Syndemic Conditions and Their Association with HIV/STI Sexual Risk Behaviors Among Transgender Women and Cisgender Men Sex Workers in Catalonia: The SexCohort Project.

BACKGROUND: Transgender women and cisgender men sex workers are vulnerable to HIV and sexually transmitted infections (STIs). This study aimed to explore in depth the prevalence of syndemic conditions and their association with the sexual risk behaviors for HIV/STI acquisition in cis men and trans women sex workers in Barcelona (Catalonia, Spain). METHOD: We conducted a study between 2014 and 2018 to determine whether syndemic conditions (frequent alcohol consumption and polydrug use (> 2) during sex with clients; experience of violence; and lack of healthcare access) are associated with HIV/STI sexual risk behaviors. A "syndemic index" was calculated based on the cumulative number of syndemic conditions (0 to 4). RESULTS: In the last year (2018), 78.8% of cisgender men and 68.1% of transgender women reported at least one syndemic condition. The most prevalent syndemic factor in both cisgender men and transgender women was violence (38.8% and 43.6% respectively). In multivariable analysis, an association was found between condomless anal sex and violence (aOR = 1.81), and frequent alcohol consumption and violence with reporting > 10 clients/week (aOR = 2.73 and 1.88, respectively). The higher the number of syndemic factors, the greater probability of having > 10 clients/week and reporting condomless anal sex with clients. CONCLUSION: Psychosocial conditions have a syndemic effect on risky sexual behaviors highlighting the need for a more holistic approach to HIV/STI prevention targeting these populations.

Impact of an intensive facility-community case management intervention on 6-month HIV outcomes among select key and priority populations in Uganda.

INTRODUCTION: Key and priority populations (with risk behaviours and health inequities) are disproportionately affected by HIV in Uganda. We evaluated the impact of an intensive case management intervention on HIV treatment outcomes in Kalangala District, predominantly inhabited by fisher folk and female sex workers. METHODS: This quasi-experimental pre-post intervention evaluation included antiretroviral therapy naïve adults aged ≥ 18 years from six health facilities in the pre-intervention (Jan 1, 2017-December 31, 2017) and intervention phase (June 13, 2018-June 30, 2019). The primary outcomes were 6-month retention and viral suppression (VS) before and after implementation of the intervention involving facility and community case managers who supported participants through at least the first three months of ART. We used descriptive statistics to compared the characteristics, overall outcomes (i.e., retention, lost to follow up, died), and VS of participants by phase, and used mixed-effects logistic regression models to determine factors associated with 6-month retention in care. Marginal (averaging over facilities) probabilities of retention were computed from the final multivariable model. RESULTS: We enrolled 606 and 405 participants in the pre-intervention and intervention phases respectively. Approximately 75% of participants were aged 25-44 years, with similar age and gender distributions among phases. Approximately 46% of participants in the intervention were fisher folk and 9% were female sex workers. The adjusted probability of 6-month retention was higher in the intervention phase, 0.83 (95% CI: 0.77-0.90) versus pre-intervention phase, 0.73 (95% CI: 0.69-0.77, p = 0.03). The retention probability increased from 0.59 (0.49-0.68) to 0.73 (0.59-0.86), p = 0.03 among participants aged 18-24 years, and from 0.75 (0.71-0.78) to 0.85 (0.78-0.91), p = 0.03 among participants aged ≥ 25 years. VS (< 1,000 copies/mL) was approximately 87% in both phases. CONCLUSIONS: After implementation of the case management intervention, we observed significant improvement in 6-month retention in all age groups of a highly mobile population of predominantly fisher folk.

Extensively drug-resistant (XDR) Neisseria gonorrhoeae causing possible gonorrhoea treatment failure with ceftriaxone plus azithromycin in Austria, April 2022.

We describe a gonorrhoea case with ceftriaxone plus high-level azithromycin resistance. In April 2022, an Austrian heterosexual male was diagnosed with gonorrhoea after sexual intercourse with a female sex worker in Cambodia. Recommended treatment with ceftriaxone (1 g) plus azithromycin (1.5 g) possibly failed. Worryingly, this is the second strain in an Asian Neisseria gonorrhoeae genomic sublineage including high-level azithromycin-resistant strains that developed ceftriaxone resistance by acquisition of mosaic penA-60.001. Enhanced resistance surveillance and actions are imperative to prevent spread.

