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Objectives. To model the relationship of unstable housing and evictions with physical and sexual violence perpetrated against women sex workers in intimate and workplace settings. Methods. We used bivariate and multivariable logistic regression with generalized estimating equations to model the association of unstable housing exposure and evictions with intimate partner violence (IPV) and workplace violence among a community-based longitudinal cohort of cisgender and transgender women sex workers in Vancouver, Canada, from 2010 through 2019. Results. Of 946 women, 85.9% experienced unstable housing, 11.1% eviction, 26.2% IPV, and 31.8% workplace violence. In multivariable generalized estimating equation models, recent exposure to unstable housing (adjusted odds ratio [AOR] = 2.04; 95% confidence interval [CI] = 1.45, 2.87) and evictions (AOR = 2.45; 95% CI = 0.99, 6.07) were associated with IPV, and exposure to unstable housing was associated with workplace violence (AOR = 1.46; 95% CI = 1.06, 2.00). Conclusions. Women sex workers face a high burden of unstable housing and evictions, which are linked to increased odds of intimate partner and workplace violence. Increased access to safe, women-centered, and nondiscriminatory housing is urgently needed. (Am J Public Health. 2023;113(4):442–452. https://doi.org/10.2105/AJPH.2022.307207 )

The COVID-19 pandemic has brought into stark focus the economic inequities faced by precarious, criminalized and racialized workers. Sex workers have been historically excluded from structural supports due to criminalization and occupational stigma. Given emerging concerns regarding sex workers’ inequitable access to COVID-19 income supports in Canada and elsewhere, our objective was to identify prevalence and correlates of accessing emergency income supports among women sex workers in Vancouver, Canada. Data were drawn from a longstanding community-based open cohort (AESHA) of cis and trans women sex workers in Metro Vancouver from April 2020–April 2021 (n = 208). We used logistic regression to model correlates of access to COVID-19 income supports. Among 208 participants, 52.9% were Indigenous, 6.3% Women of Colour (Asian, Southeast Asian, or Black), and 40.9% white. Overall, 48.6% reported accessing income supports during the pandemic. In adjusted multivariable analysis, non-injection drug use was associated with higher odds of accessing COVID-19 income supports (aOR: 2.58, 95% CI: 1.31–5.07), whereas Indigenous women faced reduced odds (aOR 0.55, 95% CI 0.30–1.01). In comparison with other service workers, access to income supports among sex workers was low overall, particularly for Indigenous sex workers, demonstrating the compounding impacts of colonization and disproportionate criminalization of Indigenous sex workers. Results highlight the need for structural supports that are low-barrier and culturally-safe to support sex workers’ health, safety and dignity.

Increased migration and im/migrant (i.e. migrant and immigrant) inequities, particularly during COVID-19, call for experiential global public health teaching to adequately prepare future leaders. W...

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.

Background Research that accurately represents how characteristics of sex work clients relate to sex workers’ labour conditions is crucial for informing evidence-based legislation which upholds sex workers’ human rights. As little quantitative research has examined how seeing regulars (repeat clients) impacts sex workers’ occupational safety, particularly under ‘end-demand’ criminalization in Canada, our study aimed to explore how seeing mostly regulars shapes workplace sexual violence and client condom refusal. Methods We drew on longitudinal data from a community-based open cohort of 900+ sex workers in Vancouver, recruited via time-location sampling during day and late-night outreach to indoor, outdoor, and online solicitation spaces. We used logistic regression analyses and multivariable GEE confounder models to 1) describe correlates of seeing mostly pre-screened, regular clients, 2) identify associations between seeing mostly regulars and odds of experiencing occupational outcomes of workplace sexual violence and client condom refusal, and 3) examine the interaction between seeing mostly regulars and work environment on workplace sexual violence and client condom refusal. Results Participants’ median age was 35, and 55.6% had completed high school. Over the 9-year study (n=925), 20.9% (193) experienced 282 events of workplace sexual violence and 40.2% (372) faced 702 events of client condom refusal. In multivariable GEE confounder models, seeing mostly regulars was associated with reduced odds of sexual violence (AOR 0.73, 95%CI 0.53-1.02, p=0.067) and client condom refusal (AOR 0.70, 95%CI 0.57-0.86). In multivariable GEE confounder models examining the additive interaction between seeing mostly regulars and work environment, participants who saw mostly regulars and primarily worked in outdoor or informal indoor venues faced significantly lower odds of experiencing workplace sexual violence (AOR 0.69, 95%CI 0.49-0.95) and client condom refusal (AOR 0.64, 95%CI 0.52 -0.80) relative to those who worked in the same venues and did not see mostly regulars. Conclusion Our findings highlight protective effects of seeing pre-screened regulars within a criminalized setting. Removal of ‘end-demand’ client criminalization is needed to enable sex workers to effectively screen clients, support HIV/STI prevention, and advance sex workers’ human rights.

