterns reflect social phenomena, they also appear to intersect with sex-based, biological experiences of symptomatology in ways that might help to further explain systematic differences between young men9s and women9s patterns of testing for STIs. Conclusions The results point to the importance of taking a social and biological view to understanding the factors that contribute to the gap between young men9s and women9s routine engagement in STI care.

OBJECTIVE Sex workers (SWs) in sub-Saharan Africa face a disproportionate HIV burden and growing concerns of severe human rights violations. Given the dearth of evidence on the burden and correlates of HIV among SWs in sub-Saharan Africa, particularly within conflict-affected settings, we examined the relationship between structural determinants (eg, war-related abduction, incarceration) and HIV infection among conflict-affected SWs in Northern Uganda. DESIGN Cross-sectional community-based research study among female SWs in conflict-affected Gulu, Northern Uganda. METHODS Interview questionnaires and voluntary HIV testing were conducted with participants recruited through SW/peer-led outreach and time-location sampling from 2011 to 2012. HIV prevalence was calculated, and bivariable and multivariable logistic regression was used to identify independent associations with HIV seroprevalence. RESULTS Of 400 SWs, 135 (33.75%) were HIV seropositive; of whom one-third were new/previously undiagnosed HIV infections. In multivariable analysis, after adjusting for age of sex work entry and education, lifetime incarceration (adjusted odds ratio: 1.93, 95% confidence interval: 1.17 to -3.20) was independently associated with HIV seroprevalence, and history of wartime abduction (adjusted odds ratio: 1.62, 95% confidence interval: 1.00 to 2.63) was marginally associated (P = 0.051). CONCLUSIONS This study documented a high rate of undiagnosed HIV infections and associations between war-related human rights violations, incarceration, and a heavy HIV burden among SWs in conflict-affected Northern Uganda. These findings highlight the serious harms of conflict and criminalization of marginalized women in sub-Saharan African contexts. SW-led interventions that address conflict experiences and policy shifts to promote a rights-based approach to HIV prevention and care remain critically needed.

Background Despite a large body of evidence globally demonstrating that the criminalization of sex workers increases HIV/STI risks, we know far less about the impact of criminalization and policing of managers and in-call establishments on HIV/STI prevention among sex workers, and even less so among migrant sex workers. Methods Analysis draws on ethnographic fieldwork and 46 qualitative interviews with migrant sex workers, managers and business owners of in-call sex work venues in Metro Vancouver, Canada. Results The criminalization of in-call venues and third parties explicitly limits sex workers’ access to HIV/STI prevention, including manager restrictions on condoms and limited onsite access to sexual health information and HIV/STI testing. With limited labour protections and socio-cultural barriers, criminalization and policing undermine the health and human rights of migrant sex workers working in –call venues. Conclusions This research supports growing evidence-based calls for decriminalization of sex work, including the removal of criminal sanctions targeting third parties and in-call venues, alongside programs and policies that better protect the working conditions of migrant sex workers as critical to HIV/STI prevention and human rights.

Due to stigma and the psychosocial repercussions of past trauma and abuse, survivors of sex trafficking may experience increased susceptibility to violence, revictimization, and various harmful health outcomes, including HIV infection. Given the paucity of research characterizing the experiences of formerly trafficked female sex workers (FSWs), we set out to describe and contextualize perceptions of HIV risk among women who have experienced past episodes of sex trafficking and who are currently engaged in sex work in Tijuana, Mexico. Based on semi-structured interviews and ethnographic fieldwork, we describe the following interrelated themes as influencing formerly trafficked FSWs' perceptions and experiences of HIV risk: economic vulnerability; susceptibility to violence; and psychological trauma. Our findings highlight the need for HIV prevention efforts to incorporate broader structural and social interventions aimed at reducing vulnerability to violence and human rights abuses among this population and improving their general economic, psychological, and social well-being.

