Occupational heat-related illness in Washington State: A descriptive study of day of illness and prior day ambient temperatures among cases and clusters, 2006-2021.

BACKGROUND: Insufficient heat acclimatization is a risk factor for heat-related illness (HRI) morbidity, particularly during periods of sudden temperature increase. We sought to characterize heat exposure on days before, and days of, occupational HRIs. METHODS: A total of 1241 Washington State workers' compensation State Fund HRI claims from 2006 to 2021 were linked with modeled parameter-elevation regressions on independent slopes model (PRISM) meteorological data. We determined location-specific maximum temperatures (Tmax,PRISM ) on the day of illness (DOI) and prior days, and whether the Tmax,PRISM was ≥10.0°F (~5.6°C) higher than the average of past 5 days ("sudden increase") for each HRI claim. Claims occurring on days with ≥10 HRI claims ("clusters") were compared with "non-cluster" claims using t tests and χ2 tests. RESULTS: Seventy-six percent of analyzed HRI claims occurred on days with a Tmax,PRISM ≥ 80°F. Claims occurring on "cluster" days, compared to "non-cluster" days, had both a significantly higher mean DOI Tmax,PRISM (99.3°F vs. 85.8°F [37.4°C vs. 29.9°C], t(148) = -18, p < 0.001) and a higher proportion of "sudden increase" claims (80.2% vs. 24.3%, χ2 [1] = 132.9, p < 0.001). Compared to "cluster" days, HRI claims occurring during the 2021 Pacific Northwest "heat dome" had a similar increased trajectory of mean Tmax,PRISM on the days before the DOI, but with higher mean Tmax,PRISM. CONCLUSIONS: Occupational HRI risk assessments should consider both current temperatures and changes in temperatures relative to prior days. Heat prevention programs should include provisions to address acclimatization and, when increases in temperature occur too quickly to allow for sufficient acclimatization, additional precautions.

Heat related illness among workers in Washington State: A descriptive study using workers' compensation claims, 2006-2017.

BACKGROUND: Heat related illness (HRI) places a significant burden on the health and safety of working populations and its impacts will likely increase with climate change. The aim of this study was to characterize the demographic and occupational characteristics of Washington workers who suffered from HRI from 2006 to 2017 using workers' compensation claims data. METHODS: We used Washington workers' compensation data linked to weather station data to identify cases of work-related HRI. We utilized Occupational Injury and Illness Classification System codes, International Classification of Diseases 9/10 codes, and medical review to identify accepted and rejected Washington State (WA) workers' compensation claims for HRI from 2006 to 2017. We estimated rates of HRI by industry and evaluated patterns by ambient temperature. RESULTS: We detected 918 confirmed Washington workers' compensation HRI claims from 2006 to 2017, 654 were accepted and 264 were rejected. Public Administration had the highest third quarter rate (131.3 per 100 000 full time employees [FTE]), followed by Agriculture, Forestry, Fishing, and Hunting (102.6 per 100 000 FTE). The median maximum daytime temperature was below the Washington heat rule threshold for 45% of the accepted HRI claims. Latinos were estimated to be overrepresented in HRI cases. CONCLUSION: The WA heat rule threshold may not be adequately protecting workers and racial disparities are present in occupational HRI. Employers should take additional precautions to prevent HRI depending on the intensity of heat exposure. States without heat rules and with large industry sectors disproportionately affected by HRI should consider regulations to protect outdoor workers in the face of more frequent and extreme heat waves.

Injury Rate Comparisons for Nonmechanized and Mechanized Logging Operations, Washington State, 2005-2014.