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 a disproportionate burden of HIV/sexually transmitted infections (STIs), violence and other human rights violations. While recent HIV prevention research has largely focused on the HIV cascade, condoms remain a cornerstone of HIV prevention, requiring further research attention. Given serious concerns regarding barriers to condom use, including policing, violence and ‘end-demand’ sex work criminalisation, we evaluated structural correlates of difficulty accessing condoms among SWs in Vancouver over an 8-year period. Methods Baseline and prospective data were drawn from a community-based cohort of women SWs (2010–2018). SWs completed semi-annual questionnaires administered by a team that included lived experience (SWs). Multivariable logistic regression using generalised estimating equations (GEE) modelled correlates of difficulty accessing condoms over time. Results Among 884 participants, 19.1% reported difficulty accessing condoms during the study. In multivariable GEE analysis, exposure to end-demand legislation was not associated with improved condom access; identifying as a sexual/gender minority (adjusted odds ratio (aOR) 1.62, 95% CI 1.16 to 2.27), servicing outdoors (aOR 1.52, 95% CI 1.17 to 1.97), physical/sexual workplace violence (aOR 1.98, 95% CI 1.44 to 2.72), community violence (aOR 1.79, 95% CI 1.27 to 2.52) and police harassment (aOR 1.66, 95% CI 1.24 to 2.24) were associated with enhanced difficulty accessing condoms. Conclusions One-fifth of SWs faced challenges accessing condoms, suggesting the need to scale-up SW-tailored HIV/STI prevention. Despite the purported goal of ‘protecting communities’, end-demand criminalisation did not mitigate barriers to condom access, while sexual/gender minorities and those facing workplace violence, harassment or those who worked outdoors experienced poorest condom accessibility. Decriminalisation of sex work is needed to support SWs’ labour rights, including access to HIV/STI prevention supplies.

In Canada, im/migrant sex workers face stigma, health access barriers, and overlapping marginalization, with end-demand law reforms in 2014 postulated to exacerbate these inequities. Yet, little quantitative evidence on how immigration status shapes HIV/STI risk exists. Drawing on community-based longitudinal cohort data (AESHA, 2010–2018), we used multivariable confounder models with logistic regression to model 1) the independent effect of precarious immigration status (any status revocable under criminal charges: permanent residency/temporary residency/undocumented) on client condom refusal, and 2) the moderating effect of precarious status on the relationship between condom refusal and exposure to end-demand law reform (2015-present). Over this 8-year study involving 758 sex workers in Metro Vancouver 16.0% were im/migrants, of whom 57% had precarious immigration status at baseline. 16.5% of participants experienced client condom refusal. Precarious immigration was associated with increased odds of facing condom refusal (adjusted odds ratio [AOR] 2.53, 95% confidence interval [CI] 1.37–4.68), and these odds were heightened post-end-demand law reforms (AOR 4.35, 95%CI 1.21–15.66). Our findings suggest that lack of citizenship rights may enhance barriers to safer sex negotiation and increase HIV/STI risk among sex workers, highlighting the need for sex work and immigration policy reforms.

