Sexually Transmitted Infections and the Risk of Reinfection Within 12 Months: A Population-Based Cohort.

BACKGROUND: Chlamydia, gonorrhea, and syphilis are common sexually transmitted infections that disproportionately affect specific groups in New Zealand (NZ). Predictors of reinfection are not well studied in NZ but could inform public health strategies to decrease sexually transmitted infection (STI) incidence. METHODS: New Zealand-wide chlamydia, gonorrhea, and syphilis cases during 2019 were identified using nationally collected data. Cases were followed-up to identify reinfection with the same STI within 12 months of initial infections. Logistic regression models were used to identify predictors for each STI reinfection. RESULTS: Determinants identified for increased odds of chlamydia reinfection were age groups 16-19 and 20-24 years, females, Maori and Pacific peoples, cases in the Northern region, and cases with at least one test before the initial infection. Age 40 years and older was associated with lower odds of gonorrhea reinfection, as was being of Asian ethnicity, living in Midland or Southern regions, and reporting heterosexual behavior. Region was the only statistically significant predictor for syphilis reinfection, with higher odds of reinfection for people living in the Central region. CONCLUSIONS: Our findings reflect disproportionate STI rates for some groups in NZ, with younger age groups, Maori and Pacific peoples, men who have sex with men, and people living in the Northern region experiencing higher odds of reinfection. Groups identified with higher odds for reinfection require increased access to culturally responsive health services to treat, understand, and prevent possible reinfection. Changes to current public health strategies could include culturally specific behavioral counseling, and improvements to and adherence to effective contract tracing.

Prevalence and Correlates of HIV Stigma Among Women Living with HIV in Metro Vancouver, Canada.

This study elucidated the prevalence and correlates of four types of HIV stigma among women living with HIV (WLWH). Data were drawn from 2 years (September 1/15 to August 31/17) of follow-up from a longitudinal community-based open cohort of 215 cisgender or transgender WLWH who lived and/or accessed care in Metro Vancouver, Canada (2014-present). Bivariate and multivariable cumulative logistic regression using generalized estimating equations for repeated measures were used to examine correlates of HIV stigma, including: (1) anticipated; (2) enacted; (3) internalized; and (4) perceived stigma. In multivariable analysis, disclosure of HIV status without consent was significantly associated with heightened: anticipated; enacted; and perceived stigma. Verbal and/or physical violence related to HIV status was significantly associated with heightened enacted, internalized and perceived stigma. Negative physical effects/symptoms of HIV was significantly associated with all stigma outcomes. Results suggest a need to support safe disclosure of HIV status and address social and structural violence against WLWH.

Ethics and the treatment as prevention strategy among transgender women living with HIV in Argentina.

While numerous ethical concerns have been voiced regarding HIV service scale-up strategies targeting key populations, few studies have examined these from the perspective of affected groups. This study therefore sought to understand transgender women's experiences and perspectives of targeted HIV services scale-up in the context of Argentina's Treatment as Prevention strategy. In 2016, 25 purposively selected transgender women living with HIV were interviewed by a peer research associate. Interviews were audio recorded, transcribed verbatim and analysed using participatory coding techniques. Findings suggest that procedures around informed consent, including the provision of full information in lay language and voluntariness, were lacking both pre- and post-HIV test. Further, many transgender women felt disrespected and disregarded by healthcare workers. While the majority of participants were unaware of Treatment as Prevention, once explained, most felt the approach was ethical overall, and helped improve equity in HIV service access. Study findings offer several community-driven suggestions to support patient rights and the ethical scale-up of HIV services for transgender women in Buenos Aires, including the need for training in and the provision of non-judgemental, gender-affirmative care and the inclusion of peer-navigators.

The Effect of Violence and Intersecting Structural Inequities on High Rates of Food Insecurity among Marginalized Sex Workers in a Canadian Setting.