Background Sex workers (SWs) experience a disproportionately high burden of HIV, with evidence indicating that complex and dynamic factors within work environments play a critical role in mitigating or producing HIV risks in sex work. In light of sweeping policy efforts to further criminalize sex work globally, coupled with emerging calls for structural responses situated in labour and human-rights frameworks, this meta-synthesis of the qualitative and ethnographic literature sought to examine SWs’ narratives to elucidate the ways in which physical, social and policy features of diverse work environments influence SWs’ agency to engage in HIV prevention. Methods We conducted a meta-synthesis of qualitative and ethnographic studies published from 2008 to 2014 to elucidate SWs’ narratives and lived experiences of the complex and nuanced ways in which physical, social, and policy features of indoor and outdoor work environments shape HIV prevention in the sex industry. Results Twenty-four qualitative and/or ethnographic studies were included in this meta-synthesis. SWs’ narratives revealed the nuanced ways that physical, social, and policy features of work environments shaped HIV risk and interacted with macrostructural constraints (e.g., criminalization, stigma) and community determinants (e.g., sex worker empowerment initiatives) to shape SWs’ agency in negotiating condom use. SWs’ narratives revealed the ways in which the existence of occupational health and safety standards in indoor establishments, as well as protective practices of third parties (e.g., condom promotion) and other SWs/peers were critical ways of enhancing safety and sexual risk negotiation within indoor work environments. Additionally, working in settings where negative interactions with law enforcement were minimized (e.g., working in decriminalized contexts or environments in which peers/managers successfully deterred unjust policing practices) was critical for supporting SWs’ agency to negotiate HIV prevention. Conclusions Policy reforms to remove punitive approaches to sex work, ensure supportive workplace standards and policies, and foster SWs’ ability to work collectively are recommended to foster the realization of SWs’ health and human rights across diverse settings. Future qualitative and mixed-methods research is recommended to ensure that HIV policies and programmes are grounded in SWs’ voices and realities, particularly in more under-represented regions such as Eastern Europe and Sub-Saharan Africa. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-2491-x) contains supplementary material, which is available to authorized users.

Although sex work and younger age increase HIV vulnerability, empirical data regarding the impacts of underage sex work are lacking. We explored associations between features of the risk environment, sex work, and drug use history, and underage sex work entry among 624 female sex workers (FSWs) in Tijuana and Ciudad Juarez, Mexico. Forty-one percent (n = 253) of women began sex work as minors, among whom HIV and any STI/HIV prevalence were 5.2 and 60.7%. Factors independently associated with increased odds of underage sex work were inhalants as the first drug used, forced first injection, number of drug treatment attempts, and recent receptive syringe sharing. Number of recent condom negotiation attempts with steady partners and depression as a reason for first injecting were negatively associated with underage entry. These results underscore the importance of efforts to prevent underage sex work and the wider factors contributing to HIV risk among vulnerable youth and underage FSWs.

Mobility is a key determinant of HIV/sexually transmitted infection (STI) transmission dynamics in Asia and Africa. Scant data exist regarding its dynamic impacts on HIV/STI risk in Central America and Mexico. Our objective was to critically review the epidemiology and social and structural context of HIV/STI risk among mobile populations in Central America and Mexico. Eligible articles were published in English or Spanish between January 1, 2000 and August 31, 2010; conducted in Central America or Mexico; specified the mobile population included; and described primary research. 2045 records were screened, 275 articles reviewed, and 22 studies included. Mobility is associated with increased HIV risk behaviors, though it also may increase preventive behaviors. Among mobile groups in Central America and Mexico, social isolation, the socio-economic impacts of displacement, gender inequalities, and stigma/discrimination shape HIV risk. Epidemiologic research and multi-level interventions that target and engage vulnerable groups in transit stations are recommended.

In 2008, 400 males ≥18 years old who paid or traded for sex with a female sex worker (FSW) in Tijuana, Mexico, in the past 4 months completed surveys and HIV/STI testing; 30 also completed qualitative interviews. To analyze environmental sources of HIV vulnerability among male clients of FSWs in Tijuana, we used mixed methods to investigate correlates of clients who met FSWs in nightlife venues and clients' perspectives on venue-based HIV risk. Logistic regression identified micro-level correlates of meeting FSWs in nightlife venues, which were triangulated with clients' narratives regarding macro-level influences. In a multivariate model, offering increased pay for unprotected sex and binge drinking were micro-level factors that were independently associated with meeting FSWs in nightlife venues versus other places. In qualitative interviews, clients characterized nightlife venues as high risk due to the following macro-level features: social norms dictating heavy alcohol consumption; economic exploitation by establishment owners; and poor enforcement of sex work regulations in nightlife venues. Structural interventions in nightlife venues are needed to address venue-based risks.