OBJECTIVES: Current industry classification systems in the United States do not differentiate mechanized and nonmechanized logging operations. The objectives of this article are to quantify injury risk differences between mechanized and nonmechanized logging operations in Washington State and to evaluate for potential injury risk tradeoffs, such as decreasing traumatic injuries while increasing nontraumatic injuries that might occur when mechanized logging operations are substituted for nonmechanized logging operations. METHODS: Using Washington State workers' compensation insurance risk classes to differentiate mechanized and nonmechanized logging operations, injury and illness claims data and employer reported hours were used to compare claim rates and to characterize injuries by type of logging operation. RESULTS: From 2005 to 2014, the accepted Washington State worker's compensation claim rate for nonmechanized logging was 46.4 per 100 full-time equivalent employees compared to 6.7 per 100 full-time equivalent (FTE) for mechanized logging activities. The rate ratio for comparing nonmechanized to mechanized logging claims rates for all accepted claims was 6.9 (95% Confidence Interval 6.4-7.5). Claim rates for traumatic injury and nontraumatic injuries in nonmechanized logging exceeded comparable rates in mechanized logging activities, although the distribution of types of injury differed by type of logging operation. A greater percentage of accepted claims in nonmechanized logging were traumatic injuries than in mechanized logging (92.2% vs. 85.0%, respectively). In addition, nonmechanized logging had higher total claim and medical costs per FTE and had a higher proportion of claims with lost work time than mechanized logging. CONCLUSION: Mechanized logging offers a considerable safety advantage over nonmechanized logging operations. Continued efforts to increase the mechanization of logging operations will result in decreased injury rates.

The Economic Effect of Chronic Comorbidities in Carpal Tunnel Syndrome Workers' Compensation Claimants, Washington State.

OBJECTIVE: Assess the effect of chronic comorbidities on hours and earnings recovery following a carpal tunnel syndrome (CTS) claim. METHODS: The hours and earnings profiles of Washington State workers' compensation claimants with CTS and controls, upper extremity fractures (UEF) claimants, were collected by linking to unemployment insurance data during 2007 to 2014. Chronic comorbidity status was determined from workers' compensation bills. RESULTS: More (43%) CTS claimants had diagnosed chronic comorbidities than UEF (24%). CTS claimants and claimants with multiple chronic comorbidities had significantly higher odds of not working post injury and poorer hours and earnings recovery compared with UEF claimants and those with no chronic comorbidities. CONCLUSIONS: This research suggests that chronic conditions should be considered as barriers to return to work among injured workers.

Think global, act local: the experience of Global Fund and PEPFAR joint cascade assessments to harmonize and strengthen key population HIV programmes in eight countries.

INTRODUCTION: The Global Fund and the US President's Emergency Plan for AIDS Relief (PEPFAR) are major donors to HIV services with key populations (KPs) to achieve the UNAIDS 95-95-95 epidemic control goals. The programmes they fund are not always well aligned or coordinated, decreasing their effectiveness. Joint assessments are designed and led by LINKAGES, a project funded by PEPFAR and the US Agency for International Development, to improve coordination among donors and on-the-ground implementation of KP HIV programmes. Joint assessments help identify barriers that prevent KPs from accessing interventions along the cascade of prevention, diagnosis and treatment services, and provide recommendations to improve and align programmes. Detailed reports from eight assessments in Malawi, Cameroon, Swaziland, Haiti, Angola, Nepal, Côte d'Ivoire and Botswana were analysed for thematic challenges, and recommendations are presented. The purpose of the paper is to identify commonalities across KP HIV programmes that were found through the assessments so others can learn and then strengthen their programmes to become more effective. DISCUSSION: The joint cascade assessments offered countries feedback on HIV programme challenges and recommendations for strengthening them at national, subnational and local levels. Shared intervention areas included: (1) robust population size estimates to inform service delivery targets and to budget resources for KP outreach; (2) accessible and KP-friendly services most relevant to individuals to increase retention in the HIV cascade; (3) decentralized, community-based services for HIV testing and antiretroviral therapy, and new approaches including self-testing and PrEP; (4) addressing structural issues of stigma, discrimination and violence against KPs to create a more enabling environment; and (5) more effective and continual tracking of KPs across the cascade, and coordinated, harmonized monitoring tools and reporting systems between donor-funded and national programmes. CONCLUSIONS: The assessment teams and country stakeholders viewed the assessments as a best practice for coordinating donor-funded programmes that may overlap or inefficiently serve KPs. Global and national HIV programmes need investments of time, resources, and commitment from stakeholders to continually course-correct to align and improve programmes for sustained impact. The type of continued partnership demonstrated by the joint assessments is key to address HIV among KPs globally.