Food security is both a basic human right and a public health necessity. Despite known gendered contexts of food insecurity, there is a dearth of research on prevalence and factors driving increased food insecurity for sex workers in a criminalized setting. The current study longitudinally examines the prevalence and structural and individual factors associated with increased odds of food insecurity among street and off-street sex workers in a Canadian urban setting. Prospective analyses drew on data from a community-based longitudinal cohort of cis and trans women in street and off-street sex work in An Evaluation of Sex Workers Health Access (2010-2014). The primary outcome was a time-updated measure of food insecurity, using the Radimer-Cornell scale. We used bivariable and multivariable logistic regression using generalized estimating equations to prospectively model correlates of food insecurity over a five-year period. Of 761 cis and trans women sex workers, 72.4% (n = 551) were food insecure over the study period. Over a third (35.2%, n = 268) identified as Indigenous and a quarter, 25.6% (n = 195) were of a gender/sexual minority. Within the 11.0% (n = 84) of women living with HIV, 96.4% (n = 81) were food insecure over the follow-up period. In multivariable analysis, Indigenous ancestry (AOR = 1.58 [95% CI 1.18, 2.10]), unstable housing (AOR = 1.27 [95% CI 1.03, 1.57]), stimulant use (AOR = 1.97 [95% CI 1.57, 2.45]), heroin use (AOR = 1.72 [95% CI 1.36, 2.19]), mental health diagnosis (AOR = 2.38 [95% CI 1.85, 3.05]), recent violence (AOR = 1.54 [95% CI 1.24, 1.91]), means of food access: reliant on food services only vs. self-sufficient (AOR = 1.78 [95% CI 1.38, 2.29]), and means of food access: both vs. self-sufficient (AOR = 2.29 [95% CI 1.84, 2.86]) were associated with food insecurity. In separate multivariable models, both recent and lifetime physical and/or sexual violence remained independently associated with food insecurity (AOR 1.54 [95% CI 1.24, 1.91]; AOR 4.62 [95% CI 2.99, 7.14], respectively). Almost all study participants living with HIV reported being food insecure. These intersecting risks demonstrate the negative impacts associated with living with HIV, experiencing food insecurity and/or physical or sexual violence. This study also highlights the potential for interventions that address structural inequities (e.g., decriminalizing sex work) to have crosscutting impacts to reduce barriers to accessing necessities (including food) or health and social services (e.g., methadone; primary care).

Family Separation and Maternal Self-rated Health: Evidence from a Prospective Cohort of Marginalized Mothers in a Canadian Setting.

OBJECTIVES: Involuntary child removal via the child protection system disproportionately affects marginalized women, yet the impacts on maternal health are under-investigated. This study prospectively examined the association of child removal with self-rated health of mothers who are sex workers. Given high levels of intergenerational family separation in this population, particularly among Indigenous sex workers, we also estimated joint effects of child removal spanning two generations. METHODS: Analyses drew on 2010-2015 data from AESHA (An Evaluation of Sex Workers' Health Access), a prospective cohort of sex workers (n = 950) in Vancouver, Canada. Using logistic regression with generalized estimating equations, we modeled the association of past child removal and current self-rated health in a sample of 466 sex workers who ever had a live birth. Joint effects of child removal and history of removal from own parents were also investigated. RESULTS: Of 466 sex workers, 180 (38.6%) reported child removal at baseline and 147 (31.6%) had a history of removal from own parents. In main effects model, child removal was associated with increased odds of poorer self-rated health [odds ratio (OR) 1.50, 95% confidence interval (CI) 1.04, 2.16]. Joint effects model showed higher odds of poorer self-rated health (OR 2.04, 95% CI 1.27, 3.27) among women with intergenerational family separation. CONCLUSION FOR PRACTICE: Child removal was negatively associated with sex workers' health that was worsened when family separation spanned two generations. Findings underscore need to develop sex worker and Indigenous-led family support services, along with tailored interventions to address health needs of those separated from their children.

