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Background: Sex workers' risk of violence and ill-health is shaped by their work environments, community and structural factors, including criminalisation. Aim: We evaluated the impact of removing police enforcement on sex workers' safety, health and access to services. Design: Mixed-methods participatory study comprising qualitative research, a prospective cohort study, mathematical modelling and routine data collation. Setting: Three boroughs in London, UK. Participants: People aged = 18 years, who provided in-person sexual services. Interventions: Simulated removal of police enforcement. Outcomes: Primary - recent or past experience of sexual, physical or emotional violence. Secondary - depression/anxiety symptoms, physical health, chlamydia/gonorrhoea, and service access. Results: A combination of enforcement by police, local authorities and immigration, being denied justice when reporting violence, and linked cuts to specialist health and support services created harmful conditions for sex workers. This disproportionately affected cisgender and transgender women who work on the streets, use drugs, are migrants and/or women of colour. Among women (n = 197), street-based sex workers experienced higher levels than indoor sex workers of recent violence from clients (73% vs. 36%), police (42% vs. 7%) and others (67% vs. 17%); homelessness (65% vs. 7%); anxiety and depression (71% vs 35%); physical ill-health (57% vs 31%); and recent law enforcement (87% vs. 9%). For street-based sex workers, recent arrest was associated with violence from others (adjusted odds ratio (AOR)) 2.77, 95% confidence interval (CI) 1.11 to 6.94). Displacement by police was associated with client violence (AOR 4.35; 95% CI 1.36 to 13.90) as were financial difficulties (AOR 4.66; CI 1.64 to 13.24). Among indoor sex workers, unstable residency (AOR 3.19; 95% CI 1.36 to 7.49) and financial difficulties (AOR 3.66; 95% CI 1.64 to 8.18) contributed to risk of client violence. Among all genders (n = 288), ethnically and racially minoritised sex workers (26.4%) reported more police encounters than white sex workers, partly linked to increased representation in street settings (51.4% vs. 30.7%; p = 0.002) but associations remained after adjusting for work setting. Simulated removal of police displacement and homelessness was associated with a 71% reduction in violence (95% credible interval 55% to 83%). Participants called for a redirection of funds from enforcement towards respectful, peer-led services. Limitations: Restriction to one urban locality prevents generalisability of findings. More interviews with under-represented participants (e.g. trans/non-binary sex workers) may have yielded further insights into inequities. Correlation between different risk factors restricted outcomes of interest for the modelling analyses, which were largely limited to experience of violence. Conclusion: Our research adds to international evidence on the harms of criminalisation and enforcement, particularly for women who work on street and/or are racially or ethnically minoritised. Findings add weight to calls to decriminalise sex work, tackle institutionally racist, misogynist and otherwise discriminatory practices against sex workers in police and other agencies, and to (re) commission experience-based, peer-led services by and for sex workers particularly benefiting the most marginalised communities. Future work: Realist informed trials, co-produced with sex workers, would provide rigorous evidence on effective approaches to protect sex workers' health, safety and rights. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 15/55/58. [ABSTRACT FROM AUTHOR]

BackgroundPeople who inject drugs (PWID) are at increased risk of tuberculosis (TB) and reduced retention in treatment. There is a need to document strategies for integrated delivery of HIV, TB and drug dependency care.MethodsThis article reviews the literature on rates of TB mono- and co-infection, and published and grey literature descriptions of TB and HIV-TB care, among PWID.ResultsLatent TB infection prevalence was high and active disease more common among HIV-positive PWID. Data on multidrug-resistant TB and co-infections among PWID were scarce. Models of TB care fell into six categories: screening and prevention within HIV-risk studies; prevention at TB clinics; screening and prevention within needle-and-syringe-exchange (NSP) and drug treatment programmes; pharmacy-based TB treatment; TB service-led care with harm reduction/drug treatment programmes; and TB treatment within drug treatment programmes. Co-location with NSP and opioid substitution therapy (OST), combined with incentives, consistently improved screening and prevention uptake. Small-scale combined TB treatment and OST achieved good adherence in diverse settings. Successful interventions involved collaboration across services; a client-centred approach; and provision of social care. No peer-reviewed studies described models of integrated HIV-TB care for PWID but grey literature highlighted key components: co-located services, provision of drug treatment, multidisciplinary staff training; and remaining barriers: staffing inefficiencies, inadequate funding, police interference, and limited OST availability.ConclusionsIntegration with drug treatment improves PWID engagement in TB services but there is a need to document approaches to HIV-TB care, improve surveillance of TB and co-infections among PWID, and advocate for improved OST availability.

