The impact of policing and homelessness on violence experienced by women who sell sex in London: a modelling study.

Street-based sex workers experience considerable homelessness, drug use and police enforcement, making them vulnerable to violence from clients and other perpetrators. We used a deterministic compartmental model of street-based sex workers in London to estimate whether displacement by police and unstable housing/homelessness increases client violence. The model was parameterized and calibrated using data from a cohort study of sex workers, to the baseline percentage homeless (64%), experiencing recent client violence (72%), or recent displacement (78%), and the odds ratios of experiencing violence if homeless (1.97, 95% confidence interval 0.88-4.43) or displaced (4.79, 1.99-12.11), or of experiencing displacement if homeless (3.60, 1.59-8.17). Ending homelessness and police displacement reduces violence by 67% (95% credible interval 53-81%). The effects are non-linear; halving the rate of policing or becoming homeless reduces violence by 5.7% (3.5-10.3%) or 6.7% (3.7-10.2%), respectively. Modelled interventions have small impact with violence reducing by: 5.1% (2.1-11.4%) if the rate of becoming housed increases from 1.4 to 3.2 per person-year (Housing First initiative); 3.9% (2.4-6.9%) if the rate of policing reduces by 39% (level if recent increases had not occurred); and 10.2% (5.9-19.6%) in combination. Violence reduces by 26.5% (22.6-28.2%) if half of housed sex workers transition to indoor sex work. If homelessness decreased and policing increased as occurred during the COVID-19 pandemic in 2020, the impact on violence is negligible, decreasing by 0.7% (8.7% decrease-4.1% increase). Increasing housing and reducing policing among street-based sex workers could substantially reduce violence, but large changes are needed.

Health risks at work mean risks at home: Spatial aspects of COVID-19 among migrant workers in precarious jobs in England.

During COVID-19 lockdowns in England, 'key workers' including factory workers, carers and cleaners had to continue to travel to workplaces. Those in key worker jobs were often from more marginalised communities, including migrant workers in precarious employment. Recognising space as materially and socially produced, this qualitative study explores migrant workers' experiences of navigating COVID-19 risks at work and its impacts on their home spaces. Migrant workers in precarious employment often described workplace COVID-19 protection measures as inadequate. They experienced work space COVID-19 risks as extending far beyond physical work boundaries. They developed their own protection measures to try to avoid infection and to keep the virus away from family members. Their protection measures included disinfecting uniforms, restricting leisure activities and physically separating themselves from their families. Inadequate workplace COVID-19 protection measures limited workers' ability to reduce risks. In future outbreaks, support for workers in precarious jobs should include free testing, paid sick leave and accommodation to allow for self-isolation to help reduce risks to workers' families. Work environments should not be viewed as discrete risk spaces when planning response measures; responses and risk reduction approaches must also take into account impacts on workers' lives beyond the workplace.

Community-led responses to COVID-19 within Gypsy and Traveller communities in England: A participatory qualitative research study.

Individuals were asked to play an active role in infection control in the COVID-19 pandemic. Yet while government messages emphasised taking responsibility for the public good (e.g. to protect the National Health Service), they appeared to overlook social, economic and political factors affecting the ways that people were able to respond. We co-produced participatory qualitative research with members of Gypsy and Traveller communities in England between October 2021 and February 2022 to explore how they had responded to COVID-19, its containment (test, trace, isolate) and the contextual factors affecting COVID-19 risks and responses within the communities. Gypsies and Travellers reported experiencing poor treatment from health services, police harassment, surveillance, and constrained living conditions. For these communities, claiming the right to health in an emergency required them to rely on community networks and resources. They organised collective actions to contain COVID-19 in the face of this ongoing marginalisation, such as using free government COVID-19 tests to support self-designed protective measures including community-facilitated testing and community-led contact tracing. This helped keep families and others safe while minimising engagement with formal institutions. In future emergencies, communities must be given better material, political and technical support to help them to design and implement effective community-led solutions, particularly where government institutions are untrusted or untrustworthy.

COVID-19 vaccination decisions among Gypsy, Roma, and Traveller communities: A qualitative study moving beyond "vaccine hesitancy".