Realizing Women Living with HIV's Reproductive Rights in the Era of ART: The Negative Impact of Non-consensual HIV Disclosure on Pregnancy Decisions Amongst Women Living with HIV in a Canadian Setting.

To better understand the structural drivers of women living with HIV's (WLWH's) reproductive rights and choices, this study examined the structural correlates, including non-consensual HIV disclosure, on WLWH's pregnancy decisions and describes access to preconception care. Analyses drew on data (2014-present) from SHAWNA, a longitudinal community-based cohort with WLWH across Metro-Vancouver, Canada. Multivariable logistic regression was used to model the effect of non-consensual HIV disclosure on WLWH's pregnancy decisions. Of the 218 WLWH included in our analysis, 24.8% had ever felt discouraged from becoming pregnant and 11.5% reported accessing preconception counseling. In multivariable analyses, non-consensual HIV disclosure was positively associated with feeling discouraged from wanting to become pregnant (AOR 3.76; 95% CI 1.82-7.80). Non-consensual HIV disclosure adversely affects WLWH's pregnancy decisions. Supporting the reproductive rights of WLWH will require further training among general practitioners on the reproductive health of WLWH and improved access to women-centred, trauma-informed care, including non-judgmental preconception counseling.

Social and structural factors increase inconsistent condom use by sex workers' one-time and regular clients in Northern Uganda.

While sex workers (SWs) bear the brunt of the epidemic in Uganda, there remains a dearth of empirical research on the structural drivers of HIV prevention among SWs. This study examined the drivers of inconsistent condom use by one-time and regular clients of young women SWs in Gulu, Northern Uganda. Data were drawn from the Gulu Sexual Health Study, a cross-sectional study of young SWs, aged 14 years and older (2011-2012). SWs were recruited using peer/SW-led outreach, in partnership with The AIDS Support Organization and other CBOs. Multivariable logistic regression was used to examine the correlates of inconsistent condom use by one-time and regular clients. In total, 84.5% of the 381 SWs servicing regular clients and 76.8% of the 393 SWs servicing one-time clients reported inconsistent client condom use. In multivariable analysis, physical/sexual violence by clients (AOR = 5.39; 95%CI 3.05-9.49), low sexual control by workers (measured by the validated Pulweritz scale) (AOR = 2.86; 95%CI 1.47-5.58), alcohol/drug use while working (AOR = 1.98; 95%CI 1.17-3.35) and migration to Gulu for sex work (AOR = 1.73; 95%CI 0.95-3.14) were positively correlated with inconsistent condom use by one-time clients. Correlates of inconsistent condom use by regular clients included: low sexual control by workers (AOR = 4.63; 95%CI 2.32-9.23); physical/sexual violence by clients (AOR = 3.48; 95%CI 1.85-6.53); police harassment (AOR = 2.57; 95%CI 1.17-5.65); and being a single mother (AOR = 2.07; 95%CI 1.09-3.93). Structural and interpersonal factors strongly influence inconsistent condom use by clients, with violence by clients and police, low sexual control by workers, migration and single-parenthood all linked to non-condom use. There is a need for peer-led structural interventions that improve access to occupational health and safety standards (e.g., violence prevention and alcohol/drug harm reduction policies/programming). Shifts away from the current punitive approaches towards SWs are integral to the success of such interventions, as they continue to undermine HIV prevention efforts.

High pregnancy incidence and low contraceptive use among a prospective cohort of female entertainment and sex workers in Phnom Penh, Cambodia.

