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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Systematic Review of Interventions to Reduce Illicit Drug Use in Female Drug-Dependent Street Sex Workers

OBJECTIVES:

Most female street-based sex workers (SSWs) are drug users and this group experience particularly poor outcomes in achieving and maintaining abstinence. In 2010 the UK adopted a recovery-orientated Drug Strategy. This strategy did not specifically highlight the complex drug treatment needs of SSWs. Therefore we sought to synthesise and critically appraise existing evidence of interventions to reduce illicit drug use in this group, in order to guide service change toward better provision for the drug treatment needs of SSWs.

METHODS:

A systematic review of evidence on the effectiveness of interventions to reduce illicit drug use in female SSWs. Following the PRISMA guidelines, a structured search strategy was used. Searches included databases, organisational and government websites to identify published and grey literature, as well as contacting experts in the field, and hand-searching reference lists and journals.

RESULTS:

Six studies, one experimental and five observational, were identified which met review inclusion criteria. Intervention approaches evaluated included substitute prescribing, educational sessions and motivational interviewing. All studies reported a positive intervention effect but the five observational studies were all subject to a relatively high risk of bias. By contrast, the experimental study provided little or no evidence of positive effect (OR for reduction of illicit drug in intervention compared to controls 1.17 95%CI 0.84-1.66 at 3 months and 1.14 (95% CI 0.8 to 1.61) at 6 months follow-up). All six studies described challenges and solutions to study recruitment, retention and follow-up, which were influenced by issues affecting SSWs' health and social stability.

CONCLUSIONS:

There is currently no strong evidence for effectiveness of interventions to reduce illicit drug use in female SSWs with problematic drug use. Thus, the development and robust evaluation of effective interventions should be a priority if recovery-orientated goals are to become more achievable for this group.

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By:  Jeal N1, Macleod J1, Turner K1, Salisbury C1.

• 1Centre for Academic Primary Care School of Social & Community medicine, University of Bristol, Bristol, UK. 

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High Prevalence of Syphilis among Street-Based Female Sex workers in Nanchang, China

Female sex workers (FSWs) play a critical role in the heterosexual transmission of human immunodeficiency virus (HIV)/sexually transmitted infections (STIs) in China. Several studies reported that street-based FSWs have higher risk behaviors than establishment-based FSWs. Therefore, street-based FSWs should be specifically targeted for HIV and STIs intervention programs.

This study aims to investigate the prevalence rates and risk factors of HIV and syphilis among FSWs in Nanchang, China.

Using convenience sampling methods, 361 street-based FSWs were recruited from August 2011 to February 2012. All participants completed an anonymous questionnaire on socioeconomic and sex behavioral information and were tested for HIV and syphilis. Risk for HIV and syphilis infection was assessed using univariate and multivariate logistic regression analyses. 

• No HIV infections were found. 
• The prevalence rate of syphilis was 43.5%. 
• Nearly 46.1% of street-based FSWs reported having education for no more than 6 years. 
• Having reproductive tract infections at current visit, duration of sex work more than 5 years, indulgence in unprotected sex trade in the last time, unprotected sex trade in the last month, and unprotected sex with boyfriend or spouse in the last month were reported by 35.2%, 43.5%, 33.8%, 60.4%, and 93.1% street-based FSWs, respectively. 

In multivariate logistic regression analysis, having reproductive tract infections at current visit, duration of sex work more than five years, and unprotected sex trade in the last month were independently associated with syphilis infection.

The prevalence rate of syphilis among street-based FSWs is very high. Most street-based FSWs in our survey had low education, long experience of commercial sex, and high rate of inconsistent condom use. Comprehensive interventions targeting this high-risk group, especially scaling up screening and ensuring consistent use of condoms during sex are needed.

Table 2

Association of sexual behavioral factors with syphilis infection among street-based female sex workers in Nanchang, Jiangxi province

Table 3

Factors associated with syphilis infection among street-based female sex workers in Nanchang, Jiangxi Province, as predicted by a multiple logistic regression model

Full article at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4228639/

By: Xiao Hua Tao, Tao Jiang,1 Dan Shao, Wei Xue, Fa Shun Ye, Ming Wang, and Mei Hua He

1Department of Gynaecology, The First People's Hospital of Jiujiang, Jiujiang, 332000, Jiangxi Province, China

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Correlates of HIV Infection among Street-Based and Venue-Based Sex Workers in Vietnam

Commercial sex work is one of the driving forces of the HIV epidemic across the world. In Vietnam, although female sex workers carry a disproportionate burden of HIV, little is known about the risk profile and associated factors for HIV infection among this population. There is a need for large-scale research to obtain reliable and representative estimates of the measures of association. 