BACKGROUND: Many people refuse vaccination and it is important to understand why. Here we explore the experiences of individuals from Gypsy, Roma, and Traveller groups in England to understand how and why they decided to take up or to avoid COVID-19 vaccinations. METHODS: We used a participatory, qualitative design, including wide consultations, in-depth interviews with 45 individuals from Gypsy, Roma, and Traveller, communities (32 female, 13 male), dialogue sessions, and observations, in five locations across England between October 2021 and February 2022. FINDINGS: Vaccination decisions overall were affected by distrust of health services and government, which stemmed from prior discrimination and barriers to healthcare which persisted or worsened during the pandemic. We found the situation was not adequately characterised by the standard concept of "vaccine hesitancy". Most participants had received at least one COVID-19 vaccine dose, usually motivated by concerns for their own and others' health. However, many participants felt coerced into vaccination by medical professionals, employers, and government messaging. Some worried about vaccine safety, for example possible impacts on fertility. Their concerns were inadequately addressed or even dismissed by healthcare staff. INTERPRETATION: A standard "vaccine hesitancy" model is of limited use in understanding vaccine uptake in these populations, where authorities and health services have been experienced as untrustworthy in the past (with little improvement during the pandemic). Providing more information may improve vaccine uptake somewhat; however, improved trustworthiness of health services for GRT communities is essential to increase vaccine coverage. FUNDING: This paper reports on independent research commissioned and funded by the National Institute for Health Research (NIHR) Policy Research Programme. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health and Social Care or its arm's length bodies, and other Government Departments.

The Effect of Systemic Racism and Homophobia on Police Enforcement and Sexual and Emotional Violence among Sex Workers in East London: Findings from a Cohort Study.

There is extensive qualitative evidence of violence and enforcement impacting sex workers who are ethnically or racially minoritized, and gender or sexual minority sex workers, but there is little quantitative evidence. Baseline and follow-up data were collected among 288 sex workers of diverse genders (cis/transgender women and men and non-binary people) in London (2018-2019). Interviewer-administered and self-completed questionnaires included reports of rape, emotional violence, and (un)lawful police encounters. We used generalized estimating equation models (Stata vs 16.1) to measure associations between (i) ethnic/racial identity (Black, Asian, mixed or multiple vs White) and recent (6 months) or past police enforcement and (ii) ethnic/racial and sexual identity (lesbian, gay or bisexual (LGB) vs. heterosexual) with recent rape and emotional violence (there was insufficient data to examine the association with transgender/non-binary identities). Ethnically/racially minoritized sex workers (26.4%) reported more police encounters partly due to increased representation in street settings (51.4% vs 30.7% off-street, p = 0.002). After accounting for street setting, ethnically/racially minoritized sex workers had higher odds of recent arrest (adjusted odds ratio 2.8, 95% CI 1.3-5.8), past imprisonment (aOR 2.3, 95% CI 1.1-5.0), police extortion (aOR 3.3, 95% CI 1.4-7.8), and rape (aOR 3.6, 95% CI 1.1-11.5). LGB-identifying sex workers (55.4%) were more vulnerable to rape (aOR 2.4, 95% CI 1.1-5.2) and emotional violence. Sex workers identifying as ethnically/racially minoritized (aOR 2.1, 95% CI 1.0-4.5), LGB (aOR 2.0, 95% CI 1.0-4.0), or who use drugs (aOR 2.0, 95% CI 1.1-3.8) were more likely to have experienced emotional violence than white-identifying, heterosexual or those who did not use drugs. Experience of any recent police enforcement was associated with increased odds of rape (aOR 3.6, 95% CI 1.3-8.4) and emotional violence (aOR 4.9, 95% CI 1.8-13.0). Findings show how police enforcement disproportionately targets ethnically/racially minoritized sex workers and contributes to increased risk of rape and emotional violence, which is elevated among sexual and ethnically/racially minoritized workers.

'We go where we know': Reflections from Mobilizing for PrEP and Sexual Health (MobPrESH) - A peer-led PrEP education programme across England, for and by women and non-binary people.

BACKGROUND: Pre-exposure prophylaxis is a highly effective method of HIV prevention but few women know about it, have access to it, or see it as relevant to them. In 2019, grassroots organization PrEPster piloted a peer-led intervention, MobPrESH (Mobilizing for Pre-Exposure prophylaxis (PrEP) and Sexual Health), across three sites in England, to mobilize for PrEP and sexual health with communities of women and non-binary people most affected by HIV, including Black women and non-binary people, people of colour, migrants, and transgender (trans) women. OBJECTIVES: We aimed to explore the accessibility, feasibility, acceptability, and 'fidelity' of MobPrESH, from the perspectives of peer mobilizers and project staff. METHODS: We conducted focus group discussions and qualitative interviews with nine peer mobilizers (most identified as Black cisgender (cis) women) and six project staff (including Black and white cis women and non-binary people). We analysed data thematically, iteratively, and inductively, informed by concepts of reproductive and social justice. RESULTS: We present findings in five thematic areas: connecting and relating to situate sexual health discussions, navigating silence and stigma, connecting within and across communities, competing pressures and structural hostilities, and resources and continuity. Community knowledge-building about PrEP is a slow, iterative process that needs investment and creation of trusted spaces that centre communities' needs and concerns. Peer mobilizers and the communities they engaged with had competing demands in their lives, and knowledge-raising about PrEP was impacted by intersecting stigmas, discrimination, and oppressions around HIV status, racism, misogyny, transphobia, homophobia, and anti-sex worker rhetoric. CONCLUSIONS: Peer-led PrEP interventions require funding and foregrounding, particularly for women and non-binary people who are Black, trans, migrants, and people of colour, situated relative to their wider health needs, life pressures, and priorities. This requires concurrent challenge of the racist and patriarchal structures that continue to obscure the sexual and reproductive health needs of racially minoritized and marginalized women and non-binary people.

