Dual Sexual and Drug-related Predictors of Hepatitis C Incidence among Sex Workers in a Canadian Setting: Gaps and Opportunities for Scale-up of Hepatitis C Virus Prevention, Treatment, and Care

Background  Hepatitis C virus (HCV) represents a significant cause of morbidity and mortality globally. While sex workers may face elevated HCV risks through both drug and sexual pathways, incidence data among sex workers are severely lacking. HCV incidence and predictors of HCV seroconversion among women sex workers in Vancouver, BC were characterized in this study. Methods  Questionnaire and serological data were drawn from a community-based cohort of women sex workers (2010–2014). Kaplan–Meier methods and Cox regression were used to model HCV incidence and predictors of time to HCV seroconversion. Results  Among 759 sex workers, HCV prevalence was 42.7%. Among 292 baseline-seronegative sex workers, HCV incidence density was 3.84/100 person-years (PY), with higher rates among women using injection drugs (23.30/100 PY) and non-injection crack (6.27/100 PY), and those living with HIV (13.27/100 PY) or acute sexually transmitted infections (STIs) (5.10/100 PY). In Cox analyses adjusted for injection drug use, age (hazard ratio (HR) 0.94, 95% confidence interval (CI) 0.86–1.01), acute STI (HR 2.49, 95% CI 1.02–6.06), and non-injection crack use (HR 2.71, 95% CI 1.18–6.25) predicted time to HCV seroconversion. Discussion  While HCV incidence was highest among women who inject drugs, STIs and the use of non-injection stimulants appear to be pathways to HCV infection, suggesting potential dual sexual/drug transmission. Integrated HCV services within sexual health and HIV/STI programs are recommended

Barriers and Facilitators to Hepatitis B Vaccination Among Sex Workers in Vancouver, Canada: Implications for Integrated HIV, STI, and Viral Hepatitis Services

Objectives Sex workers (SWs) face an increased burden of sexually transmitted and blood-borne infections, yet little is known regarding hepatitis B virus (HBV) prevention and care. This study was performed to characterize cross-sectional and prospective correlates of HBV vaccination among SWs in Vancouver.   Methods Questionnaire data were drawn from a community-based cohort of SWs (2010–2017). Multivariable logistic regression was used to examine correlates of lifetime self-reported HBV vaccination. Multivariable generalized estimating equation (GEE) regression was used to assess correlates of recent vaccination.   Results Among 855 participants, 68.3% reported lifetime HBV vaccination. Multivariable logistic regression showed that im/migrants (adjusted odds ratio (AOR) 0.50, 95% confidence interval (CI) 0.32–0.78) had lower odds of vaccination and that those using injection drugs (AOR 1.88, 95% CI 1.27– 2.78) and those who had undergone HIV testing (AOR 1.94, 95% CI 1.14–3.29) had higher odds of vaccination. In the multivariable GEE analysis, HIV seropositivity (AOR 1.93, 95% CI 1.26–2.97) and recent STI testing (AOR 2.95, 95% CI 1.99–4.39) correlated with recent HBV vaccination.   Conclusions Im/migrant SWs from HBV-endemic settings appear to face gaps in HBV prevention. Evidence-based interventions addressing gaps in voluntary HBV prevention and care are needed, including community-based and culturally safe services. Injection drug use and HIV testing were linked to enhanced vaccination, suggesting that harm reduction and HIV programmes may facilitate linkage to HBV prevention

High Burden of Previously Undiagnosed HIV Infections and Gaps in HIV Care Cascade for Conflict-Affected Female Sex Workers in Northern Uganda

Given the disproportionate HIV burden faced by female sex workers FSWs and limited data regarding their engagement in the HIV cascade of care in conflict-affected settings, we characterized the cascade of care and examined associations with new HIV diagnoses and antiretroviral therapy (ART) use in a community-based cohort of FSWs in conflict-affected Northern Uganda. Data were collected via FSW/peer-led time-location sampling and outreach, interview-administered questionnaires, and voluntary HIV testing. Of 400 FSWs, 33.5% were living with HIV, of whom 33.6% were new/previously undiagnosed infections and 32.8% were on ART. Unstable housing and heavy alcohol/drug use were independently associated with increased odds of new HIV diagnoses, whereas exposure to condom demonstrations and number of lifetime pregnancies were negatively associated. In subanalysis among known HIV-positive women, age and time since diagnosis were associated with ART use, whereas sexually transmitted infections were negatively associated. Findings suggest the need for FSW-tailored, peer-based, and integrated HIV and sexual and reproductive health programs to address gaps in HIV testing and treatment for FSWs in conflict-affected communities

