Development of a HIV Prevention Program to Promote Condom Use Among Iranian Female Sex Workers: Application of An Intervention Mapping Approach.

We used an Intervention Mapping Approach (IMA) to derive multi-level HIV prevention strategies aiming to develop an HIV prevention intervention program among female sex workers (FSWs). We also aimed at pilot testing the effects of the IMA-based "HIV Prevention and Awareness Program (HIV-PAP)" on safe sex behaviors and its determinants among FSWs in Tabriz, Iran. To develop HIV-PAP, we conducted the six-step process of IMA. At Step 1, in a cross-sectional study, 140 FSWs were face-to-face interviewed. At Step 2, the program matrix was provided based on the importance and variability for identifying priority factors. At Steps 3 and 4, the methods and strategies for behavioral change were selected, and the HIV-PAP program components and materials were developed. At Steps 5 and 6, evaluation (as a pilot testing with Static-Group Comparison design) was conducted applying a pre-experimental study, in which 30 FSWs were assigned to intervention (n = 15) and control (n = 15) groups. The intervention group participated in a two-month long program, and one month later, the initial questionnaires were completed by both groups. The respondents (M age: 33.4 years, SD: 9.7) acquired low score (less than 50%) in negotiating for condom use (49.8%) only, and moderate scores (50-65%) in perceived social support (61.6%) and knowledge (60.5%). Adjusted for other variables, the factors (R2 = 32.0%) associated with safe sex behaviors among FSWs were predisposing factors [self-efficacy (ß = 0.331), perceived norms (ß = 0.945), and perceived barriers (ß = 0.258)], condom use negotiation (ß = 1.386), and environmental factors (ß = 0.333). Our IM-based framework had an adequate fit index (χ2 = 130.8, CFI = 0.78). Looking for inter-group comparison after intervention, we found significant mean difference (MD) for knowledge (MD: 2.18; 95% Confidence Interval (CI) - .38 to 4.74, p < 0.05), self-efficacy to use condom (MD: 6.71; 95% CI - 1.85 to 9.29, p < 0.05), perceived risk (MD: 2.03; 95% CI 0.58, to 3.49, p < 0.05), perceived social support (MD: 4.64; 95% CI - 5.37 to 11.31, p < 0.01), and safe sexual behaviors (MD: 7.75; 95% CI - 4.19 to 9.71, p < 0.05). The HIV-PAP showed effectiveness in promoting safe sexual behaviors and their determinants among FSWs. Healthcare providers should better understand the determinants of safe sexual behaviors among FSWs in the settings with legal prohibitions for sex work. In such communities, they should try to either develop or adapt such stage-specific interventions, within which promoting the above-mentioned factors is the core priorities of the program.

Costing of a Combination Intervention (Kyaterekera) Addressing Sexual Risk-Taking Behaviors among Vulnerable Women in Southern Uganda.

In Uganda, women engaged in sex work (WESW) are a marginalized population at the intersection of multiple vulnerabilities. The Kyaterekera intervention is targeted at WESW in Rakai and the greater Masaka regions in Uganda and combines a traditional HIV risk-reduction approach with a savings-led economic empowerment intervention and financial literacy training. We estimated the economic costs of the Kyaterekera intervention from a program provider perspective using a prospective activity-based micro-costing method. All program activities and resource uses were measured and valued across the control arm receiving a traditional HIV risk-reduction intervention and the treatment arm receiving a matched individual development savings account and financial literacy training on top of HIV risk reduction. The total per-participant cost by arm was adjusted for inflation and discounted at an annual rate of 3% and presented in 2019 US dollars. The total per-participant costs of the control and intervention arms were estimated at $323 and $1,435, respectively, using the per-protocol sample. When calculated based on the intent-to-treat sample, the per-participant costs were reduced to $183 and $588, respectively. The key cost drivers were the capital invested in individual development accounts and personnel and transportation costs for program operations, linked to WESW's higher mobility and the dispersed pattern of hot spot locations. The findings provide evidence of the economic costs of implementing a targeted intervention for this marginalized population in resource-constrained settings and shed light on the scale of potential investment needed to better achieve the health equity goal of HIV prevention strategies.

The impact of an economic empowerment intervention on intimate partner violence among women engaged in sex work in southern Uganda: A cluster randomized control trial.