Beaten but not down! Exploring resilience among female sex workers (FSWs) in Nairobi, Kenya.

BACKGROUND: In Kenya sex work is illegal and those engaged in the trade are stigmatized and marginalized. We explored how female sex workers in Nairobi, Kenya, utilize different resources to navigate the negative consequences of the work they do. METHODS: Qualitative data were collected in October 2019 from 40 FSWs who were randomly sampled from 1003 women enrolled in the Maisha Fiti study, a 3-year longitudinal mixed-methods study exploring the relationship between HIV risk and violence and mental health. All interviews were audio-recorded, transcribed and translated. Data were thematically coded and analyzed using Nvivo 12. RESULTS: Participants' age range was 18-45 years. Before entry into sex work, all but one had at least one child. Providing for the children was expressed as the main reason the women joined sex work. All the women grew up in adverse circumstances such as poor financial backgrounds and some reported sexual and physical abuse as children. They also continued to experience adversity in their adulthood including intimate partner violence as well as violence at the workplace. All the participants were noted to have utilised the resources they have to build resilience and cope with these adversities while remaining hopeful for the future. Motherhood was mentioned by most as the reason they have remained resilient. Coming together in groups and engaging with HIV prevention and treatment services were noted as important factors too in building resilience. CONCLUSION: Despite the adverse experiences throughout the lives of FSWs, resilience was a key theme that emerged from this study. A holistic approach is needed in addressing the health needs of female sex workers. Encouraging FSWs to come together and advocating together for their needs is a key resource from which resilience and forbearance can grow. Upstream prevention through strengthening of education systems and supporting girls to stay in school and complete their secondary and/or tertiary education would help them gain training and skills, providing them with options for income generation during their adult lives.

Harmful Alcohol Use and Associated Socio-Structural Factors among Female Sex Workers Initiating HIV Pre-Exposure Prophylaxis in Dar es Salaam, Tanzania.

Harmful alcohol use is an important risk factor for premature mortality and morbidity and associated with increased HIV risk and lower uptake of and adherence to HIV interventions. This study aimed to assess the extent of harmful alcohol use and associated socio-structural vulnerability factors among female sex workers in Dar es Salaam, Tanzania, a key population in the HIV epidemic. Data from a study of female sex workers initiating pre-exposure prophylaxis (PrEP) recruited through respondent driven sampling were used. We assessed harmful alcohol use with the Alcohol Use Disorders Identification Test (AUDIT) defined as having an AUDIT score ≥ 16. Associations between harmful alcohol use and socio-structural factors were assessed using logistic regression with marginal standardization. Of the 470 women recruited, more than one third (37.3%) had a drinking pattern suggestive of harmful alcohol use. Such use was independently associated with sex work-related mobility (aPR: 1.36, 95% CI: 1.11-1.61), arrest/incarceration (aPR: 1.55, 95% CI: 1.27-1.84) and gender-based violence (aPR: 1.31, 95% CI: 1.06-1.56). The high prevalence of harmful alcohol use and the interconnectedness with socio-structural factors indicate a need for a holistic programmatic approach to health for female sex workers. Programming should not solely direct attention to individual behavior but also include strategies aiming to address socio-structural vulnerabilities.

HIV Prevalence and the HIV Treatment Cascade Among Female Sex Workers in Cross-Border Areas in East Africa.

In cross-border areas of East Africa, sexual networks include partnerships across resident, migrant, and mobile populations, and risky behaviors can coincide with fragmented health services given the challenges of cross-border coordination. Among those most at risk are female sex workers (FSWs). We map HIV prevalence among FSWs in 14 cross-border areas, estimate associations between FSW characteristics and HIV and undiagnosed HIV, and estimate progress towards the UNAIDS 90-90-90 targets. The 2016-2017 East Africa Cross-Border Integrated Health Study recruited 4040 women; 786 were classified as FSWs. Overall HIV prevalence among FSWs was 10.8% (95% CI 8.2%, 13.3%), though area-specific estimates varied considerably. Among FSWs living with HIV, 46.1% (95% CI 33.2%, 59.0%) knew their status, 80.6% (95% CI 66.3%, 94.9%) of FSWs who knew their status were on ART, and 84.8% (95% CI 66.1%, 100.0%) of FSWs on ART were virally suppressed. Results indicate a need for expanded HIV testing.