Characteristics of construction firms at risk for future workers' compensation claims using administrative data systems, Washington State.

INTRODUCTION: Construction is high-hazard industry, and continually ranks among those with the highest workers' compensation (WC) claim rates in Washington State (WA). However, not all construction firms are at equal risk. We tested the ability to identify those construction firms most at risk for future claims using only administrative WC and unemployment insurance data. METHODS: We collected information on construction firms with 10-50 average full time equivalent (FTE) employees from the WA unemployment insurance and WC data systems (n=1228). Negative binomial regression was used to test the ability of firm characteristics measured during 2011-2013 to predict time-loss claim rates in the following year, 2014. RESULTS: Claim rates in 2014 varied by construction industry groups, ranging from 0.7 (Land Subdivision) to 4.6 (Foundation, Structure, and Building Construction) claims per 100 FTE. Construction firms with higher average WC premium rates, a history of WC claims, increasing number of quarterly FTE, and lower average wage rates during 2011-2013 were predicted to have higher WC claim rates in 2014. CONCLUSIONS: We demonstrate the ability to leverage administrative data to identify construction firms predicted to have future WC claims. This study should be repeated to determine if these results are applicable to other high-hazard industries. Practical Applications: This study identified characteristics that may be used to further refine targeted outreach and prevention to construction firms at risk.

The Prevalence and Correlates of Physical and Sexual Violence Affecting Female Sex Workers in Swaziland.

Female sex workers (FSW) have a heightened vulnerability to violence and negative sexual/reproductive health outcomes. Limited research has examined how experiencing physical and sexual violence (PSV) mediates risk for poor health outcomes among FSW in Swaziland. The present analyses aim to contribute to literature linking violence with poor health outcomes, high-risk behaviors, and reduced health service-seeking among FSW. Data were analyzed from a cross-sectional study conducted in Swaziland between July and September 2011 with 325 adult women who reported exchanging sex for money, goods, or favors in the last 12 months, recruited through respondent-driven sampling (RDS). Logistic regression was used to assess the relationship between PSV and ancillary violence/abuse exposures, risk behaviors, and sexual/reproductive and mental health outcomes. PSV was conceptualized as either ever having been beaten up as a result of selling sex or ever being forced to have sex since the age of 18, or both. Prevalence of PSV in this sample was 59.0% in crude estimation, and 48.4% (95% confidence interval [CI]:[39.2,57.6]) with RDS weighting. Separate RDS-weighted estimates of being beaten up as a result of sex work and ever being forced to have sex were 32.4% (95%CI=[24.4,40.4]) and 33.1% (95%CI =[25.0,41.2%]), respectively. Experiencing PSV was associated with being blackmailed (adjusted odds ratio [aOR]= 1.93, 95%CI= [1.07,3.52]), non-injection drug use in the last 12 months (aOR= 1.84, 95%CI= [1.02,3.33]), and feeling afraid to seek health services as a result of selling sex (aOR = 1.74, 95%CI= [1.01,2.99]). Given these findings, violence prevention strategies should be prioritized in programs that address Swazi FSW health, empowerment, and safety.

Work-related musculoskeletal disorder surveillance using the Washington state workers' compensation system: Recent declines and patterns by industry, 1999-2013.