Effect of police enforcement and extreme social inequalities on violence and mental health among women who sell sex: findings from a cohort study in London, UK.

OBJECTIVES: To examine legal and social determinants of violence, anxiety/depression among sex workers. METHODS: A participatory prospective cohort study among women (inclusive of transgender) ≥18 years, selling sex in the last 3 months in London between 2018 and 2019. We used logistic generalised estimating equation models to measure associations between structural factors on recent (6 months) violence from clients or others (local residents, strangers), depression/anxiety (Patient Health Questionnaire-4). RESULTS: 197 sex workers were recruited (96% cisgender-women; 46% street-based; 54% off-street) and 60% completed a follow-up questionnaire. Street-based sex workers experienced greater inequalities compared with off-street in relation to recent violence from clients (73% vs 36%); police (42% vs 7%); intimate partner violence (IPV) (56% vs 18%) and others (67% vs 17%), as well as homelessness (65% vs 7%) and recent law enforcement (87% vs 9%). Prevalence of any STI was 17.5% (17/97). For street-based sex workers, recent arrest was associated with violence from others (adjusted OR (aOR) 2.77; 95% CI 1.11 to 6.94) and displacement by police was associated with client violence (aOR 4.35; 95% CI 1.36 to 13.90). Financial difficulties were also associated with client violence (aOR 4.66; 95% CI 1.64 to 13.24). Disability (aOR 3.85; 95% CI 1.49 to 9.95) and client violence (aOR 2.55; 95% CI 1.10 to 5.91) were associated with anxiety/depression. For off-street sex workers, financial difficulties (aOR 3.66; 95% CI 1.64 to 8.18), unstable residency (aOR 3.19; 95% CI 1.36 to 7.49), IPV (aOR 3.77; 95% CI 1.30 to 11.00) and alcohol/drug use were associated with client violence (aOR 3.16; 95% CI 1.26 to 7.92), while always screening and refusing clients was protective (aOR 0.36; 95% CI 0.15 to 0.87). Disability (aOR 5.83; 95% CI 2.34 to 14.51), unmet mental health needs (aOR 3.08; 95% CI 1.15 to 8.23) and past eviction (aOR 3.99; 95% CI 1.23 to 12.92) were associated with anxiety/depression. CONCLUSIONS: Violence, anxiety/depression are linked to poverty, unstable housing and police enforcement. We need to modify laws to allow sex workers to work safely and increase availability of housing and mental health services.

(Not) talking about fertility: the role of digital technologies and health services in helping plan pregnancy. A qualitative study.

AIM: To explore how women and their partners navigate (pre)conception healthcare and the role of Natural Cycles fertility awareness technology in this process. METHODS: In-depth interviews with 24 cisgender women aged 24-43 years who had used Natural Cycles' 'Plan a Pregnancy' mode, and six partners of Natural Cycles users, all cisgender men aged 30-39 years. Participants were recruited via direct messaging in the Natural Cycles app, social media and, for partners, snowball sampling. Purposive sampling was conducted to ensure diversity among participants. Interviews were audio-recorded and transcribed verbatim. An iterative, inductive approach was adopted for thematic data analysis. RESULTS: Natural Cycles helped most users better understand their menstrual cycles and fertility. Fertility awareness and preconception counselling with healthcare providers were uncommon. Women felt discussions about planning pregnancy in healthcare settings were often fraught with difficulties. They described not wanting to be an extra burden to overworked staff, being concerned that their worries about trying for pregnancy would be dismissed, or feeling staff did not have expertise in fertility awareness. Some women had shared their Natural Cycles data with healthcare professionals to demonstrate their menstrual cycle data or time of conception. However, it was not always clear to those not accessing services when they should seek further advice, for example, those using the app for longer time periods who had not yet conceived. CONCLUSIONS: Digital technologies can provide information and support for those wanting to conceive. They should, however, complement care in statutory services, and be accompanied by greater investment in fertility awareness and preconception support.