Women engaged in sex work (WESW) are at heightened risk of experiencing intimate partner violence (IPV) compared to women in the general population. This study examines the impact of an economic empowerment intervention on IPV among WESW in Southern Uganda. We used data from 542 WESW in Southern Uganda recruited from 19 HIV hotspots between June 2019 and March 2020. Eligible participants were 18+ years old, engaged in sex work-defined as vaginal or anal sexual intercourse in exchange for money, alcohol, or other goods, reported at least one episode of unprotected sexual intercourse in the past 30 days with a paying, casual, or regular sexual partner (spouse, main partner). We analyzed data collected at baseline, 6, and 12months of follow up. To examine the impact of the intervention on IPV, separate mixed-effects logistic regression models were run for each type of IPV (physical, emotional, and sexual) as experienced by participants in the last 90 days. Results show that the intervention was efficacious in reducing emotional and physical IPV as evidenced by a statistically significant intervention main effect for emotional IPV, χ2(1) = 5.96, p = 0.015, and a significant intervention-by-time interaction effect for physical IPV, χ2(2) = 13.19, p < 0.001. To qualify the intervention impact on physical IPV, pairwise comparisons showed that participants who received the intervention had significantly lower levels of physical IPV compared to those in the control group at six months (contrasts = -0.12 (95% CI: -0.22, -0.02), p = 0.011). The intervention, time, and intervention-by-time main effects for sexual IPV were not statistically significant. Our findings suggest economic empowerment interventions as viable strategies for reducing emotional IPV among WESW. However, it is also essential to understand the role of interventions in addressing other forms of IPV especially for key populations at high risk of violence, HIV, and STI. The study was registered at ClinicalTrials.gov, ID: NCT03583541.

Sexual Health Needs Among Men Who Engage in Transactional Sex with Men in the UK.

Men who engage in transactional sex with men (MTSM) are a high-risk population for HIV and other sexually transmitted infections. Epidemiological data have so far included them in the broad category of men who have sex with men (MSM), while research on transactional sex typically focused on female sex workers. The internet has substantially changed sex work practices and earlier findings concerning the sexual health needs of MTSM may no longer be applicable. We analyzed quantitative data from MSM based in the UK (n = 11629) taking part in the European MSM Internet Survey (EMIS-2017). Compared to non-MTSM, MTSM (n = 230; 2%) were younger, more likely to self-identify as an ethnic minority, be single, have lower education levels, struggle financially, and-controlling for age-more likely to be living with diagnosed HIV. Commonly unmet needs among all MSM were a lack of confidence in accessing HIV post-exposure prophylaxis, uncertainty about HIV status, and ignorance of where to access hepatitis vaccinations. Compared with other MSM, MTSM were notably less satisfied with the safety of their sexual practices, less confident in their ability to maintain sexual boundaries, and more likely to engage in risk because of absent precautionary resources. Given their greater opportunity for sexual risk, as well as fewer resources for negotiating safety, our findings suggest that services should prioritize MTSM in HIV prevention and sexual health promotion, including assertiveness and social skills training, in addition to knowledge-based education.

Evaluation of health status of transgender sex workers in Turkey: A qualitative study.

OBJECTIVE: Sex workers can be disadvantaged in terms of overall health due to challenging living and working conditions. This research aimed to evaluate the health status and experiences related to sexually transmitted infections (STDs) of unregistered transgender sex workers in Turkey. DESIGN: It employed a phenomenological qualitative research design. SITE: Data were collected in Istanbul between March 2021 and November 2021. PARTICIPANTS: Data were collected through in-depth interviews involving 24 people (19 sex workers and 5 physicians). METHODS: Key statements were listed during data analysis, and clusters of meanings were formed based on these statements. The participants' statements were used for contextual and structural descriptions. RESULTS: Sex workers suffer from chronic illnesses such as asthma, chronic obstructive pulmonary disease (COPD), diabetes, allergic diseases, and neurological disorders. Among the health issues affecting them, the most notable ones are STDs, psychological problems, and the risk of suicide. Sex workers also face a dilemma between choosing public hospitals and private hospitals. Majority of sex workers undergo regular testing for STDs, with the frequency varying from person to person. Reasons for not undergoing regular testing include lack of social security coverage, financial constraints, lack of information, and feeling undervalued. Some individuals are being subjected to mandatory testing. CONCLUSIONS: It is recommended that sex workers who seek and request healthcare services should be provided with detailed information and education, particularly regarding psychological problems and STDs.

Sexual and Reproductive Health Service Needs Associated with Underage Initiation of Selling Sex among Adult Female Sex Workers in Guinea-Bissau.