During COVID‐19 lockdowns in England, 'key workers' including factory workers, carers and cleaners had to continue to travel to workplaces. Those in key worker jobs were often from more marginalised communities, including migrant workers in precarious employment. Recognising space as materially and socially produced, this qualitative study explores migrant workers' experiences of navigating COVID‐19 risks at work and its impacts on their home spaces. Migrant workers in precarious employment often described workplace COVID‐19 protection measures as inadequate. They experienced work space COVID‐19 risks as extending far beyond physical work boundaries. They developed their own protection measures to try to avoid infection and to keep the virus away from family members. Their protection measures included disinfecting uniforms, restricting leisure activities and physically separating themselves from their families. Inadequate workplace COVID‐19 protection measures limited workers' ability to reduce risks. In future outbreaks, support for workers in precarious jobs should include free testing, paid sick leave and accommodation to allow for self‐isolation to help reduce risks to workers' families. Work environments should not be viewed as discrete risk spaces when planning response measures; responses and risk reduction approaches must also take into account impacts on workers' lives beyond the workplace. [ABSTRACT FROM AUTHOR]

While extensive literature documents how criminalisation harms sex workers' health and rights, limited research has critically examined how interactions between criminal-justice, health, and other systems shape support and justice for and by people who sell sex. We attend to this question by drawing on participatory, qualitative research with a diverse group of sex workers and other stakeholders in East London, UK. In addition to directly and structurally-violent enforcement practices, we identified wider, necropolitical assemblages and practices – across police, local and immigration authorities, health and social services – that disciplined sex workers' lives, responsibilised them for their health, and defunded specialist services grounded in lived realities, amid tensions over sex-work governance. These effects – grounded in notions of community and vulnerability that often privileged residents' concerns over threats to sex workers' safety and health – impacted marginalised and minoritised cis and trans women the most. Those who worked on the street and used drugs, were migrants, and/or women of colour were particularly targeted for enforcement, discounted when reporting violence and impacted by service cuts. Yet participants' appeals for redirection of funds from enforcement towards respectful, peer-led services reflected claims to social justice on their own terms. We recommend (re)commissioning health and support services that respond to sex workers' diverse realities, with and by them, alongside concerted efforts to end policies and practices that criminalise, punish, and blame. This would help to alleviate the health and social harms that we document, in support of inclusive participation in health and broader social justice goals. [ABSTRACT FROM AUTHOR]

Background Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur. Methods and findings We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing. Conclusions Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health., Author(s): Lucy Platt 1,*, Pippa Grenfell 1, Rebecca Meiksin 1, Jocelyn Elmes 1, Susan G. Sherman 2, Teela Sanders 3, Peninah Mwangi 4, Anna-Louise Crago 5 Introduction Sex workers can [...]