Road to elimination of HCV: Clinical challenges in HCV management.

Since its discovery in 1989, the road to a cure for hepatitis C virus (HCV) has been slow, but most patients can now expect to achieve a sustained virological response (SVR). With direct-acting antiviral (DAA) combination therapies such as glecaprevir/pibrentasvir and velpatasvir/sofosbuvir, 98% of patients successfully eradicate the virus, even if previous treatments failed or if resistance-associated substitutions (RASs) are present. Adverse events are rare or mild, and patients with compensated cirrhosis and other co-morbidities are often eligible for treatment. However, a small number of patients fail to eradicate the virus even after retreatment. The cause of failure is mainly due to emergence of NS5A P32 deletion mutants after initial DAA therapy in genotype 1b patients, although the reason is unknown for some patients. Alternative therapies that do not rely on NS5A inhibitors, such as sofosbuvir plus ribavirin, can be attempted in these patients. While scaled-up treatment efforts present a challenge, another problem is that many carriers are unaware of their infection. Long-term damage to the liver becomes irreversible, and patients who are not diagnosed in time can develop liver cancer or liver failure even after eliminating the virus. The long-term costs of treatment of advanced liver disease in undiagnosed patients relative to the immediate costs of DAA therapy should be considered. As no vaccine is yet available, eventual elimination of the virus requires identifying and treating undiagnosed cases and screening of high-risk populations such as injection drug users and men who have sex with men and female sex workers.

The effect of mindfulness-based stress reduction on resilience of vulnerable women at drop-in centers in the southeast of Iran.

BACKGROUND: Female sex workers and addicted women are among the vulnerable groups who impose high costs on the health system of every society. They are prone to psychological problems such as anxiety, stress, and reduced resilience due to their lifestyles. Since mindfulness-based stress reduction (MBSR) has been applied frequently by many psychotherapists to treat stress and anxiety, the present study investigated the effectiveness of MBSR on resilience of the vulnerable women. METHODS: The statistical population of this quasi-experimental study consisted of all eligible women who referred to the drop-in centers in Kerman in the southeast of Iran. Followed by random sampling, 63 vulnerable women were randomly assigned into the intervention (n = 30) and control (n = 33) groups. The MBSR intervention was conducted for the intervention group in eight 90-min sessions. Demographic information questionnaire and Connor-Davidson resilience scale were administered to collect data prior to and one month after the MBSR intervention. RESULTS: The pre-test resilience score was not significantly different between the intervention (53.40 ± 10.49) and the control (54.5 ± 9.27) groups (t = 0.43, p = 0.66). However, the posttest resilience score in the intervention group (60.66 ± 6.71) was significantly higher than the control group (53.88 ± 7.54) (t = 3.58, P = 0.001). Moreover, a comparison between the pretest and posttest scores revealed a significant decrease in resilience scores of the control group (t = 2.81, p = 0.009). CONCLUSION: Since MBSR intervention increased resilience of the vulnerable women in the intervention group, researchers, managers, counselors, community health nurses, and psychiatric nurses are suggested to implement related interventions to promote the health of women, especially vulnerable ones.

"Feeling Safe, Feeling Seen, Feeling Free": Combating stigma and creating culturally safe care for sex workers in Chicago.

BACKGROUND: Previous studies have established that sex workers experience discrimination and stigma within healthcare settings, limiting their access and receipt of culturally safe care. These barriers impact sex workers' ability and desire to routinely engage with the healthcare system. Community empowerment interventions that are culturally safe offer an effective strategy to improve access to services and health outcomes for sex workers. OBJECTIVES: This project was designed to inform the development of community empowerment interventions for sex workers by understanding their self-management, health promotion, and harm reduction needs. METHODS: In-depth interviews (N = 21) were conducted with sex workers in Chicago. Transcripts of individual interviews were analyzed in Dedoose using rapid content analysis. RESULTS: Participants had a mean age of 32.7 years; 45% identified as White, 20% as Black, 15% as Latinx, and 20% as multiple races; 80% identified as Queer. A total of 52% of participants identified as cisgender women, 33% as transgender or gender fluid, 10% as cisgender men, and 5% declined to answer. Themes of self-management practices, stigmatizing and culturally unsafe experiences with healthcare providers, and the prohibitive cost of healthcare emerged as consistent barriers to routinely accessing healthcare. Despite identifying patient-centered care as a desired healthcare model, many participants did not report receiving care that was respectful or culturally responsive. Themes also included developing strategies to identify sex worker-safe care providers, creating false self-narratives and health histories in order to safely access care, and creating self-care routines that serve as alternatives to primary care. CONCLUSION: Our findings demonstrate how patient-centered care for sex-workers in Chicago might include holistic wellness exercises, accessible pay scales for services, and destigmatizing healthcare praxis. Focus on culturally safe healthcare provision presents needs beyond individualized, or even community-level, interventions. Ongoing provider training and inbuilt, systemic responsivity to patient needs and contexts is crucial to patient-centered care.