OBJECTIVE: To assess the prevalence and predictors of underage initiation of selling sex among female sex workers (FSW) in Guinea-Bissau. METHODS: 505 adult FSW recruited using respondent-driven sampling were surveyed in 2017. Multivariable logistic regression was used to identify demographic, behavioral, and psychosocial characteristics associated with initiation of selling sex while underage (<18 years). RESULTS: A total of 26.3% (133/505) of FSW started selling sex before age 18. Underage initiation of selling sex was associated with experiencing forced sex before age 18 (adjusted odds ratio (aOR): 6.74; 95% confidence interval (CI): 2.05-22.13), and never being tested for HIV (aOR: 0.43; 95% CI: 0.20-0.91). Despite having lower odds of wanting to have children or more children (aOR: 0.31; 95% CI: 0.17-0.56), FSW who started selling sex while underage had lower odds of using highly effective contraception such as implants (aOR: 0.43; 95% CI: 0.24-0.77). Among those who were ever pregnant, a lower percentage of FSW who started selling sex while underage accessed antenatal care (56.6% vs. 74.7%, p = 0.008). CONCLUSIONS: These data suggest that early initiation of selling sex among adult FSW in Guinea-Bissau is common. Social services for youth and integrated HIV and reproductive health services are critical to address the persisting sexual and reproductive health needs of FSW who started selling sex while underage.

Mental Health and Protective Factors for Transgender and Gender-Diverse Youths Who Trade Sex: A Minnesota Statewide School-Based Study, 2019.

Objectives. To describe the prevalence of sex trading by gender and by associations with mental health concerns and protective factors. Methods. We used data from 9th and 11th graders who completed the 2019 Minnesota Student Survey. The analytic sample (n = 67 806) included transgender and gender-diverse (TGD) youths and cisgender youths who reported trading sex. Data on 7 mental health measures and 4 school-related and health care-related protective factors were collected. Results. The prevalence of sex trading (5.9%) was 5 times higher among TGD students than cisgender students (1.2%). In addition, the prevalence of all mental health concerns was high among TGD students who traded sex (e.g., 75.9% reported a lifetime suicide attempt, as compared with 45.9% of cisgender students who traded sex). Fewer statistical differences were found across protective factors. When TGD students who traded sex were compared according to sex assigned at birth, no statistically significant differences were found. Conclusions. Our findings support strong calls for increased competence regarding gender and sex trading or exploitation in clinical and school-based settings to decrease health disparities among TGD youths. Public Health Implications. In this study, we have presented unique prevalence estimates of mental health disparities among TGD students in the United States who trade sex. Our results indicate that TGD students who trade sex are at risk for mental health symptoms and that sensitivity to both gender and sex trading or exploitation will be critical to meeting the needs of this group in clinical as well as school-based settings.

Formative assessment to identify perceived benefits and barriers of HIV oral self-testing among female sex workers, service providers, outreach workers, and peer educators to inform scale-up in Kenya.

In Kenya, HIV prevalence estimates among female sex workers (FSWs) are almost five times higher than among women in the general population. However, only 68% of infected FSWs are aware of their HIV-positive status. We aimed to identify perceived benefits, opportunities, and barriers of HIV self-testing (HIVST) in improving testing coverage among FSWs. Twenty focus group discussions were conducted with 77 service providers, 42 peer educators (PEs) and outreach workers, and 37 FSWs attending drop-in centers (DiCEs) in four regions of Kenya. An additional 8 FSWs with HIV-negative or unknown status-completed in-depth interviews. Data were analyzed thematically. Acceptability of HIVST was high, with cited benefits including confidentiality, convenience, and ease of use. Barriers included absence of counseling, potential for inaccurate results, fear of partner reaction, possible misuse, and fear that HIVST could lead to further stigmatization. PEs and DiCEs were the preferred models for distributing HIVST kits. FSWs wanted kits made available free or at a nominal cost (100 Kenya Shillings or ∼USD 1). Linkage to confirmatory testing, the efficiency of distributing HIVST kits using peers and DiCEs, and the types and content of effective HIVST messaging require further research.

The Impact of the Coronavirus Disease (COVID-19) on the Health and Social Needs of Sex Workers in Singapore.

