Investigating the effects of COVID-19 on global male sex work populations: a longitudinal study of digital data.

OBJECTIVES: Recommendations of 'social distancing' and home quarantines to combat the global COVID-19 pandemic have implications for sex and intimacy, including sex work. This study examined the effects of COVID-19 on male sex work globally and investigated how men who sold sex responded to and engaged with the virus in the context of work. METHODS: This study made use of an existing database of deidentified data extracted from the online profiles maintained by male sex workers on a large, international website. Website engagement metrics were calculated for the periods before (September to December 2019) and during COVID-19 (January to May 2020); Poisson regression analyses were used to assess changes over time before and after, while a content analysis was undertaken to identify modes of engagement with the virus. RESULTS: Data were collected from 78 399 profiles representing 19 388 individuals. In the 'before' period, the number of active profiles was stable (inter-rate ratio (IRR)=1.01, 95% CI 0.99 to 1.01, p=0.339) but during COVID-19 decreased by 26.3% (IRR=0.90, 95% CI 0.89 to 0.91, p<0.001). Newly created profiles also decreased during COVID-19 (59.4%; IRR=0.71, 95% CI 0.69 to 0.74, p<0.001) after a period of stability. In total, 211 unique profiles explicitly referenced COVID-19; 185 (85.8%) evoked risk reduction strategies, including discontinuation of in-person services (41.2%), pivoting to virtual services (38.9%), COVID-19 status disclosure (20.9%), enhanced sanitary and screening requirements (12.3%) and restricted travel (5.2%). Some profiles, however, seemed to downplay the seriousness of COVID-19 or resist protective measures (14.7%). CONCLUSIONS: These findings support the contention that COVID-19 has dramatically impacted the sex industry; globally, male sex workers may be facing considerable economic strain. Targeted education and outreach are needed to support male sex workers grappling with COVID-19, including around the most effective risk reduction strategies. Those involved with the sex industry must have access to state-sponsored COVID-19 financial and other aid programmes to support individual and public health.

Rethinking the relationship between sex work, mental health and stigma: a qualitative study of sex workers in Australia.

AIMS: Sex workers may experience stigma both related to their occupation as well as to mental health issues that they face. There is limited research on the lived experience of sex workers managing mental health and stigma. This study examined the experiences of sex workers in Australia in relation to stigma surrounding sex work, and sex workers' mental health, including self-management and experiences of accessing mental health services. METHOD: Six focus groups and two interviews were conducted with 31 sex workers. Data collection was co-moderated by a sex worker and a university-based researcher. Analysis was informed by an approach which positioned sex workers as agential and capable, and which drew attention to structural aspects of stigma. RESULTS: Sex workers identified that the stigma surrounding their profession had a significant impact on their mental health. The need to manage risks through selective disclosure of sex work was a pervasive experience. Management of mental health and the stigma associated with sex work was described as a responsibility primarily of the individual through self-care activities and occasional access to mental health services. Participants reported poor treatment from mental health practitioners who saw sex workers as victims lacking agency, imposed beliefs that sex work was the pathological root cause of mental health issues, or approached the issue with fascination or voyeurism. Other presenting issues (especially mental health) were lost or obscured in therapeutic encounters resulting in suboptimal care. CONCLUSION: The threat of stigma is pervasive and has mental health implications for sex workers. Our findings point to the need for increased training and capacity development for mental health practitioners, funding for peer support services to ameliorate internalised stigma, and action from governments to introduce enabling legal environments, stigma reduction programs and structural protections from sex work stigma.

A Systems Thinking Approach to Understanding and Demonstrating the Role of Peer-Led Programs and Leadership in the Response to HIV and Hepatitis C: Findings From the W3 Project.

The central role of community and peer-led programs has been a key characteristic of the Australian partnership response to HIV and hepatitis C since the beginning of the epidemics. Despite this, peer-led programs continue to have limited capacity to demonstrate their role and value as part of a multi-sectoral response. What makes one peer-led program a better investment than another? What role does the rest of the sector have in ensuring we gain the most value from these investments? To investigate this, we facilitated interactive systems thinking methods with 10 programs working within communities of people who inject drugs, gay men, sex workers and people living with HIV across Australia. This included articulating program theories in diagram and textual form to help us understand the role of peer-based programs promoting peer leadership within the Australian HIV and hepatitis C responses. Our aim was to develop a framework for monitoring and evaluation that could be applied to peer led programs at different levels and in different contexts. We found that for peer-led programs to fulfill their role, and to navigate the rapid changes occurring in the both epidemics, they need to: demonstrate the credibility of their peer and community insights; continually adapt to changing contexts and policy priorities in tandem with their communities; and maintain influence in both community and policy systems. We developed a framework of four key functions (Engagement, Alignment, Adaptation, and Influence) which peer-based programs need to demonstrate, which form the basis for identifying quality indicators. This article presents a new way of framing and monitoring investments in peer-led programs and peer eadership actions by these programs. If health policy is committed to strengthening the leadership shown by affected communities, then we need to understand, enhance, monitor and value the role of peer-led programs and peer leadership within the overall prevention system. We believe the W3 framework, drawing on systems thinking and modeling, can support funders, policy-makers and programs to achieve this.

Rising Chlamydia and Gonorrhoea Incidence and Associated Risk Factors Among Female Sex Workers in Australia: A Retrospective Cohort Study.

BACKGROUND: Female sex workers in Australia have achieved some of the lowest documented prevalences of human immunodeficiency virus (HIV) and other sexually transmissible infections globally but rates overall are increasing in Australia and warrant closer investigation. METHODS: We constructed a retrospective cohort using repeat testing data extracted from a network of 42 sexual health clinics. Poisson and Cox regression were used to determined trends in incidence and risk factors for HIV, chlamydia, gonorrhoea, and infectious syphilis among female sex workers. RESULTS: From 2009 to 2015, 18,475 women reporting sex work attended a participating service. The overall incidence of urogenital chlamydia was 7.7/100 person years (PY), declining by 38% from 2009 to 2013 before increasing by 43% to 2015 (P < 0.001); anorectal chlamydia incidence was 0.6/100 PY, and pharyngeal was 1.9/100 PY, which increased significantly during the study period (P < 0.001, both). For gonorrhoea, the urogenital incidence was 1.4/100 PY, anorectal incidence was 0.3/100 PY, P < 0.001), and 3.6/100 PY for pharyngeal; urogenital incidence doubled during the study period, anorectal increased fivefold, and pharyngeal more than tripled (P < 0.001, all). Incidence of infectious syphilis was 0.4/100 PY, which remained stable from 2009 to 2015 (P = 0.09). There were seven incident infections of HIV among female sex workers (0.1/100 PY). Inconsistent condom use with private partners, higher number of private partner numbers, recent injecting drug use, younger age, and country of birth variously predicted sexually transmissible infections among female sex workers. CONCLUSIONS: Although infectious syphilis and HIV remain uncommon in female sex workers attending Australian sexual health clinics, the increasing incidence of gonorrhoea across anatomical sites and increasing chlamydia after a period of decline demands enhanced health promotion initiatives.