Mindfulness, Mental Health and HIV Outcomes Among Female Sex Workers in the Dominican Republic and Tanzania.

We examined the relationship between mindfulness, mental health and HIV outcomes among female sex workers (FSW) from the Dominican Republic (DR) (n = 201) and Tanzania (n = 208) using cross-sectional survey and biologic data. We employed stratified multivariate linear and logistic regression. Depression was associated with lower odds of ART adherence in the DR (AOR 0.25, 95% CI: 0.08-0.78) and of viral suppression in Tanzania (AOR 0.49, 95% CI: 0.24-0.97). In both countries, mindfulness was associated with lower odds of moderate to severe depression (AOR 0.82, 95% CI: 0.76-0.88 for the DR; AOR 0.85, 95% CI: 0.77-0.95 for Tanzania). In the DR, mindfulness was associated with lower odds of anxiety (AOR 0.83, 95% CI: 0.77-0.89), lower HIV stigma (ß = - 0.28 per unit change, 95% CI: - 0.37 to - 0.19) and greater odds of viral suppression (AOR 1.09, 95% CI: 1.02-1.15). Findings demonstrate the potential of tailored mindfulness interventions to improve mental health and HIV outcomes among FSW.

RESUMEN: Examinamos la relación entre la atención plena, la salud mental y los resultados del VIH entre las trabajadoras sexuales (TRSX) de la República Dominicana (RD) (n = 201) y Tanzania (n = 208) utilizando una encuesta transversal y datos biológicos. Empleamos regresión lineal multivariada estratificada y regresión logística. La depresión se asoció con menores probabilidades de adherencia al terapia antiretroviral (TAR) en la República Dominicana (AOR 0.25, IC del 95%: 0.08­0.78) y de supresión viral en Tanzania (AOR 0.49, IC del 95%: 0.24­0.97). En ambos países, la atención plena se asoció con menores probabilidades de depresión moderada a grave (AOR 0.82, IC del 95%: 0.76­0.88 para la República Dominicana; AOR 0.85, IC del 95%: 0.77­0.95 para Tanzania). En la República Dominicana, la atención plena se asoció con menores probabilidades de ansiedad (AOR 0.83, IC del 95%: 0.77­0.89), menor estigma del VIH (ß = − 0.28 por unidad de cambio, IC del 95%: − 0.37 to − 0.19) y mayores probabilidades de supresión viral (AOR 1.09, 95% CI: 1.02­1.15). Los hallazgos demuestran el potencial de las intervenciones de atención plena para mejorar la salud mental y los resultados del VIH entre las TRSX.

Drug Use in Street Sex worKers (DUSSK) study: results of a mixed methods feasibility study of a complex intervention to reduce illicit drug use in drug dependent female sex workers.

