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Residential mobility remains an underexplored yet critical construct that may influence the risk of violence among women who exchange sex. This study examined the longitudinal relationship between residential mobility and experience of client-perpetrated physical or sexual violence among women who exchange sex in Baltimore, Maryland. Participants were at least at 18 years of age, were cisgender women, reported having engaged in transactional sex three or more times within the last 3 months, and were willing to be contacted for 6-, 12-, and 18-month follow-up visits. Analyses of responses from 370 women who exchange sex participating in at least one study visit were conducted. Unadjusted and adjusted Poisson regression models of the association over time between residential mobility and recent experience of physical or sexual violence were fit. Generalized estimating equations with an exchangeable correlation structure and robust variance estimation were used to account for clustering of participants' responses over time. Findings demonstrated that those who had lived in at least four places in the past 6 months had a 39% increased risk of client-perpetrated physical violence (aRR: 1.39; 95% CI: 1.07–1.80; p <.05) and a 63% increased risk of sexual violence (aRR: 1.63; 95% CI: 1.14–2.32; p <.01) compared to their less-mobile counterparts. These findings provide necessary evidence of correlations over time between residential mobility and experience of client-perpetrated violence among women who exchange sex. Strengthening our understanding of how residential mobility intersects with violence is critical for the development of public health interventions that are relevant to women's lives and needs. Future interventions should explore including residential mobility, a critical pillar of housing instability, with efforts to address client-perpetrated violence. [ABSTRACT FROM AUTHOR]

Female sex workers (FSW) experience many structural vulnerabilities (SV; e.g., violence, economic insecurity) which contribute to increased risk of HIV and mental distress. However, little research has examined how SV co-occur to shape HIV risk, and none have studied mental distress. Among FSW (n = 385) in Baltimore, Maryland, latent class analysis of five binary indicators (housing insecurity; financial dependence on others; client-perpetrated physical or sexual violence; food insecurity) determined classes of SV and differential HIV risk behavior and mental health outcomes. A 3-class model fit the data best: minimal SV (i.e., low probabilities of all indicators); material needs (i.e., housing, food insecurity); and high SV (i.e., high probability of all indicators). Compared to minimal SV, high SV and material needs had significantly greater adjusted probability of drug injection and poorer adjusted depression, post-traumatic stress disorder, and mental distress scores. The high SV class had significantly higher probability of reporting condomless sex with clients compared to material needs and minimal SV. Results show the deleterious effect of co-occurring SV on HIV risk behaviors among FSW with particular emphasis on co-occurring food and housing insecurities. This is the first study of co-occurring SV on mental health outcomes in this key population. [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]

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

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

Women who exchange sex and use opioids experience substantial post-traumatic stress disorder (PTSD) symptoms. Among veterans, PTSD increases the risk of concomitant opioid-benzodiazepine use, increasing overdose risk, but this relationship is underexplored in other at-risk populations. We examined correlates of non-medical benzodiazepine use among a cohort of women who exchange sex and use opioids daily (N = 270) in Baltimore, MD. PTSD symptom severity was measured by the full PCL-5 (possible range: 0–80, categorized by tertile as low, medium, high) and four symptom-specific subscales. The prevalence of benzodiazepine use was 27% and the median PCL-5 score was 34. In adjusted models, women with high PCL-5 scores were more likely to use benzodiazepines than those with low scores, overall and across subscales. Severe PTSD symptoms conferred elevated risk of concomitant opioid-benzodiazepine use, calling attention to the importance of addressing trauma in combating the opioid and overdose crises. [ABSTRACT FROM AUTHOR]

Pre-exposure prophylaxis (PrEP) has the potential to be an empowering HIV prevention tool among female sex workers (FSW), yet little is known about PrEP awareness and interest in this population. Sex workers and Police Promoting Health in Risky Environments (SAPPHIRE) is a prospective cohort study of street-based FSW in Baltimore, MD. A cross-sectional analysis explored awareness and interest in PrEP among HIV-negative FSW. Multivariable Poisson regressions modeled associations between individual, interpersonal, and structural variables and PrEP awareness and interest. Of n = 232 FSW, 66% were white, half were less than 35 years old, 59% injected drugs daily, and 66% sold sex daily. Only 21% of FSW were aware of PrEP, though 74% were interested. PrEP awareness was associated with experiencing client condom coercion [adjusted incidence rate ratio (aIRR) = 0.50, 95% CI: 0.28–0.90] and condomless sex with an intimate partner (aIRR = 0.54, 95% CI: 0.30–0.98). PrEP interest was associated with perceiving PrEP as "very easy" to take (aIRR = 1.91, 95% CI: 1.49–2.45) and moving to an unfamiliar geographic area to sell sex (aIRR = 1.20, 95% CI: 1.04–1.39). Women who had a current gonorrhea or chlamydia infection were less likely to be interested in PrEP (aIRR = 0.75, 95% CI: 0.59–0.95). Though PrEP awareness among FSW is low, there are FSW who are significantly more likely to express interest in PrEP and outreach efforts should target these women. Results suggest that women-controlled HIV prevention methods may be important for reducing incidence among FSW. [ABSTRACT FROM AUTHOR]