The criminalization of sex work has been consistently shown to undermine workers’ Occupational Health and Safety (OHS), including sexual health. Drawing on the ‘Guide to OHS in the New Zealand Sex Industry’ (the Guide), we assessed barriers to sexual health best practices among indoor sex workers in Metro Vancouver, Canada, in the context of ongoing criminalization. Part of a longstanding community-based study, this analysis drew on 47 qualitative interviews (2017–2018) with indoor sex workers and third parties. Participants’ narratives were analyzed drawing on a social determinants of health framework and on the Guide with specific focus on sexual health. Our findings suggest that sex workers and third parties utilize many sexual health strategies, including use of Personal Protective Equipment (PPE) and peer-driven sexual health education. However, participant narratives demonstrate how structural factors such as criminalization, immigration, and stigma limit the accessibility of additional OHS best practices outlined in the Guide and beyond, including access to non-stigmatizing sexual health assessments, and distribution of diverse PPE by third parties. Our current study supports the need for full decriminalization of sex work, including im/migrant sex work, to allow for the uptake of OHS guidelines that support the wellbeing and autonomy of all sex workers.

ObjectivesGlobally, criminalisation has shaped sex workers’ structural exclusion from occupational protections, and this exclusion has been exacerbated during the COVID-19 pandemic. While community organisations aim to bridge this gap through providing health and safety resources for sex workers, many were forced to scale back services when Canadian provinces declared a state of emergency at the pandemic onset. As little empirical research has examined the impacts of sex work community services interruptions amid COVID-19, our objectives were to (1) examine the correlates of interrupted access to community services and (2) model the independent association between interrupted access to community services and changes in working conditions (ie, self-reported increases in workplace violence or fear of violence), among sex workers during the COVID-19 pandemic.Design, setting and participantsAs part of an ongoing community-based cohort of sex workers in Vancouver, Canada (An Evaluation of Sex Workers Health Access, 2010–present), 183 participants completed COVID-19 questionnaires between April 2020 and April 2021.AnalysisCross-sectional analysis used bivariate and multivariable logistic regression with explanatory and confounder modelling approaches.Results18.6% of participants (n=34) reported interrupted access to community services (closure/reduction in drop-in hours, reduced access to spaces offering sex worker supports and/or reduced access/contact with outreach services). In multivariable analysis, sex workers who had difficulty maintaining social supports during COVID-19 (adjusted OR, AOR 2.29, 95% CI 0.95 to 5.56) and who experienced recent non-fatal overdose (AOR 2.71, 95% CI 0.82 to 8.98) faced marginally increased odds of service interruptions. In multivariable confounder analysis, interrupted access to community services during COVID-19 was independently associated with changes in working conditions (ie, self-reported increases in workplace violence or fear of violence; AOR 4.00, 95% CI 1.01 to 15.90).ConclusionsFindings highlight concerning implications of community service interruptions for sex workers’ labour conditions. Sustainable funding to community organisations is urgently needed to uphold sex workers’ occupational safety amid COVID-19 and beyond.

ObjectivesIn 2014, Canada implemented end-demand sex work legislation that criminalises clients and third parties (eg, managers, security personnel, etc) involved in sex work. The focus of this analysis is to explore how the criminalisation of clients shapes the occupational health and safety of sex workers.DesignAs part of a longstanding community-based study (An Evaluation of Sex Workers’ Health Access), this analysis draws on 47 in-depth qualitative interviews with indoor sex workers and third parties. Informed by an intersectional lens and guided by a structural determinants of health framework, this work seeks to characterise the impact of client criminalisation in shaping the occupational health and safety of indoor sex workers.SettingIndoor sex work venues (eg, massage parlour, in-call, brothel, etc) operating in Metro Vancouver, Canada.Participants47 predominately racialised sex workers and third parties working in indoor environments between 2017 and 2018.ResultsWhile participants highlighted that the majority of their client interactions were positive, their narratives emphasised how end-demand criminalisation impeded their occupational safety. The criminalisation of clients was linked to reduced ability to negotiate the terms of sexual transactions, including type of service, price and sexual health. Client preference for cash payments to maintain anonymity led to increased risk of robbery and assault due to knowledge of high cash flow in sex work venues and a reluctance to seek police protection. Workers also noted that client fear of being prosecuted or ‘outed’ by police enhanced feelings of shame, which was linked to increased aggression by clients.ConclusionPolicies and laws that criminalise clients are incompatible with efforts to uphold the occupational health and safety and human rights of sex workers. The decriminalisation of sex work is urgently needed in order to support the well-being and human rights of all those involved in the Canadian sex industry.