Male clients of female sex workers (FSWs) may act as a bridge to the general population contributing to the spread of HIV and other sexually transmitted infections in the United States and Mexico. This study used cross-sectional data to identify psychosexual and social cognitive factors associated with sexual risk behavior in a bi-national sample of 300 male clients of FSWs recruited in Tijuana, Mexico from June to October, 2008. In a multiple regression analysis, the number of unprotected vaginal sex acts with FSWs was associated with higher sexual compulsivity scores, lower self-efficacy for condom use, greater use of illicit drugs, and more financial need. Behavioral interventions are urgently needed to assist clients of FSWs in reducing high-risk behaviors in an effort to prevent the spread of HIV/STIs in this high-risk population and their sexual partners.

Communities dependent on natural resource extraction (e.g. oil/gas, mining) are routinely exposed to rhetoric that associates notions of progress (including health and social welfare) with a booming economy. These places frequently experience demographic and social disruptions associated with reliance on resource-extraction sectors (e.g. the influx of young male workers and money, increasing rates of drug/alcohol consumption, infrastructural shortfalls). However, research regarding the problematic health and social impacts associated with resource-extraction booms are markedly absent from contemporary research pertaining to high-income countries. This paper investigates how an economic boom is perceived to affect young people's health and social well-being in Fort St. John, a booming oil/gas community in British Columbia, Canada. We conducted ethnographic fieldwork (8 weeks), including in-depth interviews with 25 young people (ages 15–25) and 14 health and social service providers. Participants identified...

BACKGROUND Tijuana, situated adjacent to San Diego, CA on the US-Mexico border, is experiencing an emerging HIV epidemic, with prevalence among female sex workers (FSWs) having risen in recent years from

In Canada, STI rates are high and rising, especially amongst young men. Meanwhile, the needs of young men regarding STI testing services are poorly understood, as are the socio-cultural and structural factors that influence young men's sexual health-seeking behaviours. To better understand this phenomenon, we draw on interviews with 45 men (ages 15-25) from British Columbia, Canada. Our research reveals how structural forces (e.g. STI testing procedures) interact with socio-cultural factors (e.g. perceptions of masculinities and feminities) to shape young men's experiences with STI testing. STI testing was characterised as both a potentially sexualised experience (e.g. fears of getting an erection during genital examinations), and as a process where young men experience multiple vulnerabilities associated with exposing the male body in clinical service sites. In response, participants drew on dominant ideals of masculinity to reaffirm their predominately hetero-normative gender identities. Despite growing up in an era where sexual health promotion efforts have been undertaken, participants did not feel they had permission to engage in discussions with other men about sexual health issues. Attending to young men's perspectives on STI testing represents a starting point in reforming our approaches to addressing how socio-cultural and structural factors shape these experiences.

OBJECTIVES: To determine sociodemographic and behavioral correlates of HIV infection among male clients of female sex workers (FSWs) in Tijuana. METHODS: Four hundred men aged 18 years or older who had paid or traded for sex with a FSW in Tijuana during the past 4 months were recruited in Tijuanas zone of tolerance where prostitution is practiced openly under a municipal permit system. Efforts were made to balance the sample between residents of the United States (San Diego County) and of Mexico (Tijuana). Participants underwent interviews and testing for HIV syphilis gonorrhea and Chlamydia. Logistic regression identified correlates of HIV infection. RESULTS: Mean age was 36.6 years. One-quarter had injected drugs within the previous 4 months. Lifetime use of heroin cocaine and methamphetamine was 36 50 and 64% respectively. Men had frequented FSWs for an average of 11 years visiting FSWs an average of 26 times last year. In the past 4 months one-half reported having unprotected sex with a FSW; 46% reported being high fairly or very often when having sex with a FSW. Prevalence of HIV syphilis gonorrhea and Chlamydia was 4 2 2.5 and 7.5%; 14.2% were positive for at least one infection. Factors independently associated with HIV infection were living in Mexico ever using methamphetamine living alone and testing positive for syphilis. CONCLUSION: Male clients of FSWs in Tijuana had a high sex and drug risk profile. Although sexually transmitted infection prevalence was lower than among FSWs HIV prevalence was comparable suggesting the need for interventions among clients to prevent spread of HIV and sexually transmitted infections.