Fertility and digital technology: narratives of using smartphone app 'Natural Cycles' while trying to conceive.

Fertility awareness apps, which help to identify the 'fertile window' when conception is most likely, have been hailed as 'revolutionising' women's reproductive health. Despite rapidly growing popularity, little research has explored how people use these apps when trying to conceive and what these apps mean to them. We draw on in-depth, qualitative interviews, adopting a critical digital health studies lens (a sub-field of science and technology studies), to explore the experiences of cisgender women and partners with one such app, Natural Cycles, in the context of their daily lives. We found that many women valued the technology as a 'natural', inobtrusive alternative to biomedical intervention, and a means of controlling and knowing their bodies, amid a dearth of fertility-related education and care. Yet this technology also intervened materially and affectively into the spaces of their lives and relationships and privileged disembodied metrics (temperature) over embodied knowledge. Meanwhile, app language, advertising and cost have contributed to characterising 'typical' users as white, heterosexual, affluent, cisgender women without disabilities. In the context of neoliberal shifts towards bodily self-tracking, technologies appealing as novel, liberating and 'natural' to individuals who can access them may nevertheless reproduce highly gendered reproductive responsibilities, anxieties and broader health and social inequalities.

'Just another vial ': a qualitative study to explore the acceptability and feasibility of routine blood-borne virus testing in an emergency department setting in the UK.

OBJECTIVES: Increased test uptake for HIV and viral hepatitis is fast becoming a health priority at both national and global levels. Late diagnosis of these infections remains a critical public health concern in the UK. Recommendations have been issued to expand blood-borne virus (BBV) testing in alternative settings. Emergency departments (EDs) offer a potentially important point of testing. This paper presents findings from a qualitative study which aimed to explore the acceptability and feasibility of a routine opt-out combined BBV testing intervention implemented at an inner London ED. METHODS: We conducted 22 semistructured interviews with patients and service providers in the ED over a 4-month period during the intervention pilot. A grounded analytical approach was employed to conduct thematic analysis of qualitative study data. RESULTS: Core interrelating thematic areas, identified and analytically developed in relation to test intervention implementation and experience, included the following: the remaking of routine test procedure; notions of responsibility in relation to status knowledge and test engagement; the opportunity and constraints of the ED as a site for testing; and the renegotiation of testing cultures within and beyond the clinic space. CONCLUSION: Study findings demonstrate how relational and spatial dynamics specific to the ED setting shape test meaning and engagement. We found acceptability of the test practice was articulated through narratives of situated responsibility, with the value of the test offset by perceptions of health need and justification of the test expense. Participant accounts indicate that the nontargeted approach of the test affords a productive disruption to 'at-risk' identities, yet they also reveal limits to the test intervention's 'normalising' effect. Evaluation of the intervention must attend to the situated dynamics of the test practice if opportunities of an opt-out BBV test procedure are to be fully realised. Findings also highlight the critical need to further evaluate post-test intervention practices and experiences.

Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies.

BACKGROUND: Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur. METHODS AND FINDINGS: We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing. CONCLUSIONS: Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.

Integrated opioid substitution therapy and HIV care: a qualitative systematic review and synthesis of client and provider experiences.

People who use drugs in many contexts have limited access to opioid substitution therapy and HIV care. Service integration is one strategy identified to support increased access. We reviewed and synthesized literature exploring client and provider experiences of integrated opioid substitution therapy and HIV care to identify acceptable approaches to care delivery. We systematically reviewed qualitative literature. We searched nine bibliographic databases, supplemented by manual searches of reference lists of articles from the database search, relevant journals, conferences, key organizations and consultation with experts. Thematic synthesis was used to develop descriptive themes in client and provider experiences. The search yielded 11 articles for inclusion, along with 8 expert and policy reports. We identify five descriptive themes: the convenience and comprehensive nature of co-located care, contrasting care philosophies and their role in shaping integration, the limits to disclosure and communication between clients and providers, opioid substitution therapy enabling HIV care access and engagement, and health system challenges to delivering integrated services. The discussion explores how integrated opioid substitution therapy and HIV care needs to adapt to specific social conditions, rather than following universal approaches. We identify priorities for future research. Acceptable integrated opioid substitution therapy and HIV care for people who use drugs and providers is most likely through co-located care and relies upon attention to stigma, supportive relationships and client centred cultures of delivery. Further research is needed to understand experiences of integrated care, particularly delivery in low and middle income settings and models of care focused on community and non-clinic based delivery.

Tuberculosis, injecting drug use and integrated HIV-TB care: a review of the literature.