BACKGROUND: Work-related musculoskeletal disorders (WMSDs) are common and place large economic and social burdens on workers and their communities. We describe recent WMSD trends and patterns of WMSD incidence among the Washington worker population by industry. METHODS: We used Washington State's workers' compensation compensable claims from 1999 to 2013 to describe incidence and cost of WMSD claims by body part and diagnosis, and to identify high-risk industries. RESULTS: WMSD claim rates declined by an estimated annual 5.4% (95% CI: 5.0-5.9%) in Washington State from 1999 to 2013, but WMSDs continue to account for over 40% of all compensable claims. High risk industries identified were Construction; Transportation and Warehousing; Health Care and Social Assistance; and Manufacturing. CONCLUSIONS: As documented in other North American contexts, this study describes an important decline in the incidence of WMSDs. The Washington State workers' compensation system provides a rich data source for the surveillance of WMSDs.

Workers' compensation claims not reported in the Survey of Occupational Injuries and Illnesses: Injury and claim characteristics.

BACKGROUND: Underreporting in the nation's primary source of non-fatal occupational injury and illness data are well documented, but worker-level characteristics of unreported cases have not been fully explored. METHODS: Bureau of Labor Statistics' Survey of Occupational Injuries and Illnesses (SOII) data were linked to Washington workers' compensation claims to identify injury and claim characteristics associated with unreported cases. Workers' compensation administrative date data were used to characterize timing of disability and SOII case eligibility. RESULTS: Based on claim date data, one in five lost time claims with an injury date in the survey year were likely ineligible for SOII case reporting during the survey year. Among SOII-eligible claims, those involving sprains or strains, employer protests, and those not eligible for work disability payments until months after the initial injury were least likely to be reported in SOII. CONCLUSIONS: SOII case capture is limited both by its cross sectional survey design and employer underreporting. Am. J. Ind. Med. 60:264-275, 2017. © 2017 Wiley Periodicals, Inc.

Effectiveness of OSHA Outreach Training on carpenters' work-related injury rates, Washington State 2000-2008.

INTRODUCTION: Despite the size and breadth of OSHA's Outreach Training program for construction, information on its impact on work-related injury rates is limited. METHODS: In a 9-year dynamic cohort of 17,106 union carpenters in Washington State, the effectiveness of OSHA Outreach Training on workers' compensation claims rate was explored. Injury rates were calculated by training status overall and by carpenters' demographic and work characteristics using Poisson regression. RESULTS: OSHA Outreach Training resulted in a 13% non-significant reduction in injury claims rates overall. The protective effect was more pronounced for carpenters in their apprenticeship years, drywall installers, and with increasing time since training. CONCLUSIONS: In line with these observed effects and prior research, it is unrealistic to expect OSHA Outreach Training alone to have large effects on union construction workers' injury rates. Standard construction industry practice should include hazard awareness and protection training, coupled with more efficient approaches to injury control. Am. J. Ind. Med. 60:45-57, 2017. © 2016 Wiley Periodicals, Inc.

A Case-Crossover Study of Heat Exposure and Injury Risk in Outdoor Agricultural Workers.

BACKGROUND: Recent research suggests that heat exposure may increase the risk of traumatic injuries. Published heat-related epidemiological studies have relied upon exposure data from individual weather stations. OBJECTIVE: To evaluate the association between heat exposure and traumatic injuries in outdoor agricultural workers exposed to ambient heat and internal heat generated by physical activity using modeled ambient exposure data. METHODS: A case-crossover study using time-stratified referent selection among 12,213 outdoor agricultural workers with new Washington State Fund workers' compensation traumatic injury claims between 2000 and 2012 was conducted. Maximum daily Humidex exposures, derived from modeled meteorological data, were assigned to latitudes and longitudes of injury locations on injury and referent dates. Conditional logistic regression was used to estimate odds ratios of injury for a priori daily maximum Humidex categories. RESULTS: The mean of within-stratum (injury day and corresponding referent days) standard deviations of daily maximum Humidex was 4.8. The traumatic injury odds ratio was 1.14 (95% confidence interval 1.06, 1.22), 1.15 (95% confidence interval 1.06, 1.25), and 1.10 (95% confidence interval 1.01, 1.20) for daily maximum Humidex of 25-29, 30-33, and ≥34, respectively, compared to < 25, adjusted for self-reported duration of employment. Stronger associations were observed during cherry harvest duties in the June and July time period, compared to all duties over the entire study period. CONCLUSIONS: Agricultural workers laboring in warm conditions are at risk for heat-related traumatic injuries. Combined heat-related illness and injury prevention efforts should be considered in high-risk populations exposed to warm ambient conditions in the setting of physical exertion.