Biomedical HIV prevention tools including oral pre-exposure prophylaxis (PrEP) and vaginal microbicidal rings hold unique value for high-risk women who may have limited capacity for condom negotiation, including the key populations of sex workers and drug users. Commercial sex is a PrEP indicator in CDC guidelines, yet little is known about female sex workers' (FSWs) knowledge of and attitudes toward PrEP or the recently developed monthly vaginal microbicide rings. We describe knowledge and attitudes toward PrEP and microbicide rings in a sample of 60 mostly drug-using FSWs in Baltimore, Maryland, a high HIV-prevalence US city. Just 33% had heard of PrEP, but 65% were interested in taking daily oral PrEP and 76% were interested in a microbicide vaginal ring; 87% were interested in at least one of the two methods. Results suggest method mix will be important as biomedical tools for HIV prophylaxis are implemented and scaled up in this population, as 12% were interested in PrEP but not vaginal rings, while 19% were interested in vaginal rings but not in PrEP. Self-efficacy for daily oral adherence was high (79%) and 78% were interested in using PrEP even if condoms were still necessary. Women who had experienced recent client-perpetrated violence were significantly more interested in PrEP (86% vs 53%, p = 0.009) and microbicidal rings (91% vs 65%, p = 0.028) than women who had not recently experienced violence. No differences were observed by demographics nor HIV risk behaviors, suggesting broad potential interest in daily PrEP and monthly-use vaginal microbicides in this high-risk population. [ABSTRACT FROM AUTHOR]

Background: Women who exchange sex (WES) experience extensive interpersonal violence from multiple perpetrators. Violence towards WES contributes to poor mental and behavioral health outcomes, including high rates of drug use. However, it is difficult to disentangle the temporal relationship between drug use and violence among WES.Methods: We used data from 251 WES, who completed baseline and 6-month follow up surveys. WES reported baseline sociodemographic characteristics, including homelessness and hunger. Participants reported their drug use by type and violent experiences by perpetrator at each time point. We conducted a path analysis examining the associations between drug use and violent victimization over time.Results: Participants were on average 37.8 years old, non-Hispanic White (57.4%) and experiencing high levels of structural vulnerability (59.4% homelessness; 58.6% weekly hunger). Drug use and violence were significantly correlated within each time point. Prospectively, baseline violent victimization was significantly associated with drug use (ß (SE) = 0.13 (0.06)) and violence (ß (SE) = 0.47 (0.05)) at follow up. Baseline drug use was associated with drug use at follow up (ß (SE) = 0.45 (0.05)) but was not significantly associated with violence at follow up (ß (SE) = 0.10 (0.06)).Conclusions: Violence and drug use are closely linked in this population; and violence appears to facilitate sustained drug use. Interventions to address the dual epidemics of violence and substance use in this population should address underlying trauma as well as socio-structural drivers of violence as well as tailored harm reduction services for this population. [ABSTRACT FROM AUTHOR]

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

Resilience represents adaptability and empowerment and can buffer against the consequences of traumatic events. Cisgender and transgender women in street-based sex work are at high risk for trauma, yet data on their resilience are sparse. A clearer understanding of resilience and its correlates is useful for informing sex worker-centered interventions. Using the Connor-Davidson 10-item Resilience Scale (range, 0–40), we describe resilience among 165 cisgender and 42 transgender street-based women sex workers in Baltimore, Maryland. Longitudinal cohort data were used to examine correlates of resilience in each population. Analyses are conducted using multiple linear regression. The mean resilience score was 24.2 (95% confidence interval, 23.6–24.8) among cisgender women sex workers and 32.2 among transgender women sex workers (95% confidence interval, 30.8–32.7). Among cisgender participants, positive correlates of resilience were being Black, Hispanic, or other race (ß = 2.7; p =.004), having housing (ß = 1.9; p =.034), social cohesion score (ß = 0.18; p =.047), and daily drug injection (ß = 3.7; p <.001); negative correlates of resilience were sexual violence (ß = –4.8; p =.006) and exposure to egregious police acts (ß = –0.6; p =.015). Among transgender participants, higher education level (ß = 8.8; p <.001), food security (ß = 3.5; p =.005), and housing stability (ß = 2.0; p <.001) were associated with increased resilience, and daily noninjection drug use (excluding marijuana; ß = –3.3; p <.001) and physical violence (ß = –2.9; p <.001) were associated with reduced resilience. This study is the first to characterize factors that may influence resilience among cisgender and transgender women sex workers. Results highlight tangible intervention targets for promoting mental health and safety among a uniquely vulnerable population of women. [ABSTRACT FROM AUTHOR]

Female sex workers (FSW) are a marginalized and vulnerable population at high risk of gender-based violence within and outside of their occupation. However, FSW remain underrepresented in the trauma and mental health literature. The aims of this study were to (a) characterize exposure to violence among street-based FSW, including violence type, patterns over the life course, and key perpetrator groups, and (b) examine the multivariate associations between posttraumatic stress disorder (PTSD) symptom severity and two constructs (revictimization across life stages and cumulative violence). Data were drawn from the Sex Workers and Police Promoting Health in Risky Environments (SAPPHIRE) study, an observational community-based cohort of street-based FSW recruited through targeted sampling across Baltimore, Maryland (USA) in 2016 to 2017. PTSD symptom severity was measured using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5). At baseline, 61% of FSW screened positive for PTSD symptoms. The mean PCL-5 score was 38.6. We documented extensive histories of sexual and physical violence (lifetime: 81.8%; childhood and adult revictimization: 15.0% for sexual and 37.7% for physical). The vast majority of perpetrators were male and included paying clients, police officers, family members, and intimate partners. Exposure to childhood and adult sexual violence were independently associated with higher PTSD severity (p <.05), with marginal associations observed for physical violence. Data supported a cumulative violence model of PTSD severity (p <.05). Binge drinking also appeared to be a contributing factor (p <.05). The levels of PTSD observed among our sample were comparable with that reported among treatment-seeking war veterans. Our findings underscore the urgent need for tailored trauma-informed interventions and policies to address violence among urban street-based FSW, a population experiencing extremely high levels of violence, PTSD, and substance use. [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]

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