The goal of this paper is to determine the association between traveling to engage in sex work in another country and recent access to HIV testing among substance-using female sex workers (FSWs) in the Mexico-Guatemala border region. From 2012 to 2015, through modified time-location sampling and peer referral, 255 FSWs were recruited at Mexico's southern border. Participants completed questionnaires on sociodemographics, migration and mobility experiences, work environment factors, and substance use. A conceptual framework, as depicted by a directed acyclic graph (DAG), guided our analysis. Crude and adjusted logistic regression models were used to evaluate the relationships between mobility experiences and HIV testing in the past year. Overall HIV testing was low (41%); after considering relevant covariates (i.e., interaction with health services and organizations, and sex work characteristics) traveling to engage in sex work in another country was found to be positively associated with HIV testing in the past year. Future efforts need to consider voluntary and non-stigmatizing prevention HIV services and focus on reaching out to less mobile women.El objetivo de este artículo es determinar la asociación entre viajar a otro país para ejercer el comercio sexual y el acceso a una prueba reciente de VIH, en una población de mujeres trabajadoras sexuales en la frontera de México con Guatemala. Entre el 2012 y 2015, utilizando un muestreo por conveniencia y por referencia de pares, se invitó a 255 mujeres trabajadoras sexuales en la frontera sur de México a participar en este proyecto de investigación. Las participantes completaron una encuesta que comprendió preguntas sociodemográficas así como experiencias de migración y movilidad, características del trabajo sexual, y patrones de uso de sustancia. Utilizamos un marco conceptual que se ilustra en una Gráfica Acíclica Dirigida (DAG) el cual sirvió para guiar nuestro análisis. Realizamos análisis de regresión logística cruda y ajustada para evaluar la asociación entre experiencias de movilidad y haber recibido una prueba de VIH en el último año. En general, el porcentaje de haber recibido una prueba de VIH en el último año fue bajo (41%); después de considerar covariables relevantes; (ej., interacción con organizaciones y servicios de salud, características del trabajo sexual) encontramos que viajar a otro país para ejercer el comercio sexual está asociado con haber recibido una prueba de VIH en el último año. Es importante que, en el futuro, se concentren esfuerzos en servicios de prevención del VIH que sean voluntarios, no estigmatizantes, y que se enfoquen en mujeres trabajadoras sexuales menos móviles.

Despite a high prevalence of substance use among women sex workers (SWs), rigorous social epidemiologic data on substance use treatment experiences among SWs remains limited. Given these gaps and the disproportionate burden of criminalization borne by Indigenous SWs, we evaluated (1) structural correlates of unsuccessful attempts to access substance use treatment; and (2) the interaction between policing and Indigenous ancestry on unsuccessful attempts to access treatment among SWs who use drugs.Prospective data were from an open community-based cohort of women SWs (2010-2019) in Vancouver, Canada. Bivariate and multivariable logistic regression with generalized estimating equations(GEE) assessed correlates of unsuccessful attempts to access treatment. A multivariable GEE confounder model examined the interaction between Indigenous ancestry and policing on unsuccessful attempts to access treatment.Amongst 645 SWs who used drugs, 32.1 % reported unsuccessful attempts to access substance use treatment during the 9.5-year study. In multivariable GEE analysis, unsuccessful substance use treatment access was associated with identifying as a sexual/gender minority (AOR: 1.90, 95 %CI:1.37-2.63), opioid use (AOR: 1.43, 95 %CI: 1.07-1.91), and exposure to homelessness (AOR: 1.72; 95 %CI:1.33-2.21), police harassment (AOR: 1.48, 95 %CI:1.03-2.13), workplace violence (AOR: 1.80, 95 %CI: 1.31-2.49) and intimate partner violence (AOR: 2.11, 95 %CI:1.50-2.97). In interaction analysis, Indigenous SWs who experienced police harassment faced the highest odds of unsuccessful attempts to access substance use treatment (AOR: 2.59, 95 %CI:1.65-4.05).Findings suggest a need to scale-up culturally-safe, trauma-informed addictions, gender-based violence, and sex worker services, alongside dismantling of systemic racism across and beyond health and addictions services.