Putting the t in tools: a roadmap for implementation of new global and regional transgender guidance.

Transgender (trans) activists and global health partners have collaborated to develop new tools and guidance for assessing and addressing HIV and other health needs within trans populations. Trans women experience a heavy burden of HIV and other sexually transmitted infections (STIs), high incidence of violence and difficulties accessing gender-affirming services. At the same time, little has been published on trans men's health, HIV issues, needs and experiences. Young trans people are especially marginalized and vulnerable, with few programmes and services specifically tailored to their needs. Trans-specific data and guidance are needed to adapt the global response to HIV to meet the needs of the trans population. While the needs of this group have only recently received attention, global, regional and other technical guidance documents are being developed to address these gaps. Regional blueprints for comprehensive care for trans people in Latin America, the Caribbean, and Asia and the Pacific are now available. These tools - supported by the Pan American Health Organization, World Health Organization, US President's Emergency Plan for AIDS Relief and the United Nations Development Programme, in collaboration with regional trans groups - provide a contextual map, indicating opportunities for interventions in health, HIV, violence, stigma and discrimination, social protection and human rights. Global guidance includes the World Health Organization's Policy Brief: Transgender People and HIV, and the interagency publication, Implementing Comprehensive HIV and STI Programmes with Transgender People. Community empowerment and capacity building are the focus of the new tools for global and regional transgender guidance. The goal is to strengthen and ensure community-led responses to the HIV challenge in trans populations. This article describes the new tools and guidance and considers the steps needed to use them to appropriately support and engage transgender populations within national AIDS, STI, and sexual and reproductive health responses and programmes. The time to use these tools and guidance for advocacy, strategic planning, capacity building, programme design and training is now.

Social cohesion, social participation and HIV testing among men who have sex with men in Swaziland.

Social cohesion and social participation are social factors that may help reduce HIV risks and optimize health-seeking behaviors. We examined the association between these factors and HIV testing in the last 12 months among men who have sex with men (MSM) in Swaziland using a cross-sectional survey conducted with 326 men, 18 years of age or older reporting having sex with another man in the last 12 months. Social capital analyses included measures of social cohesion and social participation. The social cohesion measurement scale was created through exploratory factor analysis using polychoric correlations to determine unidimensionality and Cronbach's Alpha to assess internal consistency. The measurement scale was divided at the 25th and 75th percentiles using "high," "medium" and "low" levels of social cohesion for between-group comparisons. The social participation index included four questions regarding participation, resulting in a participation index ranging from 0 to 4. In the final multivariate logistic regression model, an increase in the level of social participation was found to be significantly associated with HIV testing in the last 12 months, adjusting for age, income, reporting a casual partner, family exclusion and rejection by other MSM due to sexual orientation (adjusted odds ratio [aOR]: 1.3, 95% confidence interval [CI] 1.1-1.7, p < .01). MSM with high social cohesion had almost twice the odds of HIV testing in the last 12 months (aOR: 1.8, 95% CI 1.1-3.3, p < .05) as MSM with medium social cohesion, though the overall social cohesion variable was not found to be significant using a Wald test in either the adjusted or unadjusted logistic regression models. These data suggest that building solidarity and trust within and between groups may be a strategy to improve uptake of HIV testing.