This study involved secondary data analysis of the 'HIV/STI Integrated Biological and Behavioral Surveillance' study in Vietnam in 2009-2010 to examine the correlates of HIV among female sex workers. Data collected from 5298 female sex workers, including 2530 street-based sex workers and 2768 venue-based sex workers from 10 provinces in Vietnam, were analyzed using descriptive statistics, bivariate and multivariate logistic regression analyses. 

HIV prevalence among the overall FSW population was 8.6% (n = 453). However, when stratified by female sex worker subpopulations, HIV prevalence was 10.6% (n = 267) for street-based sex workers and 6.7% (n = 186) for venue-based sex workers. Factors independently associated with HIV infection in multivariate analysis, regardless of sex work types, injecting drug use, high self-perceived HIV risk, and age ≥ 25 years. 

Additional factors independently associated with HIV risk within each female sex worker subpopulation included having ever been married among street-based sex workers and inconsistent condom use with clients and having sex partners who injected drugs among venue-based sex workers. 

Apart from strategies addressing modifiable risk behaviours among all female sex workers, targeted strategies to address specific risk behaviours within each female sex worker subpopulation should be adopted.

Via: http://goo.gl/kvF5pz  Purchase full article at: http://goo.gl/ch3X0k

By:  Le TT1, Nguyen QC2, Tran HT2, Schwandt M1, Lim HJ3.

• 1Department of Community Health and Epidemiology, College of Medicine University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
• 2FHI 360 Vietnam, Hanoi, Vietnam.
• 3Department of Community Health and Epidemiology, College of Medicine University of Saskatchewan, Saskatoon, Saskatchewan, Canada  

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Intimate-Partner and Client-Initiated Violence among Female Street-Based Sex Workers in China: Does a Support Network Help?

Globally, female street-based sex workers are vulnerable to gender-based violence. Previous research has shown having a peer social network can reduce sex workers’ risks of victimization. However, mechanisms of how social network impacts violence among female street-based sex workers are still far from clear.

Our study was based on data abstracted from a paper-and-pencil survey administered among 218 female street-based sex workers in Shanghai, China. We focused on self-reported client-initiated violence and intimate-partner violence in emotional, physical, and sexual forms. Social networks were characterized by the size and sources of financial and psychosocial support (e.g. family, friends, and peers). Multi-variable logistic regression was used to estimate adjusted odds ratios (AOR) of each type of violence exposure by social network structure after the adjustment of age, education, and years in Shanghai.

The street-based female sex workers in our study were 

• primarily rural-to-urban migrants (95.7%) 
• with an average age of 41 years old. 
• 24.3% and 62.8% of the sex workers reported intimate-partner violence and client-initiated violence respectively. 
• Lack of financial support, as defined by having only one individual or none in her peer support system to help financially, was significantly associated with self-reported intimate-partner violence. 
• Respondents who reported client-initiated violence, by contrast, were more likely to report lacked psychosocial support from family and peers.

 This study is one of the first to systematically analyze the associations between social network and gender-based violence among street-based female sex worker. We reported a high prevalence of both types of gender-based violence and their complex associations with family, friends, and peer support network. Policies with goals to reduce violence against women may apply these findings to leverage social network in the interventions against gender-based violence.

Below:  Types of violence reported by female street-based sex workers who experienced intimate-partner violence or client-initiated violence in Shanghai, China from 2011-2012 (N = 218)

Full article at: http://goo.gl/NPhyzm

By: 

Katie Hail-Jares, Sugy Choi, Z. Jennifer Huang

Department of International Health, School of Nursing and Health Studies, Georgetown University, Washington, D.C., United States of America

Ruth C. F. Chang

Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, United States of America

Huang Zheng

Shanghai Piao Xue, Shanghai, China

Na He

Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China

  

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