Considering Risk Contexts in Explaining the Paradoxical HIV Increase among Female Sex Workers in Mumbai & Thane, India

BACKGROUND:

The period 2006-2009 saw intensive scale-up of HIV prevention efforts and an increase in reported safer sex among brothel and street-based sex workers in Mumbai and Thane (Maharashtra, India). Yet during the same period, the prevalence of HIV increased in these groups. A better understanding of sex workers' risk environment is needed to explain this paradox.

METHODS:

In this qualitative study we conducted 36 individual interviews, 9 joint interviews, and 10 focus group discussions with people associated with HIV interventions between March and May 2012.

RESULTS:

Dramatic changes in Mumbai's urban landscape dominated participants' accounts, with dwindling sex worker numbers in traditional brothel areas attributed to urban restructuring. Gentrification and anti-trafficking efforts explained an escalation in police raids. This contributed to dispersal of sex work with the sex-trade management adapting by becoming more hidden and mobile, leading to increased vulnerability. Affordable mobile phone technology enabled independent sex workers to trade in more hidden ways and there was an increased dependence on lovers for support. The risk context has become ever more challenging, with animosity against sex work amplified since the scale up of targeted interventions. Focus on condom use with sex workers inadvertently contributed to the diversification of the sex trade as clients seek out women who are less visible. Sex workers and other marginalised women who sell sex all strictly prioritise anonymity. Power structures in the sex trade continue to pose insurmountable barriers to reaching young and new sex workers. Economic vulnerability shaped women's decisions to compromise on condom use. Surveys monitoring HIV prevalence among 'visible' street and brothel-bases sex workers are increasingly un-representative of all women selling sex and self-reported condom use is no longer a valid measure of risk reduction.

CONCLUSIONS:

Targeted harm reduction programmes with sex workers fail when implemented in complex urban environments that favour abolition. Increased stigmatisation and dispersal of risk can no longer be considered as unexpected. Reaching the increasing proportion of sex workers who intentionally avoid HIV prevention programmes has become the main challenge. Future evaluations need to incorporate building 'dark logic' models to predict potential harms.

“… Because of the ban we [bar girls] have to sell our rooms, our jewellery; we are facing lot of problems. Circumstances have made us to do what we did not wish to do [sex-work]. Previously we used to take one week just to tell our name to the customer. Now when a bar girl walks on the road, looking at man, at the back of her mind, she thinks - this is a rich person, he should come to me. … We used to think several times before taking one customer in a month. Now we take four customers in a day. Earlier what we used to earn through dance now we are not getting by sleeping.” [ORWs & PEs, (23)].

“Yes, at the time of breaking seal (virginity) the condom is not used. For that they pay INR 40,000 to 50,000 [about USD 1000/-] for [being with the girl for] 24 hours. They keep the girl for one or two days with them, and do the sex with her by drinking liquor. They [clients] think that since the girl is ‘seal pack’ she does not have HIV infection. So they do not use condom.” [PE, (6)].

“I have an HIV positive sex worker … even when she knows her status and after we have counselled her, she does not use condom with her regular partner. He knows about the fact that she is positive; … he told us that because he loved her he wouldn’t use condom [with her].” [Head, CBO (15)]...

Full article at:   http://goo.gl/aHwsvI

By:  Bandewar SV1, Bharat S2, Kongelf A3, Pisal H4, Collumbien M5.

• 1Independent Senior Research Professional in Bioethics, Global Health, and Program Evaluation, Pune, MH, 411 008, India. sunita.bandewar@utoronto.ca.
• 2School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, MH, India. sbharat@tiss.edu.
• 3Present address: Norwegian Red Cross, Vestlia 4, Jessheim, Norway. kongelf.anine@gmail.com.
• 4Independent Senior Research Professional, Pune, MH, India. hema_pisal@hotmail.com.
• 5London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, UK. martine.collumbien@lshtm.ac.uk. 
• BMC Public Health. 2016 Jan 28;16(1):85. doi: 10.1186/s12889-016-2737-2.

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Determinants of Heterosexual Adolescents Having Sex with Female Sex Workers in Singapore

OBJECTIVES:

We assessed the proportion of and socio-ecological factors associated with ever having had sex with female sex workers (FSWs) among heterosexual adolescents. We also described the characteristics of the adolescents who reported inconsistent condom use with FSWs.

METHODS:

This is a cross-sectional study (response rate: 73%) of 300 heterosexually active male adolescents of 16 to 19 years attending a national STI clinic in Singapore between 2009 and 2014. We assessed the ecological factors (individual, parental, peer, school and medial influences) and sexual risk behaviors using a self-reported questionnaire. Poisson regression was used to obtain the adjusted prevalence ratios (aPR) and confidence intervals (CI).

RESULTS:

The proportion of heterosexual male adolescents who had ever had sex with FSWs was 39%. Multivariate analysis showed that significant factors associated with ever having had sex with FSWs were sex initiation before 16 years old (aPR 1.79 CI: 1.30-2.46), never had a sexually active girlfriend (aPR 1.75 CI 1.28-2.38), reported lower self-esteem score (aPR 0.96 CI: 0.93-0.98), higher rebelliousness score (aPR 1.03 CI: 1.00-1.07) and more frequent viewing of pornography (aPR 1.47 CI: 1.04-2.09). Lifetime inconsistent condom use with FSWs was 30%.

CONCLUSIONS:

A significant proportion of heterosexual male adolescents attending the public STI clinic had ever had sex with FSWs. A targeted intervention that addresses different levels of influence to this behavior is needed. This is even more so because a considerable proportion of adolescents reported inconsistent condom use with FSWs, who may serve as a bridge of STI transmission to the community. National surveys on adolescent health should include the assessment of frequency of commercial sex visits and condom use with FSWs for long-term monitoring and surveillance.