Northeastern British Columbia, Canada, is undergoing in-migration of young people attracted by jobs in the oil/gas sectors. Chlamydia rates among youth ages 15-24 are increasing and exceed the provincial average by 22%. Testing for sexually transmitted infections (STIs) reduces the disease burden, contributing to prevention. We conducted ethnographic fieldwork, including interviews with 25 youth and 14 service providers, to document their perceptions regarding youth's access to STI testing. Five key barriers to access were identified: limited opportunities for access, geographic inaccessibility, local social norms, limited information, and negative interactions with providers. To address youths' needs, we recommend active STI prevention and testing service delivery models that incorporate a locally tailored public awareness campaign, outreach to oil/gas workers, condom distribution, expanded clinic hours and drop-in STI testing, specialized training for health care providers, and inter-sectoral partnerships between public health, non-profit organizations, and industry.

Background: Northeastern British Columbia is undergoing rapid in-migration of young, primarily male workers in response to the “boom” in the oil/gas industries. Accompanying the boom is a rise in Chlamydia rates among youth, which exceed the provincial average by 22%. STI testing reduces the disease burden, contributing to STI prevention. Objectives: 1) To document youths’ perceptions regarding the socio-cultural and structural forces that affect young oil/gas workers’ access to STI testing; 2) to gather service providers’ perspectives on sexual health service delivery for workers; and 3) to develop recommendations to improve the accessibility of STI testing. Methods: We conducted ethnographic fieldwork (8 weeks) in a remote oil/gas community, including in-depth interviews with 25 young people (ages 15-25) and 14 health and social service providers. Results: Participants identified limited opportunities to access testing, geographic isolation, and ‘rigger’ culture as three key categories inhibiting STI testing among oil/gas workers. Discussion: These results suggest the need for place-based approaches to STI control. Innovative outreach strategies are suggested to address oil/gas workers’ needs, including a locally tailored STI awareness campaign, condom distribution, expanded clinic hours, and onsite STI testing. Key words: Sexually transmitted infections; testing; oil and gas workers; youth; sexual health; British Columbia Resume Contexte : Le Nord-Est de la Colombie-Britannique recoit une forte vague d’immigration de jeunes travailleurs, principalement des hommes, en reponse a la forte expansion de l’industrie petroliere et gaziere. Cette expansion s’accompagne chez les jeunes d’une hausse des chlamydioses, dont le taux est superieur de 22 % a la moyenne provinciale. Comme ils reduisent la charge de morbidite, les tests de detection d’infections transmissibles sexuellement (ITS) sont un outil de prevention a ne pas negliger. Objectifs : 1) Rendre compte des perceptions, chez les jeunes, des forces socioculturelles et structurelles qui influent sur l’acces des travailleurs de l’industrie petroliere et gaziere aux tests de detection d’ITS; 2) recueillir l’opinion des dispensateurs de services quant a la prestation des services de sante sexuelle a ces travailleurs; et 3) elaborer des recommandations afin d’ameliorer l’accessibilite des tests de detection d’ITS. Methode : Nous avons effectue un travail ethnographique sur le terrain (8 semaines) dans une localite petroliere et gaziere eloignee, en menant des entretiens en profondeur avec 25 jeunes gens (de 15 a 25 ans) et 14 dispensateurs de soins de sante et de services sociaux. Resultats : Selon nos repondants, le manque d’acces aux tests, l’isolement geographique et la culture machiste du milieu de travail etaient les trois principaux obstacles aux tests de detection d’ITS dans l’industrie petroliere et gaziere. Discussion : Ces resultats montrent que la lutte contre les ITS exige une approche liee au lieu. Nous proposons des strategies d’approche novatrices pour repondre aux besoins des travailleurs de l’industrie petroliere et gaziere, dont une campagne d’information adaptee aux conditions locales, la distribution de condoms, le prolongement des heures d’ouverture des cliniques et la prestation de tests de detection d’ITS sur place. Mots cles : infections transmissibles sexuellement; tests; travailleurs de l’industrie petroliere et gaziere; jeunes; sante sexuelle; Colombie-Britannique