We evaluated the impact of the coronavirus disease (COVID-19) on the sex work industry and assessed how it has impacted the health and social conditions of sex workers in Singapore. We conducted a sequential exploratory mixed methods study amidst the COVID-19 pandemic from April to October 2020, including in-depth interviews with 24 stakeholders from the sex work industry and surveyor-administered structured surveys with 171 sex workers. COVID-19 had a substantial impact on sex workers' income. The illegality of sex work, stigma, and the lack of work documentation were cited as exclusionary factors for access to alternative jobs or government relief. Sex workers had experienced an increase in food insecurity (57.3%), housing insecurity (32.8%), and sexual compromise (8.2%), as well as a decrease in access to medical services (16.4%). Being transgender female was positively associated with increased food insecurity (aPR = 1.23, 95% CI [1.08, 1.41]), housing insecurity (aPR = 1.28, 95% CI [1.03, 1.60]), and decreased access to medical services (aPR = 1.74, 95% CI [1.23, 2.46]); being a venue-based sex worker was positively associated with increased food insecurity (aPR = 1.46, 95% CI [1.00, 2.13]), and being a non-Singaporean citizen or permanent resident was positively associated with increased housing insecurity (aPR = 2.59, 95% CI [1.73, 3.85]). Our findings suggest that COVID-19 has led to a loss of income for sex workers, greater food and housing insecurity, increased sexual compromise, and reduced access to medical services for sex workers. A lack of access to government relief among sex workers exacerbated such conditions. Efforts to address such population health inequities should be implemented.

Access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: Coverage, barriers and facilitators.

The provision of comprehensive prevention services is vital for reducing the high burden of HIV amongst Ukrainian female sex workers (FSWs). To identify barriers and facilitators that influence access to HIV prevention amongst this population between 2009 and 2017, we developed a literature-informed conceptual framework and conducted a document analysis to identify the components of the Ukrainian prevention package (PP). Using the Integrated Bio Behavioural Surveillance Surveys, we then conducted descriptive analyses to explore PP coverage from 2009 to 2017 and the influence of factors, identified by our conceptual framework. After increasing over four years, a drop in PP coverage was observed from 2013 onwards. Being a client of a non-governmental organisation, street and highway solicitation, non-condom use, and knowledge of HIV may influence access to HIV prevention in the Ukrainian context. Future interventions should consider barriers and facilitators to HIV prevention and the multiple structural levels on which they operate.

Early Assessment of Integrated Knowledge Translation Efforts to Mobilize Sex Workers in Their Communities.

Researchers have recently increased their efforts to find more effective strategies to reduce the gap between the production of academic knowledge and its uptake in policy and practice. We focus attention on sex workers in Canada who have limited access to societal resources and are hampered by punitive laws prohibiting their work. The initial aim of our study was to work with sex worker organizations and allied agencies to develop a training program for sex workers to help them understand Canada's most recent criminal justice approach to adult sex commerce. What has emerged from our integrated knowledge translation process during the first year of the study's operation has been a change to a broader focus on mobilizing sex workers around their occupational and social rights. In this paper, we first give an overview of recent changes in Canada's prostitution laws and then report qualitative findings from interviews with members of our partner organizations. Interviewees appreciated the change in research direction and the emergent collaborative process among themselves and the authors, but also noted challenges regarding shifting research timelines, balancing power between themselves and the academic researchers, and reaching consensus on research plans among community partners themselves. We discuss the findings in relation to successful knowledge translation strategies that aim to ensure the research questions we ask, and the empirical processes we engage in, are advantageous to those we aim to benefit.

Myths, misconceptions, othering and stigmatizing responses to Covid-19 in South Africa: A rapid qualitative assessment.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is a new strain of virus in the Coronavirus family that has not been previously identified. Since SARS-CoV-2 is a new virus, everyone is at risk of catching the Coronavirus disease 2019 (Covid-19). No one has immunity to the virus. Despite this, misconceptions about specific groups of people who are immune to Covid-19 emerged with the onset of the pandemic. This paper explores South African communities' misconceptions about who is most vulnerable to Covid-19. A rapid qualitative assessment was conducted remotely in Gauteng, KwaZulu-Natal and the Western Cape provinces of South Africa. Recruitment of study participants took place through established relationships with civil society organizations and contacts made by researchers. In total, 60 key informant interviews and one focus group discussion was conducted. Atlas.ti.8 Windows was used to facilitate qualitative data analysis. The qualitative data was coded, and thematic analysis used to identify themes. The results show a high level of awareness and knowledge of the transmission and prevention of SARS-CoV-2. Qualitative data revealed that there is awareness of elderly people and those with immunocompromised conditions being more vulnerable to catching Covid-19. However, misconceptions of being protected against the virus or having low or no risk were also evident in the data. We found that false information circulated on social media not only instigated confusion, fear and panic, but also contributed to the construction of misconceptions, othering and stigmatizing responses to Covid-19. The study findings bring attention to the importance of developing communication materials adapted to specific communities to help reduce misconceptions, othering and stigmatization around Covid-19.