OBJECTIVES: The majority of female street-based sex workers (SSWs) are dependent on illicit drugs and sell sex to fund their drug use. They typically face multiple traumatic experiences, starting at a young age, which continue through sex work involvement. Their trauma-related symptoms tend to increase when drug use is reduced, hindering sustained reduction. Providing specialist trauma care to address post-traumatic stress disorder (PTSD) alongside drug treatment may therefore improve treatment outcomes. Aims to (1) evaluate recruitment and retention of participants; (2) examine intervention experiences and acceptability; and (3) explore intervention costs using a mixed methods feasibility study. SETTING: Female SSW charity premises in a large UK inner city. PARTICIPANTS: Females aged 18 years or older, who have sold sex on the street and used heroin and/or crack cocaine at least once a week in the last calendar month. INTERVENTION: Female SSW-only drug treatment groups in a female SSW-only setting delivered by female staff. Targeted PTSD screening then treatment of positive diagnoses with eye movement desensitisation and reprocessing (EMDR) therapy by female staff from a specialist National Health Service trauma service. RESULTS: (1) Of 125 contacts, 11 met inclusion criteria and provided informed consent, 4 reached the intervention final stage, (2) service providers said working in collaboration with other services was valuable, the intervention was worthwhile and had a positive influence on participants. Participants viewed recruitment as acceptable and experienced the intervention positively. The unsettled nature of participant's lives was a key attendance barrier. (3) The total cost of the intervention was £11 710, with staff costs dominating. CONCLUSIONS: Recruitment and retention rates reflected study inclusion criteria targeting women with the most complex needs. Two participants received EMDR demonstrating that the three agencies working together was feasible. Staff heavy costs highlight the importance of supporting participant attendance to minimise per participant costs in a future trial.

HIV Prevalence, Risk Factors for Infection, and Uptake of Prevention, Testing, and Treatment among Female Sex Workers in Namibia.

BACKGROUND: In most settings, Female Sex Workers (FSW) bear a disproportionate burden of Human Immunodeficiency Virus (HIV) disease worldwide. Representative data to inform the development of behavioral and biomedical interventions for FSW in Namibia have not been published. OBJECTIVES: Our objectives were to measure HIV prevalence, identify risk factors for infection, and describe uptake of prevention, testing, and treatment among FSW in Namibia. METHODS: We conducted cross-sectional surveys using Respondent-driven Sampling (RDS) in the Namibian cities of Katima Mulilo, Oshikango, Swakopmund/Walvis Bay, and Windhoek. Participating FSW completed behavioral questionnaires and rapid HIV testing. RESULTS: City-specific ranges of key indicators were: HIV prevalence (31.0-52.3%), reached by prevention programs in the past 12 months (46.9-73.6%), condom use at last sex with commercial (82.1-91.1%) and non-commercial (87.0-94.2%) partners, and tested for HIV within past 12 months or already aware of HIV-positive serostatus (56.9-82.1%). Factors associated with HIV infection varied by site and included: older age, having multiple commercial or non-commercial sex partners, unemployment, being currently out of school, and lower education level. Among HIV-positive FSW, 57.1% were aware of their HIV-positive serostatus and 33.7% were on antiretroviral treatment. DISCUSSION: Our results indicate extremely high HIV prevalence and low levels of case identification and treatment among FSW in Namibia. Our results, which are the first representative community-based estimates among FSW in Namibia, can inform the scale-up of interventions to reduce the risk for HIV acquisition and onward transmission, including treatment as prevention and pre-exposure prophylaxis.

Uptake and retention on HIV pre-exposure prophylaxis among key and priority populations in South-Central Uganda.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) programmes have been initiated in sub-Saharan Africa to prevent HIV acquisition in key populations at increased risk. However, data on PrEP uptake and retention in high-risk African communities are limited. We evaluated PrEP uptake and retention in HIV hyperendemic fishing villages and trading centres in south-central Uganda between April 2018 and March 2019. METHODS: PrEP eligibility was assessed using a national risk screening tool. Programme data were used to evaluate uptake and retention over 12 months. Multivariable modified Poisson regression estimated adjusted prevalence ratios (aPR) and 95% Confidence intervals (CIs) of uptake associated with covariates. We used Kaplan-Meier analysis to estimate retention and multivariable Cox regression to estimate adjusted relative hazards (aRH) and 95% CIs of discontinuation associated with covariates. RESULTS AND DISCUSSION: Of the 2985 HIV-negative individuals screened; 2750 (92.1 %) were eligible; of whom 2,536 (92.2%) accepted PrEP. Male (aPR = 0.91, 95% CI = 0.85 to 0.97) and female (aPR = 0.85, 95% CI = 0.77 to 0.94) fisher folk were less likely to accept compared to HIV-discordant couples. Median retention was 45.4 days for both men and women, whereas retention was higher among women (log rank, p < 0.001) overall. PrEP discontinuation was higher among female sex workers (aRH = 1.42, 95% CI = 1.09 to 1.83) and female fisher folk (aRH = 1.99, 95% CI = 1.46 to 2.72), compared to women in discordant couples. Male fisher folk (aRH = 1.37, 95% CI = 1.07 to 1.76) and male truck drivers (aRH = 1.49, 95% CI = 1.14 to 1.94) were more likely to discontinue compared to men in discordant couples. Women 30 to 34 years tended to have lower discontinuation rates compared to adolescents 15 to 19 years (RH = 0.78 [95% CI = 0.63 to 0.96]). CONCLUSIONS: PrEP uptake was high, but retention was very low especially among those at the highest risk of HIV: fisher folk, sex workers and truck drivers and adolescent girls. Research on reasons for PrEP discontinuation could help optimize retention.