Below:  Percentage of sexually active adolescents aged 16–19 years who used condom inconsistently with female sex workers in the past year by country of female sex workers

Below:  Percentage of sexually active adolescents aged 16–19 years who used condom inconsistently with female sex workers in the past year by type of female sex workers

Full article at:   http://goo.gl/IkwOlI

By:  Ng JY¹, Wong ML¹.

¹Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.

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Scale-Up, Retention & HIV/STI Prevalence Trends among Female Sex Workers Attending VICITS Clinics in Guatemala

Since 2007, Guatemala integrated STI clinical service with an HIV prevention model into four existing public health clinics to prevent HIV infection, known as the VICITS strategy. We present the first assessment of VICITS scale-up, retention, HIV and STI prevalence trends, and risk factors associated with HIV infection among Female Sex Workers (FSW) attending VICITS clinics in Guatemala.

Demographic, behavioral and clinical data were collected using a standardized form. Data was analyzed by year and health center. HIV and STI prevalence were estimated from routine visits. Retention was estimated as the percent of new users attending VICITS clinics who returned for at least one follow-up visit to any VICITS clinic within 12 months. Separate multivariate logistic regression models were conducted to investigate factors associated with HIV infection and program retention.

During 2007-2011 5,682 FSW visited a VICITS clinic for the first-time. HIV prevalence varied from 0.4% to 5.8%, and chlamydia prevalence from 0% to 14.3%, across sites. Attending the Puerto Barrios clinic, having a current syphilis infection, working primarily on the street, and using the telephone or internet to contact clients were associated with HIV infection. The number of FSW accessing VICITS annually increased from 556 to 2,557 (361%) during the period. In 2011 retention varied across locations from 7.7% to 42.7%. Factors negatively impacting retention included current HIV diagnosis, having practiced sex work in another country, being born in Honduras, and attending Marco Antonio Foundation or Quetzaltenango clinic sites. Systematic time trends did not emerge, however 2008 and 2010 were characterized by reduced retention.

Our data show local differences in HIV prevalence and clinic attendance that can be used to prioritize prevention activities targeting FSW in Guatemala. VICITS achieved rapid scale-up; however, a better understanding of the causes of low return rates is urgently needed.

Below:  Number of active FSW attending VICITS clinics over time by clinic, Guatemala, 2007–2011

Risk factors associated with HIV infection among FSW attending VICITS clinics for the first time, Guatemala, 2007–2011 (N = 4,021).

Variable	OR (95% CI)	AOR (95% CI)
Age
18–24	1.00
25–34	1.09 (0.61–1.95)
≥35	2.10 (1.04–4.24)
Clinic
Zone 3	1.00	1.00
FMA	2.09 (1.06–4.10)	0.73 (0.31–1.71)
Puerto Barrios	4.58 (2.40–8.74)	4.52 (2.09–9.78)
Quetzaltenango	0.75 (0.18–3.15)	1.11 (0.26–1.71)
Highest level of education completed
<Primary	1.00	1.00
Primary	0.44 (0.24–0.81)	0.51 (0.28–0.93)
≥HS	0.54 (0.26–1.11)	0.73 (0.35–1.54)
Current syphilis infection	6.13 (2.13–17.59)	4.32 (1.46–12.81)
Sex work location
Strip club	1.00	1.00
Bar	2.42 (1.17–5.02)	1.37 (0.61–3.11)
Street	3.69 (1.67–8.18)	4.14 (1.60–10.69)
Brothels based at residential homes	0.94 (0.33–2.72)	1.01 (0.35–2.94)
Other (telephone or internet)	3.13 (1.15–8.54)	3.40 (1.11–10.38)

Full article at: http://goo.gl/49AN6S

By: Morales-Miranda S1, Jacobson JO1, Loya-Montiel I1, Mendizabal-Burastero R1, Galindo-Arandi C1, Flores C2, Chen SY3.

• 1Center for Health Studies, Universidad del Valle de Guatemala, Guatemala City, Guatemala.
• 2National STI/HIV/AIDS Program, Ministry of Public Health, Guatemala City, Guatemala.
• 3Division of Global HIV/AIDS, Centers for Disease Control and Prevention - Central America Regional Office, Guatemala City, Guatemala. 

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Heterosexual Men Who Patronise Entertainment Establishments Versus Brothels in an Asian Urban Setting – Which Group Practises Riskier Sexual Behaviours?

Below:  Reasons for unprotected last sex with different partner types for men who patronised entertainment establishments

Below:  Reasons for unprotected last sex with different partner types for men who patronised brothels

Men who patronised entertainment establishments (EEs) were younger, more likely to be single, more highly-educated and comprised more professionals compared to the brothel group. On multivariable analysis, consistent condom use for vaginal sex decreased at the EE setting (aOR 0.64; 95 % CI: 0.42 –0.97) and with alcohol use before sex (aOR 0.67; 95 % CI: 0.46 – 0.98) and increased with perceived high risk of getting HIV/STIs from partner (aOR 2.08; 95 % CI: 1.30 – 3.32) and partner’s request for condom use (aOR 5.48; 95 % CI: 1.20 – 25.11). For consistent condom use with oral sex, this decreased at the EE setting (aOR 0.64; 95 % CI: 0.39 – 0.98) and with alcohol use before sex (aOR 0.50; 95 % CI: 0.31 – 0.81) and increased with partner’s request for condom use (aOR 5.19; 95 % CI: 1.38 – 19.57).

Men who patronised EEs practised risker sexual behaviours compared to the brothel group. Priority should be given for intervention programmes to target men who patronise EEs, which could involve the female EE workers, the EE owners as well as the managers for effective HIV/STI prevention.

Read more at:   http://ht.ly/QTgpj HT @NUSingapore