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.

Substance use and depressive psychiatric symptoms have been associated with migration and mobility. The Mexico-Guatemala border is a key transit point for internal, regional, and international migration flows. However, there is limited knowledge of the role of substance use, migration, and mobility on mental health among migrants at this border. Our paper explores the association of migration and mobility patterns with possible major depressive symptoms among migrants at this key geographic region. We recruited 392 substance-using migrants using modified time-location sampling. Crude and adjusted logistic regression models were developed. We found that 12% of the sample had possible major depressive symptoms. After adjusting for relevant covariates, including gender, income, and perceived homelessness, we found that recent rural-urban and short-term migrants had higher odds of possible major depressive symptoms, whereas international migrants had lower odds. Findings of this paper suggest that although migrants experience hardship and uncertainty, they may respond with complex and nuanced forms of coping and planning.

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.

Introduction This open access book provides a comprehensive overview of the health inequities and human rights issues faced by sex workers globally across diverse contexts, and outlines evidence-based strategies and best practices. Sex workers face severe health and social inequities, largely as the result of structural factors including punitive and criminalized legal environments, stigma, and social and economic exclusion and marginalization. Although previous work has largely emphasized an elevated burden and gaps in HIV and sexually transmitted infection (STI) services in sex work, less attention has been paid to the broader health and human rights concerns faced by sex workers. This contributed volume addresses this gap. The chapters feature a variety of perspectives including academic, community, implementing partners, and government to synthesize research evidence as well as lessons learned from local-level experiences across different regions, and are organized under three parts: Burden of health and human rights inequities faced by sex workers globally, including infectious diseases (e.g., HIV, STIs), violence, sexual and reproductive health, and drug use Structural determinants of health and human rights, including legislation, law enforcement, community engagement, intersectoral collaboration, stigma, barriers to health access, im/migration issues, and occupational safety and health Evidence-based services and best practices at various levels ranging from individual and community to policy-level interventions to identify best practices and avenues for future research and interventions Sex Work, Health, and Human Rights is an essential resource for researchers, policy-makers, governments, implementing partners, international organizations and community-based organizations involved in research, policies, or programs related to sex work, public health, social justice, gender-based violence, women's health and harm reduction.

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.

Author(s): Argento, Elena; Goldenberg, Shira; Braschel, Melissa; Machat, Sylvia; Strathdee, Steffanie A; Shannon, Kate | Abstract: BackgroundFollowing a global wave of end-demand criminalization of sex work, the Protection of Communities and Exploited Persons Act (PCEPA) was implemented in Canada, which has implications for the health and safety of sex workers. This study aimed to evaluate the impact of the PCEPA on sex workers' access to health, violence, and sex worker-led services.MethodsLongitudinal data were drawn from a community-based cohort of ~900 cis and trans women sex workers in Vancouver, Canada. Multivariable logistic regression examined the independent effect of the post-PCEPA period (2015-2017) versus the pre-PCEPA period (2010-2013) on time-updated measures of sex workers' access to health, violence supports, and sex worker/community-led services.ResultsThe PCEPA was independently correlated with reduced odds of having access to health services when needed (AOR 0.59; 95%CI: 0.45-0.78) and community-led services (AOR 0.77; 95%CI: 0.62-0.95). Among sex workers who experienced physical violence/sexual violence or trauma, there was no significant difference in access to counseling supports post-PCEPA (AOR 1.24; 95%CI: 0.93-1.64).ConclusionSex workers experienced significantly reduced access to critical health and sex worker/community-led services following implementation of the new laws. Findings suggest end-demand laws may exacerbate and reproduce harms of previous criminalized approaches to sex work in Canada. This study is one of the first globally to evaluate the impact of end-demand approaches to sex work. There is a critical evidence-based need to move away from criminalization of sex work worldwide to ensure full labor and human rights for sex workers. Findings warn against adopting end-demand approaches in other cities or jurisdictions.