BACKGROUND: While HIV and unintended pregnancies are both occupational risks faced by female sex workers, the epidemiology of pregnancy and its drivers in this population remains understudied. This includes Cambodia, where the drivers of pregnancy among female entertainment and sex workers (FESW) remain unknown. The current study aimed to examine factors associated with incident pregnancy, as well as describe contraceptive use among FESW in Phnom Penh, Cambodia. METHODS: This analysis drew from the Young Women's Health Study (YWHS)-2, a 12-month observational cohort of 220 FESW aged 15-29 years, conducted between August 2009 and August 2010. Interviewer-administered questionnaires were conducted at baseline and quarterly thereafter, alongside HIV and pregnancy testing. Bivariate and multivariable extended Cox regression analysis was used to examine correlates of incident pregnancy. RESULTS: At baseline, 6.8% of participants were pregnant, and only 10.8% reported using hormonal contraceptives, with 11.3% reporting an abortion in the past 3 months. Pregnancy incidence was high, at 22/100 person-years (95% CI: 16.3-30.1). In multivariable analysis, younger age (19-24 years versus 25-29 years) (Adjusted Hazards Ratio (AHR): 2.28; 95% Confidence Interval (CI) 1.22-4.27), lower income (400,000-600,000 Riel (≤150$USD) versus > 600,000 Riel (> 150$USD)) (AHR 2.63; 95% CI 1.02-6.77) positively predicted pregnancy, while higher self-reported condom self-efficacy were associated with reduced pregnancy incidence (AHR 0.89; 95% CI 0.81-0.98). CONCLUSIONS: Results document high incidence of pregnancy and unmet reproductive health needs among FESWs in Cambodia. Findings point to an urgent need for multi-level interventions, including venue-based HIV/STI and violence prevention interventions, in the context of legal and policy reform. High pregnancy incidence in this population may also undermine recruitment and retention into HIV prevention intervention trials. The exploration of innovative and comprehensive sex worker-tailored sexual and reproductive health service models, also as part of HIV prevention intervention trials, is warranted.

Use of injectable hormonal contraception and HSV-2 acquisition in a cohort of female sex workers in Vancouver, Canada.

OBJECTIVES: Increased risk of herpes simplex virus 2 (HSV-2) has been proposed as a possible indirect pathway through which hormonal contraceptives (specifically depot medroxyprogesterone acetate (DMPA)) may increase the risk of HIV acquisition among women. We investigated the effects of DMPA on HSV-2 acquisition among female sex workers. METHODS: Longitudinal data were drawn from a prospective cohort of sex workers in Vancouver, Canada. The primary outcome was HSV-2 seroconversion. Extended Cox regression analyses were used to model the independent effect of DMPA use on HSV-2 acquisition. RESULTS: Between January 2010 and February 2014, 149 HSV-2 seronegative women were enrolled, contributing to 228 person-years (py) of follow-up. Of these, 19 (13.3%) reported DMPA use. There were 39 HSV-2 seroconversions (12 among DMPA users and 27 among non-users) over the study period (median follow-up of 18.6 months (IQR 8.4-29.9)), resulting in an overall incidence rate of 17.1 cases per 100 py (95% CI 12.4 to 23.6). Incidence rates were higher among DMPA users (57.4 cases per 100 py, 95% CI 31.4 to 105.0) compared with non-users (13.1 cases per 100 py, 95% CI 8.9 to 19.1). After adjusting for key confounders, use of DMPA remained an independent predictor of HSV-2 acquisition (adjusted HR 4.43, 95% CI 1.90 to 10.35). CONCLUSIONS: The high observed incidence rates of HSV-2, together with a strong association between DMPA exposure and HSV-2 acquisition, raise serious concerns about the provision of optimal reproductive and sexual healthcare to sex workers in this setting. Given the known links between HSV-2 and HIV, our findings underscore the need for further research to better understand the potential association between DMPA and increased risk of HSV-2 and other STIs to help inform the development of safer reproductive choices for women worldwide.

Food Insecurity Increases HIV Risk Among Young Sex Workers in Metro Vancouver, Canada.