Background: Northeastern British Columbia, Canada, is undergoing rapid in-migration of young, primarily male, workers in response to the “boom” in the oil/gas industries. Chlamydia rates in the region exceed the provincial average by 32% (294.6 cases per 100 000 persons compared with 213.3). Evidence indicates that sociocultural and structural determinants of young people’s sexual health are key to consider in the design of interventions. Objectives: To investigate how sociocultural and structural features related to the oil/gas boom are perceived to affect the sexual behaviour of youth in a Northeastern “boomtown”. Methods: The study included ethnographic fieldwork (8 weeks) and in-depth interviews with 25 youth (ages 15–25 years) and 14 health/social service providers. Results: Participants identified four main ways in which the sociocultural and structural conditions created by the boom affect sexual behaviours, fuelling the spread of sexually transmitted infections (STIs): mobility of oil/gas workers; binge partying; high levels of disposable income and gendered power dynamics. Conclusions: The sociocultural and structural conditions that are fostered by a resource-extraction boom appear to exacerbate sexual health inequalities among youths who live and work in these rapidly urbanising, remote locales. To meet the needs of this population, we recommend STI prevention and testing service delivery models that incorporate STI testing outreach to oil/gas workers and condom distribution. Global, national and local STI control efforts should consider the realities and needs of similar subpopulations of young people.

© 2015 Elsevier Ltd. Objective: This study quantitatively examined the prevalence and correlates of short-term sex work cessation among female sex workers who inject drugs (FSW-IDUs) and determined whether injection drug use was independently associated with cessation. Methods: We used data from FSW-IDUs (n. =. 467) enrolled into an intervention designed to increase condom use and decrease sharing of injection equipment but was not designed to promote sex work cessation. We applied a survival analysis that accounted for quit-re-entry patterns of sex work over 1-year stratified by city, Tijuana and Ciudad Juarez, Mexico. Results: Overall, 55% of participants stopped sex work at least once during follow-up. Controlling for other characteristics and intervention assignment, injection drug use was inversely associated with short-term sex work cessation in both cities. In Ciudad Juarez, women receiving drug treatment during follow-up had a 2-fold increase in the hazard of stopping sex work. In both cities, income from sources other than sex work, police interactions and healthcare access were independently and significantly associated with shorter-term cessation. Conclusions: Short-term sex work cessation was significantly affected by injection drug use. Expanded drug treatment and counseling coupled with supportive services such as relapse prevention, job training, and provision of alternate employment opportunities may promote longer-term cessation among women motivated to leave the sex industry.

BACKGROUND:Migrant women in sex work experience unique risks and protective factors related to their sexual health. Given the dearth of knowledge in high-income countries, we explored factors associated with inconsistent condom use by clients among migrant female sex workers over time in Vancouver, BC. METHODS:Questionnaire and HIV/sexually transmitted infection testing data from a longitudinal cohort, An Evaluation of Sex Workers Health Access, were collected from 2010 to 2013. Logistic regression using generalized estimating equations was used to model correlates of inconsistent condom use by clients among international migrant sex workers over a 3-year study period. RESULTS:Of 685 participants, analyses were restricted to 182 (27%) international migrants who primarily originated from China. In multivariate generalized estimating equations analyses, difficulty accessing condoms (adjusted odds ratio [AOR], 3.76; 95% confidence interval [CI], 1.13-12.47) independently correlated with increased odds of inconsistent condom use by clients. Servicing clients in indoor sex work establishments (e.g., massage parlors) (AOR, 0.34; 95% CI, 0.15-0.77), and high school attainment (AOR, 0.22; 95% CI, 0.09-0.50) had independent protective effects on the odds of inconsistent condom use by clients. CONCLUSIONS:Findings of this longitudinal study highlight the persistent challenges faced by migrant sex workers in terms of accessing and using condoms. Migrant sex workers who experienced difficulty in accessing condoms were more than 3 times as likely to report inconsistent condom use by clients. Laws, policies, and programs promoting access to safer, decriminalized indoor work environments remain urgently needed to promote health, safety, and human rights for migrant workers in the sex industry.

ObjectiveTo explore experiences during childhood and adolescence that influenced reproductive and sexual health among women who had entered the sex industry in adolescence.MethodsA qualitative study was conducted using information provided by 25 female sex workers (FSWs) from Tijuana, Mexico, who reported entering the sex industry when younger than 18 years. In-depth, semi-structured interviews were conducted with all participants between January 31, 2011, and July 8, 2011.ResultsFour interrelated themes that shaped health experiences-early sexual abuse, early illicit drug use, ongoing violence, and limited access to reproductive and sexual health care-were identified. Participants reporting these experiences were at risk of unintended teenaged pregnancy, spontaneous abortion or stillbirth, and untreated sexually transmitted infections.ConclusionPrograms and policies that address social, structural, and individual vulnerabilities during adolescence and adulthood are required to promote reproductive and sexual health among FSWs in Tijuana, Mexico.