BACKGROUND: People who inject drugs (PWID) are at increased risk of tuberculosis (TB) and reduced retention in treatment. There is a need to document strategies for integrated delivery of HIV, TB and drug dependency care. METHODS: This article reviews the literature on rates of TB mono- and co-infection, and published and grey literature descriptions of TB and HIV-TB care, among PWID. RESULTS: Latent TB infection prevalence was high and active disease more common among HIV-positive PWID. Data on multidrug-resistant TB and co-infections among PWID were scarce. Models of TB care fell into six categories: screening and prevention within HIV-risk studies; prevention at TB clinics; screening and prevention within needle-and-syringe-exchange (NSP) and drug treatment programmes; pharmacy-based TB treatment; TB service-led care with harm reduction/drug treatment programmes; and TB treatment within drug treatment programmes. Co-location with NSP and opioid substitution therapy (OST), combined with incentives, consistently improved screening and prevention uptake. Small-scale combined TB treatment and OST achieved good adherence in diverse settings. Successful interventions involved collaboration across services; a client-centred approach; and provision of social care. No peer-reviewed studies described models of integrated HIV-TB care for PWID but grey literature highlighted key components: co-located services, provision of drug treatment, multidisciplinary staff training; and remaining barriers: staffing inefficiencies, inadequate funding, police interference, and limited OST availability. CONCLUSIONS: Integration with drug treatment improves PWID engagement in TB services but there is a need to document approaches to HIV-TB care, improve surveillance of TB and co-infections among PWID, and advocate for improved OST availability.

Systematic review examining differences in HIV, sexually transmitted infections and health-related harms between migrant and non-migrant female sex workers.

OBJECTIVES: To assess the evidence of differences in the risk of HIV, sexually transmitted infections (STI) and health-related behaviours between migrant and non-migrant female sex workers (FSWs). METHODS: Systematic review of published peer-reviewed articles that reported data on HIV, STIs or health-related harms among migrant compared with non-migrant FSWs. Studies were mapped to describe their methods and focus, with a narrative synthesis undertaken to describe the differences in outcomes by migration status overall and stratified by country of origin. Unadjusted ORs are presented graphically to describe differences in HIV and acute STIs among FSWs by migration and income of destination country. RESULTS: In general, migrant FSWs working in lower-income countries are more at risk of HIV than non-migrants, but migrants working in higher-income countries are at less risk. HIV prevalence was higher among migrant FSWs from Africa in high-income countries. Migrant FSWs in all countries are at an increased risk of acute STIs. Study designs, definitions of FSWs and recruitment methods are diverse. Behavioural data focussed on sexual risks. DISCUSSION: The lack of consistent differences in risk between migrants and non-migrants highlights the importance of the local context in mediating risk among migrant FSWs. The higher prevalence of HIV among some FSWs originating from African countries is likely to be due to infection at home where HIV prevalence is high. There is a need for ongoing monitoring and research to understand the nature of risk among migrants, how it differs from that of local FSWs and changes over time to inform the delivery of services.

Risk of sexually transmitted infections and violence among indoor-working female sex workers in London: the effect of migration from Eastern Europe.

OBJECTIVES: To examine risk factors associated with HIV and sexually transmitted infections (STIs) and experience of physical and sexual violence among sex workers in London, with a particular focus on differences in risk between migrants from Eastern Europe (EE) or the Former Soviet Union (FSU) and UK-born sex workers. METHODS: The authors conducted a cross-sectional survey of sex workers born in the UK, EE or FSU (n = 268), collecting behavioural data, testing for antibodies to HIV and Treponema pallidum, and testing for infection with Chlamydia trachomatis or Neisseria gonorrhoea. FINDINGS: Migrants were younger, saw more clients, and were less likely to use contraception; few reported being coerced into sex work. Overall, prevalence of HIV was 1.1% (95% CI -0.1% to 2.4%), prevalence of syphilis was 2.2% (95% CI 0.4 to 4.0%), and prevalence of infection with chlamydia or gonorrhoea was 6.4% (95% CI 3.2% to 9.6%). Risk factors associated with any infection included having no contact with an outreach worker, age, and having a non-paying sex partner. Increased risk of physical violence from clients was associated with a history of imprisonment or arrest and having a non-paying sex partner. CONCLUSION: Findings suggest an association between outreach services and reduced risk of STIs and between having non-paying partners and increased risk of STIs. Findings also suggest an association between enforcement policies, such as arrest or imprisonment, and drug use and increased risk of physical violence. Interventions are needed to expand outreach, improve uptake of contraceptives for migrants, and reduce levels of violence for all women.