This research aimed to determine the effect of food insecurity on sexual HIV risk with clients among youth sex workers (YSWs) <30 years in Metro Vancouver, Canada. Data were drawn from a prospective community cohort of sex workers (2010-2013). We examined the independent relationship between YSWs' food insecurity and being pressured into sex without a condom by clients ("client condom refusal"). Of 220 YSWs, 34.5 % (n = 76) reported client condom refusal over the 3.5-year study period and 76.4 % (n = 168) reported any food insecurity. Adjusting for other HIV risk pathways, food insecurity retained an independent effect on client condom refusal (AOR 2.08, 95 % CI 1.23-3.51), suggesting that food insecurity is significantly associated with HIV risk among YSWs. This study indicates a critical relationship between food insecurity and HIV risk, and demonstrates YSWs' particular vulnerability. Public policies for food assistance as a harm reduction measure may be key to addressing this disparity.

A narrative analysis of the birth stories of early-age mothers.

The telling of birth stories (i.e. stories that describe women's experiences of giving birth) is a common and important social practice. Whereas most research on birth narratives reflects the stories of middle-class, 'adult' women, we examine how the birth stories told by early-age mothers interconnect with broader narratives regarding social stigma and childbearing at 'too early' an age. Drawing on narrative theory, we analyse in-depth interviews with 81 mothers (ages 15-24 years) conducted in Greater Vancouver and Prince George, Canada, in 2014-15. Their accounts of giving birth reveal the central importance of birth narratives in their identity formation as young mothers. Participants' narratives illuminated the complex interactions among identity formation, social expectations, and negotiations of social and physical spaces as they narrated their experiences of labour and birth. Through the use of narrative inquiry, we examine the ways in which re-telling the experience of giving birth serves to situate young mothers in relation to their past and future selves. These personal stories are also told in relation to a meta-narrative regarding social stigma faced by 'teenage' mothers, as well as the public's 'gaze' on motherhood in general - even within the labour and delivery room.

High rates of Unintended Pregnancies among Young Women Sex Workers in Conflict-affected Northern Uganda: The Social Contexts of Brothels/Lodges and Substance Use.

This study aimed to examine the correlates of unintended pregnancies among young women sex workers in conflict-affected northern Uganda. Data were drawn from the Gulu Sexual Health Study, a cross-sectional study of young women engaged in sex work. Bivariable and multivariable logistic regression was used to examine the correlates of ever having an unintended pregnancy. Among 400 sex workers (median age=20 years; IQR 19-25), 175 (43.8%) reported at least one unintended pregnancy. In multivariable analysis, primarily servicing clients in lodges/brothels [Adjusted Odds Ratio (AOR= 2.24; 95% Confidence Interval: 1.03-4.84)], hormonal contraceptive usage [AOR=1.68; 95%CI 1.11-2.59] and drug/alcohol use while working [AOR= 1.64; 95%CI 1.04-2.60] were positively correlated with previous unintended pregnancy. Given that unintended pregnancy is an indicator of unmet reproductive health need, these findings highlight a need for improved access to integrated reproductive health and HIV services, catered to sex workers' needs. Sex work-led strategies (e.g., peer outreach) should be considered, alongside structural strategies and education targeting brothel/lodge owners and managers.

Recent im/migration to Canada linked to unmet health needs among sex workers in Vancouver, Canada: Findings of a longitudinal study.

Despite universal health care in Canada, sex workers (SWs) and im/migrants experience suboptimal health care access. In this analysis, we examined the correlates of unmet health needs among SWs in Metro Vancouver over time. Data from a longitudinal cohort of women SWs (An Evaluation of Sex Workers Health Access [AESHA]) were used. Of 742 SWs, 25.5% reported unmet health needs at least once over the 4-year study period. In multivariable logistic regression using generalized estimating equations, recent im/migration had the strongest impact on unmet health needs; long-term im/migration, policing, and trauma were also important determinants. Legal and social supports to promote im/migrant SWs' access to health care are recommended.

Global epidemiology of HIV among female sex workers: influence of structural determinants.

Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1-31) and 20% in Canada (95% UI 3-39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per µL could avert 34% (95% UI 25-42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8-36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33-46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.

Barriers to Cervical Screening Among Sex Workers in Vancouver.