Correlates of trichomoniasis among female sex workers who inject drugs in two Mexico-US border cities.

This paper evaluates correlates of trichomoniasis among female sex workers who inject drugs (FSWIDs) in two Mexico-US border cities. HIV-negative FSWIDs aged 18 years or older were enrolled in a study between 2008 and 2010 in Tijuana and Ciudad Juarez (Cd.), Mexico. All participants underwent a baseline interviewer-administered survey and did a rapid test for trichomoniasis. Using regression to estimate prevalence ratios, we examined sociodemographics, sex work characteristics, sexual health and behavior, substance use, and police and violence exposures as potential correlates of trichomoniasis. Of 584 women (284 in Tijuana, 300 in Cd. Juarez), prevalence of trichomoniasis was 33.6%. Factors associated with trichomoniasis in multivariable analysis were having money stolen by police in the past six months (adjusted prevalence ratio [aPR] =1.448, 95% confidence interval [CI] = 1.152-1.821), recent methamphetamine use (aPR = 1.432, CI = 1.055-1.944), lifetime syphilis infection (aPR = 1.360, CI = 1.061-1.743), ever use of a home remedy to treat vaginal symptoms (aPR = 1.301, CI = 1.027-1.649), and number of regular clients in the past month (aPR = 1.006 per client, CI = 1.004-1.009), while controlling for age and city of interview. Alongside the need for trichomoniasis surveillance and treatment programs, findings indicate that both structural and behavioral factors serve as primary correlates of trichomoniasis among FSWIDs in these cities.

Preferences for Pre-exposure Prophylaxis Service Delivery Among Female Sex Workers in Malawi: A Discrete Choice Experiment.

Female sex workers (FSW) in Malawi have among the highest HIV prevalence estimates worldwide. Daily oral pre-exposure prophylaxis (PrEP) is an effective HIV prevention method, yet preferences for PrEP delivery among FSW are lacking. Eight focus group discussions, a literature review, and cognitive interviews were conducted to identify modifiable PrEP delivery attributes and inform discrete-choice experiment (DCE) development for FSW in Lilongwe. Enrolled FSW received an interviewer-assisted DCE. Data were analyzed using mixed logit regression. Dispensing location was most preferred, followed by the provision of additional services. Women preferred receiving PrEP at family planning clinics or non-governmental organization run drop-in centers. Cervical cancer screening was the most preferred additional service, while pregnancy testing and partner risk reduction counseling were less valued. This study was the first study to examine PrEP delivery preferences in Malawi using DCE-a powerful elicitation tool to apply to other key populations at risk for HIV.

Post-exposure prophylaxis following consented sexual exposure: impact of national recommendations on user profile, drug regimens and estimates of averted HIV infections.

OBJECTIVES: The aim of the study was to describe the characteristics, impact and outreach of post-exposure prophylaxis (PEP) for sexual exposure in Brazil. METHODS: We used secondary data from the Brazilian Ministry of Health to describe the impact of national guidelines on the frequency of prescription, user profile and antiretroviral regimens. We also estimated the number of potentially averted HIV infections attributable to PEP for consented sexual exposure between 2009 and 2017. RESULTS: A total of 260 457 PEP regimens were prescribed to individuals ≥ 14 years old; 104 613 (40.2%) were prescribed for consented sexual exposure, with an increasing frequency since 2011. Drugs used in PEP regimens underwent significant modifications during the period, reflecting national recommendations. We estimated that there were up to 3138 potentially averted HIV infections attributable to PEP for consented sexual exposure between 2009 and 2017. CONCLUSIONS: In the context of a combined HIV prevention strategy, PEP is still an essential tool for individuals for whom other methods are contraindicated or fail to be applied.