Objectives: To examine legal and social determinants of violence, anxiety/depression among sex workers.Methods: A participatory prospective cohort study among women (inclusive of transgender) ≥18 years, selling sex in the last 3 months in London between 2018 and 2019. We used logistic generalised estimating equation models to measure associations between structural factors on recent (6 months) violence from clients or others (local residents, strangers), depression/anxiety (Patient Health Questionnaire-4).Results: 197 sex workers were recruited (96% cisgender-women; 46% street-based; 54% off-street) and 60% completed a follow-up questionnaire. Street-based sex workers experienced greater inequalities compared with off-street in relation to recent violence from clients (73% vs 36%); police (42% vs 7%); intimate partner violence (IPV) (56% vs 18%) and others (67% vs 17%), as well as homelessness (65% vs 7%) and recent law enforcement (87% vs 9%). Prevalence of any STI was 17.5% (17/97). For street-based sex workers, recent arrest was associated with violence from others (adjusted OR (aOR) 2.77; 95% CI 1.11 to 6.94) and displacement by police was associated with client violence (aOR 4.35; 95% CI 1.36 to 13.90). Financial difficulties were also associated with client violence (aOR 4.66; 95% CI 1.64 to 13.24). Disability (aOR 3.85; 95% CI 1.49 to 9.95) and client violence (aOR 2.55; 95% CI 1.10 to 5.91) were associated with anxiety/depression. For off-street sex workers, financial difficulties (aOR 3.66; 95% CI 1.64 to 8.18), unstable residency (aOR 3.19; 95% CI 1.36 to 7.49), IPV (aOR 3.77; 95% CI 1.30 to 11.00) and alcohol/drug use were associated with client violence (aOR 3.16; 95% CI 1.26 to 7.92), while always screening and refusing clients was protective (aOR 0.36; 95% CI 0.15 to 0.87). Disability (aOR 5.83; 95% CI 2.34 to 14.51), unmet mental health needs (aOR 3.08; 95% CI 1.15 to 8.23) and past eviction (aOR 3.99; 95% CI 1.23 to 12.92) were associated with anxiety/depression.Conclusions: Violence, anxiety/depression are linked to poverty, unstable housing and police enforcement. We need to modify laws to allow sex workers to work safely and increase availability of housing and mental health services. [ABSTRACT FROM AUTHOR]

Fertility awareness apps, which help to identify the 'fertile window' when conception is most likely, have been hailed as 'revolutionising' women's reproductive health. Despite rapidly growing popularity, little research has explored how people use these apps when trying to conceive and what these apps mean to them. We draw on in‐depth, qualitative interviews, adopting a critical digital health studies lens (a sub‐field of science and technology studies), to explore the experiences of cisgender women and partners with one such app, Natural Cycles, in the context of their daily lives. We found that many women valued the technology as a 'natural', inobtrusive alternative to biomedical intervention, and a means of controlling and knowing their bodies, amid a dearth of fertility‐related education and care. Yet this technology also intervened materially and affectively into the spaces of their lives and relationships and privileged disembodied metrics (temperature) over embodied knowledge. Meanwhile, app language, advertising and cost have contributed to characterising 'typical' users as white, heterosexual, affluent, cisgender women without disabilities. In the context of neoliberal shifts towards bodily self‐tracking, technologies appealing as novel, liberating and 'natural' to individuals who can access them may nevertheless reproduce highly gendered reproductive responsibilities, anxieties and broader health and social inequalities. [ABSTRACT FROM AUTHOR]

Aim: To explore how women and their partners navigate (pre)conception healthcare and the role of Natural Cycles fertility awareness technology in this process., Methods: In-depth interviews with 24 cisgender women aged 24-43 years who had used Natural Cycles' 'Plan a Pregnancy' mode, and six partners of Natural Cycles users, all cisgender men aged 30-39 years. Participants were recruited via direct messaging in the Natural Cycles app, social media and, for partners, snowball sampling. Purposive sampling was conducted to ensure diversity among participants. Interviews were audio-recorded and transcribed verbatim. An iterative, inductive approach was adopted for thematic data analysis., Results: Natural Cycles helped most users better understand their menstrual cycles and fertility. Fertility awareness and preconception counselling with healthcare providers were uncommon. Women felt discussions about planning pregnancy in healthcare settings were often fraught with difficulties. They described not wanting to be an extra burden to overworked staff, being concerned that their worries about trying for pregnancy would be dismissed, or feeling staff did not have expertise in fertility awareness. Some women had shared their Natural Cycles data with healthcare professionals to demonstrate their menstrual cycle data or time of conception. However, it was not always clear to those not accessing services when they should seek further advice, for example, those using the app for longer time periods who had not yet conceived., Conclusions: Digital technologies can provide information and support for those wanting to conceive. They should, however, complement care in statutory services, and be accompanied by greater investment in fertility awareness and preconception support., Competing Interests: Competing interests: None of the authors have any involvement in Natural Cycles and they did not receive any financial or other incentive to conduct this research other than their usual university salaries. Before developing the Freyja proposal, RSF and JS received an honorarium from Natural Cycles to participate in an expert workshop aimed at identifying research gaps in relation to fertility awareness methods., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)