OBJECTIVES: We longitudinally examined the social, structural, and geographic correlates of cervical screening among sex workers in Metropolitan Vancouver, British Columbia, to determine the roles that physical and social geography play in routine reproductive health care access. METHODS: Analysis drew on (2010-2013) data from an open prospective cohort of sex workers (An Evaluation of Sex Workers' Health Access). We used multivariable logistic regression with generalized estimating equations (GEE) to model correlates of regular cervical screening. RESULTS: At baseline, 236 (38.6%) of 611 sex workers in our sample had received cervical screening, and 63 (10.3%) were HIV-seropositive. In multivariable GEE analysis, HIV-seropositivity (adjusted odds ratio [AOR] = 1.65; 95% confidence interval [CI] = 1.06, 2.58) and accessing outreach services (AOR = 1.35; 95% CI = 1.09, 1.66) were correlated with regular cervical screening. Experiencing barriers to health care access (e.g., poor treatment by health care staff, limited hours of operation, and language barriers) reduced odds of regular Papanicolaou testing (AOR = 0.81; 95% CI = 0.65, 1.00). CONCLUSIONS: Sex workers in Metropolitan Vancouver had suboptimal levels of cervical screening. Innovative mobile outreach service delivery models offering cervical screening as one component of sex worker-targeted comprehensive sexual and reproductive health services may hold promise.

Social Cohesion Among Sex Workers and Client Condom Refusal in a Canadian Setting: Implications for Structural and Community-Led Interventions.

Community empowerment can be a powerful determinant of HIV risk among sex workers (SWs). This study modeled the impact of social cohesion on client condom refusal among SWs in Vancouver. Longitudinal data were drawn from a prospective cohort of SWs (2010-2013). Lippman and colleagues' Social Cohesion Scale measured SWs' connectedness (i.e., perception of mutual aid, trust, support). Multivariable logistic regression examined the independent effect of social cohesion on client condom refusal. Of 654 SWs, 22 % reported baseline client condom refusal and 34 % over 3 years. The baseline median social cohesion score was 24 (IQR 20-29, range 4-45). In the final confounding model, for every one-point increase in the social cohesion score, average odds of condom refusal decreased by 3 % (AOR 0.97; 95 % CI 0.95-0.99). Community empowerment can have a direct protective effect on HIV risk. These findings highlight the need for a legal framework that enables collectivization and SW-led efforts in the HIV response.

Structural Barriers to Antiretroviral Therapy Among Sex Workers Living with HIV: Findings of a Longitudinal Study in Vancouver, Canada.

In light of limited data on structural determinants of access and retention in antiretroviral therapy (ART) among sex workers, we examined structural correlates of ART use among sex workers living with HIV over time. Longitudinal data were drawn from a cohort of 646 female sex workers in Vancouver, Canada (2010-2012) and linked pharmacy records on ART dispensation. We used logistic regression with generalized estimating equations (GEE) to examine correlates of gaps in ART use (i.e., treatment interruptions or delayed ART initiation), among HIV seropositive participants (n = 74). Over a 2.5-year period, 37.8 % of participants experienced gaps in ART use (i.e., no ART dispensed in a 6-month period). In a multivariable GEE model, younger age, migration/mobility, incarceration, and non-injection drug use independently correlated with gaps in ART use. In spite of successes scaling-up ART in British Columbia, younger, mobile, or incarcerated sex workers face persistent gaps in access and retention irrespective of drug use. Community-based, tailored interventions to scale-up entry and retention in ART for sex workers should be further explored in this setting.

Work environments and HIV prevention: a qualitative review and meta-synthesis of sex worker narratives.