Unreported workers' compensation claims to the BLS Survey of Occupational Injuries and Illnesses: Establishment factors.

BACKGROUND: Studies suggest employers underreport injuries to the Bureau of Labor Statistics Survey of Occupational Injuries and Illnesses (SOII); less is known about reporting differences by establishment characteristics. METHODS: We linked SOII data to Washington State workers' compensation claims data, using unemployment insurance data to improve linking accuracy. We used multivariable regression models to estimate incidence ratios (IR) of unreported workers' compensation claims for establishment characteristics. RESULTS: An estimated 70% of workers' compensation claims were reported in SOII. Claims among state and local government establishments were most likely to be reported. Compared to large manufacturing establishments, unreported claims were most common among small educational services establishments (IR = 2.47, 95%CI: 1.52-4.01) and large construction establishments (IR = 2.05, 95%CI: 1.77-2.37). CONCLUSIONS: Underreporting of workers' compensation claims to SOII varies by establishment characteristics, obscuring true differences in work injury incidence. Findings may differ from previous research due to differences in study methods.

Characterizing the Individual, Social, and Structural Determinants of Condom Use Among Men Who Have Sex with Men in Swaziland.

Within the broadly generalized HIV epidemic in Swaziland, men who have sex with men (MSM) have specific HIV acquisition and transmission risks. In the current era of expanding antiretroviral therapy-based prevention and treatment approaches, condom use remains a core component of mitigating these risks. A cross-sectional study characterizing the vulnerabilities for HIV among MSM in Swaziland was analyzed to describe factors associated with condom use at last sex with a male partner. Bivariate and multivariate logistic regression analyses were conducted to assess correlates of condom use at last sex with both casual and regular male partners. Disclosure of sexual practices to a healthcare provider and being able to count on other MSM to support condom use were significantly associated with condom use at last sex with a causal and a regular partner, respectively. Reporting difficulty insisting on condom use was inversely associated with condom use at last sex with both regular and casual partners. In addition, having faced legal discrimination was similarly inversely associated with condom use at last sex with a regular partner. Condom use among MSM in Swaziland may increase with improved partner communication, provider sensitization to encourage sexual disclosure, and the promotion of safer sex norms within MSM communities. These approaches, in combination with existing and emerging evidence of informed and human rights affirming prevention and HIV treatment approaches may reduce the incidence of HIV among MSM in Swaziland and all those in their sexual networks.

Work-related injuries to animal care workers, Washington 2007-2011.

BACKGROUND: For workers engaged in animal care, workplace hazards are common and may outnumber those experienced by human healthcare workers. METHODS: We used accepted Washington State workers' compensation claims for the period from January 1, 2007 and December 31, 2011 to compare injury rates and types of injuries across animal care occupations. RESULTS: Work-related injuries frequently affect veterinary support staff and those working in pet stores, shelters, grooming facilities and kennels. Animal-related injuries were the most commonly reported injury type experienced by all groups, though the animal source of injury appears to differ by work setting. CONCLUSIONS: Workplace related injuries among animal care workers are common and most often caused by physical insults resulting from worker-animal interaction.

Contrasting patterns of care for musculoskeletal disorders and injuries of the upper extremity and knee through workers' compensation and private health care insurance among union carpenters in Washington State, 1989 to 2008.

BACKGROUND: Musculoskeletal symptoms and disorders (MSDIs) are common reasons for visits to medical providers in the general population and they are common work-related complaints. Prior reports raise concerns as to whether declines in workers' compensation (WC) rates represent true improvement in occupational health and safety or shifting of care to other payment systems. METHODS: By linking administrative records, we compared patterns of WC claims and private health care utilization for disorders of the upper extremity (UE) and knee among a large cohort of union carpenters over a 20-year period. RESULTS: As WC claim rates declined, private health care utilization increased. The increase was muted somewhat but sustained when adjusting for other patterns of health care utilization. CONCLUSIONS: Findings suggest the decline of WC claim rates do not solely represent improved occupational safety in this population, but also a considerable shifting of care to their private insurance coverage over time.