Helping women transition out of sex work: study protocol of a mixed-methods process and outcome evaluation of a sex work exiting program.

BACKGROUND: For women who want to, exiting sex work can be challenging. Numerous programs strive to help women wanting to exit sex work and secure alternative sources of income by providing targeted support at key moments during the transition, yet few of those initiatives are rigorously evaluated. In 2017 "Exit Doors Here", a 9-month sex work exiting program based on the critical time intervention (CTI) approach, was developed to provide wrap-around support services (e.g., health, addiction, housing, education, and employment supports) to women wishing to transition towards exiting sex work. METHODS: We present the design of an evaluation study of Exit Doors Here which combines quantitative and qualitative methods to assess participant recruitment and retention into the program, program fidelity, and relationships with service providers (process evaluation), as well as progress made by participants in terms of strengthening their social support networks and moving closer to achieving their housing, pre-employment (i.e., educational, training and volunteering), and income-related goals, as well as their involvement in sex work (outcome evaluation). Each year for 4 years, between 25 and 30 Exit Doors Here clients will be invited to complete an interviewer-administered questionnaire at the beginning and after completing the program, and to share data from their CTI charts and related documentation. Once a year, program staff and peer workers will be interviewed, and service providers will be surveyed. DISCUSSION: Conducting a formative (process) evaluation will allow us to inform program implementation and improve program delivery early on for maximum benefit. The summative (outcome) evaluation will provide much needed evidence on the effectiveness of CTI in supporting a traditionally underserved population to achieve the housing, pre-employment and income-related goals they value, and their progress towards reducing their involvement in, and eventually exiting, sex work.

Intersectional stigmas and HIV-related outcomes among a cohort of key populations enrolled in stigma mitigation interventions in Senegal.

OBJECTIVES: The current study aims to assess longitudinal differences in stigma and HIV outcomes among key populations at risk for and living with HIV. DESIGN: Key populations enrolled into two parallel prospective cohorts; one for female sex workers and one for sexual and gender minorities (SGMs). Participants were recruited from three urban areas in Senegal; were followed for 24 months; and had the option to participate in an integrated stigma mitigation intervention. METHODS: Participants included individuals both at risk for and living with HIV. Sociobehavioral questionnaires and biological HIV testing were administered every 3-4 months. Longitudinal analyses used nonparametric Chi-squared test for trends and multivariable logistic regression with generalized estimating equations. RESULTS: 183 SGM and 192 sex workers were enrolled. Among SGM participants, 39.9% were living with HIV at baseline and incidence over 24 months was 3.21/100 person-years. Among sex workers, 36.6% were living with HIV at baseline and incidence was 1.32/100 person-years. Among SGM, perceived healthcare stigma (P < 0.001), anticipated healthcare stigma (P < 0.001), and perceived friend stigma (P = 0.047) reduced, but differed by HIV status for perceived [adjusted odds ratio (aOR): 3.51; 95% confidence interval (CI): 1.75, 7.06] and anticipated healthcare stigmas (aOR: 2.85; 95% CI: 1.06-7.67). Among sex workers perceived healthcare stigma (P = 0.043) and perceived friend stigma (P = 0.006) reduced. Viral suppression increased among SGM (P = 0.028) and was associated with perceived (aOR: 2.87; 95% CI: 1.39-5.55) and enacted healthcare stigma (aOR: 0.42; 95% CI: 0.18-0.99). CONCLUSION: Overall, there were decreases in stigmas observed but clear differences in stigma patterns by HIV status. These data highlight the need to consider specific strategies to address multiple intersecting stigmas as a means of improving HIV-related prevention and treatment outcomes among key populations with diverse identities.

Self-reported access to health care, communicable diseases, violence and perception of legal status among online transgender identifying sex workers in the UK.