BACKGROUND: Sex workers (SWs) experience a disproportionately high burden of HIV, with evidence indicating that complex and dynamic factors within work environments play a critical role in mitigating or producing HIV risks in sex work. In light of sweeping policy efforts to further criminalize sex work globally, coupled with emerging calls for structural responses situated in labour and human-rights frameworks, this meta-synthesis of the qualitative and ethnographic literature sought to examine SWs' narratives to elucidate the ways in which physical, social and policy features of diverse work environments influence SWs' agency to engage in HIV prevention. METHODS: We conducted a meta-synthesis of qualitative and ethnographic studies published from 2008 to 2014 to elucidate SWs' narratives and lived experiences of the complex and nuanced ways in which physical, social, and policy features of indoor and outdoor work environments shape HIV prevention in the sex industry. RESULTS: Twenty-four qualitative and/or ethnographic studies were included in this meta-synthesis. SWs' narratives revealed the nuanced ways that physical, social, and policy features of work environments shaped HIV risk and interacted with macrostructural constraints (e.g., criminalization, stigma) and community determinants (e.g., sex worker empowerment initiatives) to shape SWs' agency in negotiating condom use. SWs' narratives revealed the ways in which the existence of occupational health and safety standards in indoor establishments, as well as protective practices of third parties (e.g., condom promotion) and other SWs/peers were critical ways of enhancing safety and sexual risk negotiation within indoor work environments. Additionally, working in settings where negative interactions with law enforcement were minimized (e.g., working in decriminalized contexts or environments in which peers/managers successfully deterred unjust policing practices) was critical for supporting SWs' agency to negotiate HIV prevention. CONCLUSIONS: Policy reforms to remove punitive approaches to sex work, ensure supportive workplace standards and policies, and foster SWs' ability to work collectively are recommended to foster the realization of SWs' health and human rights across diverse settings. Future qualitative and mixed-methods research is recommended to ensure that HIV policies and programmes are grounded in SWs' voices and realities, particularly in more under-represented regions such as Eastern Europe and Sub-Saharan Africa.

Sex Work and Motherhood: Social and Structural Barriers to Health and Social Services for Pregnant and Parenting Street and Off-Street Sex Workers.

Our study documents the correlates of barriers to pregnancy and mothering among sex workers in Vancouver, Canada. We used baseline data from An Evaluation of Sex Workers' Health Access (AESHA), a prospective cohort of sex workers. Among the 399 sex workers who had ever been pregnant or had a child, 35% reported having ever experienced a barrier, with lower education, homelessness, and history of injecting drugs significantly correlated with pregnancy and mothering barriers. Our findings highlight a critical need for tailored and nonjudgmental services and supports, including improved programs to address intersecting aspects of poverty, health literacy, stigma, and substance use.

Decisions, decisions: the importance of condom use decision making among HIV sero-discordant couples in a prospective cohort study in Uganda.

OBJECTIVES: We examined sexual decision making type among couples in HIV sero-discordant partnerships in Uganda, and investigated how sexual decision making type changed over time and its effect on condom use. METHODS: Data were drawn from a longitudinal cohort of HIV sero-discordant couples, recruited through the AIDS Support Organisation in Jinja, Uganda. Sexual decision making was measured using the Sexual Relationship Power Scale, and couples' individual self-report answers were matched to assess agreement for decision making type and condom use. Generalised linear mixed effects modelling was used to assess statistically significant differences in time trend of sexual decision making type, and to investigate the independent association of decision making type on condom use status over time. RESULTS: Of the 533 couples included in this analysis, 345 (65%) reported using condoms at last sex at study enrolment. In the time trend analysis of decision making, the proportion of couples who decided together increased over time while the proportions of couples who reported that one partner decided or no one decided/did not use condoms, decreased over time (overall p<0.001). Compared with couples who decided together, those who disagreed (adjusted OR=0.42, 95% CI 0.28 to 0.64) and those where one partner decided (adjusted OR=0.20, 95% CI 0.12 to 0.34) had significantly lower odds of condom use at last sex, even after controlling for confounders. CONCLUSIONS: Couples who disagreed on decision making, or agreed that one partner decides alone, had significantly lower odds of reporting condom use compared with couples who decided together. HIV counselling interventions that encourage joint sexual decision making may improve condom use within this population.