Workers' compensation claims for musculoskeletal disorders and injuries of the upper extremity and knee among union carpenters in Washington State, 1989-2008.

BACKGROUND: Numerous aspects of construction place workers at risk of musculoskeletal disorders and injuries (MSDIs). Work organization and the nature of MSDIs create surveillance challenges. METHODS: By linking union records with workers' compensation claims, we examined 20-year patterns of MSDIs involving the upper extremity (UE) and the knee among a large carpenter cohort. RESULTS: MSDIs were common and accounted for a disproportionate share of paid lost work time (PLT) claims; UE MSDIs were three times more common than those of the knee. Rates declined markedly over time and were most pronounced for MSDIs of the knee with PLT. Patterns of risk varied by extremity, as well as by age, gender, union tenure, and predominant work. Carpenters in drywall installation accounted for the greatest public health burden. CONCLUSIONS: A combination of factors likely account for the patterns observed over time and across worker characteristics. Drywall installers are an intervention priority.

Stigma, sexual health, and human rights among women who have sex with women in Lesotho.

In recent years, gender and sexual minorities have become increasingly visible across sub-Saharan Africa, marking both the progression and violation of their human rights. Using data from a study with sexual minorities in Lesotho, this analysis leveraged the social ecological model to examine relationships between stigma, human rights, and sexual health among women who have sex with women in Lesotho. A community-based participatory approach was used for the mixed-method, cross-sectional study. A total of 250 women who have sex with women completed a structured questionnaire, of which 21 participated in a total of three focus group discussions. Stigma was common within and outside the health sector. Stigma and human rights abuses were associated with increased risk for HIV and STIs. Interventions to address stigma at the structural, community, and interpersonal levels are essential to ensuring sexual health and rights for women who have sex with women in Lesotho.

Reconceptualizing the HIV epidemiology and prevention needs of Female Sex Workers (FSW) in Swaziland.

BACKGROUND: HIV is hyperendemic in Swaziland with a prevalence of over 25% among those between the ages of 15 and 49 years old. The HIV response in Swaziland has traditionally focused on decreasing HIV acquisition and transmission risks in the general population through interventions such as male circumcision, increasing treatment uptake and adherence, and risk-reduction counseling. There is emerging data from Southern Africa that key populations such as female sex workers (FSW) carry a disproportionate burden of HIV even in generalized epidemics such as Swaziland. The burden of HIV and prevention needs among FSW remains unstudied in Swaziland. METHODS: A respondent-driven-sampling survey was completed between August-October, 2011 of 328 FSW in Swaziland. Each participant completed a structured survey instrument and biological HIV and syphilis testing according to Swazi Guidelines. RESULTS: Unadjusted HIV prevalence was 70.3% (n = 223/317) among a sample of women predominantly from Swaziland (95.2%, n = 300/316) with a mean age of 21(median 25) which was significantly higher than the general population of women. Approximately one-half of the FSW(53.4%, n = 167/313) had received HIV prevention information related to sex work in the previous year, and about one-in-ten had been part of a previous research project(n = 38/313). Rape was common with nearly 40% (n = 123/314) reporting at least one rape; 17.4% (n = 23/314)reported being raped 6 or more times. Reporting blackmail (34.8%, n = 113/314) and torture(53.2%, n = 173/314) was prevalent. CONCLUSIONS: While Swaziland has a highly generalized HIV epidemic, reconceptualizing the needs of key populations such as FSW suggests that these women represent a distinct population with specific vulnerabilities and a high burden of HIV compared to other women. These women are understudied and underserved resulting in a limited characterization of their HIV prevention, treatment, and care needs and only sparse specific and competent programming. FSW are an important population for further investigation and rapid scale-up of combination HIV prevention including biomedical, behavioral, and structural interventions.