Trabajadores sexuales masculinos: entre el sexo seguro y el riesgo. Etnografía en una sauna gay de Barcelona, España / Male sex workers: between safe sex and risk. Ethnography in a gay sauna in Barcelona, Spain

Resumen Esta etnografía se realizó en Barcelona, ciudad que ofrece diferentes recursos de ocio homosexual, como las saunas gay. El objetivo fue analizar desde los estudios sobre género y masculinidades, cómo se articula la sexualidad, la percepción sobre la infección por VIH y otras infecciones de transmisión sexual (ITS), y las medidas preventivas en trabajadores sexuales masculinos (TSM) usuarios de saunas gay. Se realizaron 10 entrevistas en profundidad y observación entre 2012 y 2016. Las prácticas de sexo seguro son más frecuentes con clientes, mientras que las de riesgo se realizan más con parejas no comerciales. La orientación sexual juega un rol relevante, los homosexuales asumen más prácticas de riesgo en el trabajo sexual que los heterosexuales. Consumo de drogas o la escasez de redes de apoyo se relacionaron con mayor vulnerabilidad social y conductas de riesgo. Contraer el VIH aún genera miedo, mientras que tener otras ITS se percibe como parte de la vida sexual de un hombre. El TSM afianza una masculinidad con múltiples parejas sexuales, breadwinner y por otra parte, cuestiona un modelo heteronormativo. Las intervenciones para la prevención del VIH e ITS en este colectivo, deberían considerar los determinantes sociales como las precarias alternativas laborales y el ofrecer mayor soporte social.

Abstract This ethnography was conducted in Barcelona, a city that provides different gay leisure resources, such as gay saunas. We aimed to analyze from studies on gender and masculinities, how sexuality, perception of HIV infection and other sexually transmitted infections (STIs), and preventive measures are articulated in gay sauna male sex workers (MSW). Ten in-depth interviews and observation were conducted between 2012 and 2016. Safe sex practices are more frequent with clients, while risk practices are carried out more with non-commercial partners. Sexual orientation plays an important role. Homosexuals assume riskier practices in sex work than heterosexuals. Drug use or lack of support networks were associated with higher social vulnerability and risk behaviors. Contracting HIV still creates fear, while having other STIs is perceived as part of a man's sexual life. The MSW affirms masculinity with concurrent sexual partners, breadwinner, and on the other hand, questions a heteronormative model. Interventions for the prevention of HIV and STIs in this group should consider social determinants such as inferior work alternatives and the provision of more significant social support.

Male sex workers: between safe sex and risk. Ethnography in a gay sauna in Barcelona, Spain. / Trabajadores sexuales masculinos: entre el sexo seguro y el riesgo. Etnografía en una sauna gay de Barcelona, España.

This ethnography was conducted in Barcelona, a city that provides different gay leisure resources, such as gay saunas. We aimed to analyze from studies on gender and masculinities, how sexuality, perception of HIV infection and other sexually transmitted infections (STIs), and preventive measures are articulated in gay sauna male sex workers (MSW). Ten in-depth interviews and observation were conducted between 2012 and 2016. Safe sex practices are more frequent with clients, while risk practices are carried out more with non-commercial partners. Sexual orientation plays an important role. Homosexuals assume riskier practices in sex work than heterosexuals. Drug use or lack of support networks were associated with higher social vulnerability and risk behaviors. Contracting HIV still creates fear, while having other STIs is perceived as part of a man's sexual life. The MSW affirms masculinity with concurrent sexual partners, breadwinner, and on the other hand, questions a heteronormative model. Interventions for the prevention of HIV and STIs in this group should consider social determinants such as inferior work alternatives and the provision of more significant social support.