Given heterogeneous evidence regarding the impacts of migration on HIV/sexually transmitted infections (STIs) among female sex workers (FSWs), we explored factors associated with international migration among FSWs in Vancouver, Canada. We draw on baseline questionnaire and HIV/STI testing data from a community-based cohort, AESHA, from 2010-2012. Logistic regression identified correlates of international migration. Of 650 FSWs, 163 (25.1 %) were international migrants, who primarily worked in formal indoor establishments. HIV/STI prevalence was lower among migrants than Canadian-born women (5.5 vs. 25.9 %). In multivariate analysis, international migration was positively associated with completing high school, supporting dependents, and paying a third party, and negatively associated with HIV, injecting drugs and inconsistent condom use with clients. Although migrants experience lower workplace harms and HIV risk than Canadian-born women, they face concerning levels of violence, police harassment, and HIV/STIs. Research exploring structural and socio-cultural factors shaping risk mitigation and migrants’ access to support remains needed.

To longitudinally examine female sex workers' (FSWs') uptake of a women-only, sex-work-specific drop-in service and its impact on their access to sexual and reproductive health (SRH) services.For the present longitudinal analysis, data were drawn from the AESHA (An Evaluation of Sex Workers' Health Access) study, a community-based, open, prospective cohort of FSWs from Vancouver, BC, Canada. Data obtained between January 2010 and February 2013 were analyzed. Participants are followed up on a semi-annual basis. Multivariable logistic regression using generalized estimating equations was used to identify correlates of service uptake.Of 547 FSWs included in the present analysis, 330 (60.3%) utilized the services during the 3-year study period. Service use was independently associated with age (adjusted odds ratio [AOR] 1.04; 95% confidence interval [CI] 1.03-1.06), Aboriginal ancestry (AOR 2.18; 95% CI 1.61-2.95), injection drug use (AOR 1.67; 95% CI 1.29-2.17), exchange of sex for drugs (AOR 1.40; 95%CI 1.15-1.71), and accessing SRH services (AOR 1.65; 95% CI 1.35-2.02).A sex-work-specific drop-in space for marginalized FSWs had high uptake. Women-centered and low-threshold drop-in services can effectively link marginalized women with SRH services.

Author(s): Goldenberg, Shira M; Chettiar, Jill; Simo, Annick; Silverman, Jay G; Strathdee, Steffanie A; Montaner, Julio SG; Shannon, Kate | Abstract: ObjectivesTo explore factors associated with early sex work initiation and model the independent effect of early initiation on HIV infection and prostitution arrests among adult sex workers (SWs).DesignBaseline data (2010-2011) were drawn from a cohort of SWs who exchanged sex for money within the last month and were recruited through time location sampling in Vancouver, Canada. Analyses were restricted to adults ≥18 years old.MethodsSWs completed a questionnaire and HIV/sexually transmitted infection testing. Using multivariate logistic regression, we identified associations with early sex work initiation (l18 years old) and constructed confounder models examining the independent effect of early initiation on HIV and prostitution arrests among adult SWs.ResultsOf 508 SWs, 193 (38.0%) reported early sex work initiation, with 78.53% primarily street-involved SWs and 21.46% off-street SWs. HIV prevalence was 11.22%, which was 19.69% among early initiates. Early initiates were more likely to be Canadian born [adjusted odds ratio (AOR): 6.8, 95% confidence interval (CI): 2.42 to 19.02], inject drugs (AOR: 1.6, 95% CI: 1.0 to 2.5), and to have worked for a manager (AOR: 2.22, 95% CI: 1.3 to 3.6) or been coerced into sex work (AOR: 2.3, 95% CI: 1.14 to 4.44). Early initiation retained an independent effect on increased risk of HIV infection (AOR: 2.5, 95% CI: 1.3 to 3.2) and prostitution arrests (AOR: 2.0, 95% CI: 1.3 to 3.2).ConclusionsAdolescent sex work initiation is concentrated among marginalized, drug, and street-involved SWs. Early initiation holds an independent increased effect on HIV infection and criminalization of adult SWs. Findings suggest the need for evidence-based approaches to reduce harm among adult and youth SWs.