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.

Although human trafficking is recognized as a major human rights violation, there is limited evidence regarding the vulnerabilities that contribute to female adolescents’ risk of being forced or coerced into the sex trade. Vulnerabilities such as gender-based violence, economic and social inequalities have been shown to shape the risk of sexual exploitation among adolescents. In-depth interviews (n=18) with current sex workers who reported being deceived or forced into the sex trade as adolescents (

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 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.

Objective. To determine the impact of engagement with third parties (i.e., managers, receptionists, or owners of in-call venues; advertisers; security; spotters; and others) on sex workers’ occupational health access. Methods. We drew longitudinal data from An Evaluation of Sex Workers’ Health Access, a community-based cohort of more than 900 women sex workers. We used multivariable logistic regression and generalized estimating equations to (1) examine factors correlated with accessing third-party administrative or security services and (2) evaluate the impact of third-party services on access to mobile condom distribution and sex worker and community-led services (2010–2016). Finally, we evaluated changes in accessing third-party services pre–post end-demand criminalization (2010–2017). Results. Im/migrant sex workers (persons with any type of legal status who were born in another country; adjusted odds ratio [AOR] = 2.32; 95% confidence interval [CI] = 1.35, 3.98) had higher odds of accessing third-party services. In confounder models, third-party services were independently correlated with increased access to mobile condom distribution (AOR = 1.84; 95% CI = 1.47, 2.31) and sex worker and community-led services (AOR = 1.61; 95% CI = 1.15, 2.24). End-demand criminalization was linked to a decrease in access to third-party services (AOR = 0.79; 95% CI = 0.63, 0.99). Conclusions. This research suggests that access to administrative and security services from third parties increases sex workers’ occupational health and safety. Policy reforms to ensure sex workers’ labor rights, including access to hiring third parties, are recommended.

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

Public health regulations practices surrounding sex work and their enforcement can have unintended consequences for HIV and sexually transmitted infection (STI) prevention and care among sex workers. This analysis was based on qualitative in-depth (n = 33) and focus groups interviews (n = 20) conducted with migrant female sex workers in Tecún Umán and Quetzaltenango, Guatemala, and explored the implementation of sex work regulations and related consequences for HIV prevention and care among migrant sex workers. Sex work regulations were found to have health-related benefits (e.g., access to HIV/STI testing) as well as negative impacts, such as abuse by police and harassment, detention/deportation of migrant sex workers. Whereas public health regulations may improve access to HIV/STI testing, their implementation may inadvertently jeopardize sex workers' health through unintended negative consequences. Non-coercive, evidence-based public health and sex work policies and programs are needed to expand access to HIV/STI prevention and care among migrant sex workers, while protecting their dignity and human rights.

Despite reports of high levels of violence among women migrants in Central America, limited evidence exists regarding the health and safety of migrant sex workers in Central America. This study is based on 16 months of field research (November 2012–February 2015), including ethnographic fieldwork, in-depth interviews, and focus groups conducted with 52 internal and international migrant female sex workers in Tecún Úman and Quetzaltenango, Guatemala, key transit and destination communities for both international and internal migrants. The analysis explored migration-related determinants of susceptibility to violence experienced by migrant sex workers across different phases of migration. Violence in home communities and economic considerations were key drivers of migration. Unsafe transit experiences (e.g., undocumented border crossings) and negative interactions with authorities in destination settings (e.g., extortion) contributed to migrant sex workers’ susceptibility to violence, while enhanced access to information on immigration policies and greater migration and sex work experience were found to enhance agency and resilience. Findings suggest an urgent need for actions that promote migrant sex workers’ safety in communities of origin, transit, and destination, and programmes aimed at preventing and addressing human rights violations within the context of migration and sex work.

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.