Esta etnografía se realizó en Barcelona, ciudad que ofrece diferentes recursos de ocio homosexual, como las saunas gay. El objetivo fue analizar desde los estudios sobre género y masculinidades, cómo se articula la sexualidad, la percepción sobre la infección por VIH y otras infecciones de transmisión sexual (ITS), y las medidas preventivas en trabajadores sexuales masculinos (TSM) usuarios de saunas gay. Se realizaron 10 entrevistas en profundidad y observación entre 2012 y 2016. Las prácticas de sexo seguro son más frecuentes con clientes, mientras que las de riesgo se realizan más con parejas no comerciales. La orientación sexual juega un rol relevante, los homosexuales asumen más prácticas de riesgo en el trabajo sexual que los heterosexuales. Consumo de drogas o la escasez de redes de apoyo se relacionaron con mayor vulnerabilidad social y conductas de riesgo. Contraer el VIH aún genera miedo, mientras que tener otras ITS se percibe como parte de la vida sexual de un hombre. El TSM afianza una masculinidad con múltiples parejas sexuales, breadwinner y por otra parte, cuestiona un modelo heteronormativo. Las intervenciones para la prevención del VIH e ITS en este colectivo, deberían considerar los determinantes sociales como las precarias alternativas laborales y el ofrecer mayor soporte social.

A qualitative study into female sex workers' experience of stigma in the health care setting in Hong Kong.

BACKGROUND: Hong Kong has gained a good reputation for its quality public health care services. However, there is a growing recognition that social stigma is a potential obstacle when female sex workers (FSWs) access health care services. There are a lack of studies focusing on how FSWs experience and cope with stigma when accessing health care services in Hong Kong. OBJECTIVE: This study aims to explore how FSWs experience stigma and develop coping strategies when accessing health care services in Hong Kong. METHODS: This is a qualitative interview study. Staff of non-governmental organizations (NGOs) that serve sex workers in Hong Kong facilitated the process of recruiting the participants. In-depth individual interviews were conducted with 22 FSWs, focusing on their experiences of stigma and coping strategies when accessing health care services. A directed content analysis approach was adopted to analyze the data. RESULTS: The interview data can be grouped into three themes: experience of stigma in the health care setting; coping with the stigma of sex work; and the call for non-judgmental holistic health care. CONCLUSION: This study contributes to an understanding of the experience of stigma and stigma coping strategies of FSWs when accessing health care services in Hong Kong. stigma remains an important issue for a large proportion of FSWs when they seek timely professional help, openly disclose their sex work identity, and receive comprehensive health care services. The study also highlights the need to address multiple healthcare needs of FSWs beyond STDs. Moreover, the study contributes to increasing awareness of, and respect for, the human right of FSWs to receive non-discriminatory health services.

Antenatal care presentation and engagement in the context of sex work: exploring barriers to care for sex worker mothers in South Africa.

BACKGROUND: Late presentation combined with limited engagement in antenatal care (ANC) increases risk of vertical transmission among mothers living with HIV. Female sex workers (FSW) have more than four times greater burden of HIV than other women of reproductive age in South Africa and the majority of FSW are mothers. For mothers who sell sex and are at increased HIV acquisition risk, timely and routine ANC seeking is especially vital for prevention of vertical transmission. This study represents a mixed-methods study with FSW in Port Elizabeth, South Africa, to characterize factors influencing ANC seeking behaviors in a high HIV prevalence context. METHODS: FSW (n = 410) were recruited into a cross-sectional study through respondent-driven sampling between October 2014 and April 2015 and tested for HIV and pregnancy. A sub-sample of pregnant and postpartum women (n = 30) were invited to participate in in-depth interviews (IDIs) to explore their current or most recent pregnancy experiences. IDIs were coded using a modified grounded theory approach and descriptive analyses assessed the frequency of themes explored in the qualitative analysis among the quantitative sample. RESULTS: In the quantitative survey, 77% of FSW were mothers (313/410); of these, two-thirds were living with HIV (212/313) and 40% reported being on antiretroviral therapy (ART) (84/212). FSW in the qualitative sub-sample reported unintended pregnancies with clients due to inconsistent contraceptive use; many reported discovering their unintended pregnancies between 4 and 7 months of gestation. FSW attributed delayed ANC seeking and ART initiation in the second or third trimesters to late pregnancy detection. Other factors limiting engagement in ANC included substance and alcohol use and discontent with previous healthcare-related experiences. CONCLUSIONS: Late pregnancy discovery, primarily because pregnancies were unplanned, contributed to late ANC presentation and delayed ART initiation, increasing risks of vertical HIV transmission. Given limited ART coverage among participants, addressing the broader sexual and reproductive health and rights needs of mothers who sell sex has important implications for preventing vertical transmission of HIV. Integrating comprehensive family planning services into FSW programming, as well as providing active linkage to ANC services may reduce barriers to accessing timely ANC, decreasing risks of vertical transmission.