OBJECTIVES: Transgender-identifying sex workers (TGISWs) are among the most vulnerable groups but are rarely the focus of health research. Here we evaluated perceived barriers to healthcare access, risky sexual behaviours and exposure to violence in the United Kingdom (UK), based on a survey of all workers on BirchPlace, the main transgender sex commerce website in the UK. STUDY DESIGN: The study design used in the study is an opt-in text-message 12-item questionnaire. METHODS: Telephone contacts were harvested from BirchPlace's website (n = 592 unique and active numbers). The questionnaire was distributed with Qualtrics software, resulting in 53 responses. RESULTS: Our survey revealed significant reported barriers to healthcare access, exposure to risky sexual behaviours and to physical violence. Many transgender sex workers reportedly did not receive a sexual screening, and 28% engaged in condomless penetrative sex within the preceding six months, and 68% engaged in condomless oral sex. 17% responded that they felt unable to access health care they believed medically necessary. Half of the participants suggested their quality of life would be improved by law reform. CONCLUSIONS: TGISWs report experiencing a high level of risky sexual behaviour, physical violence and inadequate healthcare access. Despite a National Health System, additional outreach may be needed to ensure access to services by this population.

Sexual and reproductive health among adolescent girls and young women in Mombasa, Kenya.

This secondary data analysis of a cross-sectional survey conducted in Mombasa, Kenya characterises sexual and reproductive health (SRH) indicators among adolescent girls and young women (AGYW) engaged in casual and transactional sexual relationships as well as sex work. It describes the association between awareness of local HIV programmes and SRH services uptake for AGYW engaged in sex work. Thirty-eight percent of the participants reported a history of pregnancy. Among participants not trying to get pregnant, 27% stated that they were not currently using any form of contraception. Of the participants who had an abortion, 59% were completed under unsafe conditions. For AGYW engaged in sex work, awareness of local HIV prevention programmes was associated with increased STI testing within the last year (29%) as well as at least one HIV test (99%) compared to those who were not aware of local programming (18% and 92%, respectively); however, only 26% of participants engaged in sex work had heard of local HIV prevention programmes. There were no associations between awareness of local HIV programming and rates of dual contraception use, safe abortion, most recent birth attended by a skilled health professional or testing for HIV during pregnancy. Our study found high need for SRH services, particularly, access to contraception and safe abortion. Continued efforts are required to improve access to the full spectrum of SRH interventions, including family planning services and access to safe abortion in addition to HIV prevention to promote health equity.

Drug use, sexual risk, and structural vulnerability among female sex workers in two urban centers of the Dominican Republic: The EPIC study.

BACKGROUND: Evidence in different countries suggest an association between sex work and drug use. In the Dominican Republic an estimated 60,000-100,000 women work in the sex industry. However, little is known about their drug use behaviors. OBJECTIVE: To characterize the burden of drug use and examine correlates of these behaviors among female sex workers in the Dominican Republic. METHODS: Data for this analysis comes from a cross-sectional study among key populations at risk for HIV. A community sample of female sex workers (N = 389) was recruited using passive and active recruitment strategies. Participants completed a behavioral survey between 2015 and 2016. Logistic regression models were constructed to examine predictors of drug use. RESULTS: Protective factors against marijuana and crack or cocaine use included being heterosexual, having a higher level of education, regular employment, and fewer male sexual partners. Increased odds of crack or cocaine use were associated with incarceration, having slept in a place not meant for human habitation in the last six months, and having ever lived in a batey (a community around a sugar mill where workers and their families live). Participants that used marijuana were generally younger, while those that used crack or cocaine were older. CONCLUSIONS: Our findings highlight characteristics of the social and economic environment that require further research to optimize prevention and care strategies for this population. Public health interventions are needed that address drug use, sexual risk-taking, and helping female sex workers and their families achieve a healthy life.

Associations Between Economic Factors and Condom Use Behavior Among Female Sex Workers in Dakar and Mbour, Senegal.

Condom use remains a mainstay of HIV prevention programs around the world. However, data characterizing economic determinants of condom use among female sex workers (FSW) are limited, including in Senegal. We recruited 718 FSWs via respondent-driven sampling. Bivariate and multivariable regressions were conducted to assess the associations between economic variables and condom use at last sex. Paying rent (aRR: 1.07, 95%CI 1.01-1.13) was positively associated with condom use at last sex with new clients. No statistically significant associations were found between condom use and financial responsibility for dependent children, having additional source of income, sharing sex work earnings, or the ability to borrow from other FSWs, regardless of sexual partner types. The relationship between economic marginalization and consistent condom use among sex workers is complex reinforcing the need for behavioral economic research and prevention to be integrated into HIV prevention and treatment research and programs.

Structural barriers to condom access in a community-based cohort of sex workers in Vancouver, Canada: influence of policing, violence and end-demand criminalisation.

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.