Interpersonal and Structural Contexts of Intimate Partner Violence Among Female Sex Workers in Conflict-Affected Northern Uganda

Intimate partner violence (IPV) is the most prevalent form of violence against women, yet remains under-researched among sex workers in sub-Saharan Africa. We explored the interpersonal and structural determinants of recent IPV among female sex workers in northern Uganda. This analysis drew on data from a community-based cross-sectional study (conducted May 2011–January 2012), involving 379 female sex workers in Gulu, northern Uganda. Using logistic regression and multivariable modeling, we examined the correlates of recent male-perpetrated physical or sexual IPV. Of 379 women with noncommercial partners, 59 percent reported having experienced recent moderate/severe physical or sexual IPV. Reporting recent client violence (adjusted odds ratio (AOR): 3.67; 95 percent confidence interval [CI]: 2.31–5.83), doing what their partner wanted (AOR: 2.46; 95 percent CI: 1.46–4.13), and forced sexual debut (AOR: 1.92; 95 percent CI: 1.20–3.05) were independently associated with moderate/severe IPV; recent police arrest and/or incarceration were/was marginally significantly associated with IPV (AOR: 2.25; 95 percent CI: 0.86–5.88, p = 0.097). Greater odds of IPV among sex workers were associated with recent workplace violence, forced sexual debut, and gendered power dynamics favoring male partner control. Programs and policies promoting the safety and health of marginalized women and addressing gender dynamics and violence are needed

Sex Workers’ Access to Police Assistance in Safety Emergencies and Means of Escape from Situations of Violence and Confinement under an “End Demand” Criminalization Model: A Five City Study in Canada

There is limited available evidence on sex workers (SW) ability to access police protection or means of escaping situations of violence and confinement under an “end demand” criminalization model. Of 200 SW in five cities in Canada, 62 (31.0%) reported being unable to call 911 if they or another SW were in a safety emergency due to fear of police detection (of themselves, their colleagues or their management). In multivariate logistic regression, police harassment–linked to social and racial profiling in the past 12 months (being carded or asked for ID documents, followed by police or detained without arrest) (Adjusted Odd Ratio (AOR): 5.225, 95% Confidence Interval (CI): 2.199–12.417), being Indigenous (AOR: 2.078, 95% CI: 0.849–5.084) or being in Ottawa (AOR: 2.317, 95% CI: 0.865–6.209) were associated with higher odds of being unable to call 911, while older age was associated with lower odds (AOR: 0.941 per year older, 95% CI: 0.901–0.982). In descriptive statistics, of 115 SW who had experienced violence or confinement at work in the past 12 months, 19 (16.52%) reported the incident to police. Other sex workers with shared expenses were the most commonly reported group to have assisted sex workers to escape situations of violence or confinement in the past 12 months (n = 13, 35.14%). One of the least commonly reported groups to have assisted sex workers to escape situations of violence or confinement in the past 12 months were police (n = 2, 5.41%). The findings of this study illustrate how the current “end demand” criminalization framework compromises sex workers’ access to assistance in safety emergencies.Medicine, Faculty ofReviewedFacult

Seeing pre-screened, regular clients associated with lower odds of workplace sexual violence and condom refusal amidst sex work criminalization: findings of a community-based cohort of sex workers in Metro Vancouver, Canada (2010-2019)

Background Research that accurately represents how characteristics of sex work clients relate to sex workers’ labour conditions is crucial for informing evidence-based legislation which upholds sex workers’ human rights. As little quantitative research has examined how seeing regulars (repeat clients) impacts sex workers’ occupational safety, particularly under ‘end-demand’ criminalization in Canada, our study aimed to explore how seeing mostly regulars shapes workplace sexual violence and client condom refusal. Methods We drew on longitudinal data from a community-based open cohort of 900+ sex workers in Vancouver, recruited via time-location sampling during day and late-night outreach to indoor, outdoor, and online solicitation spaces. We used logistic regression analyses and multivariable GEE confounder models to 1) describe correlates of seeing mostly pre-screened, regular clients, 2) identify associations between seeing mostly regulars and odds of experiencing occupational outcomes of workplace sexual violence and client condom refusal, and 3) examine the interaction between seeing mostly regulars and work environment on workplace sexual violence and client condom refusal. Results Participants’ median age was 35, and 55.6% had completed high school. Over the 9-year study (n=925), 20.9% (193) experienced 282 events of workplace sexual violence and 40.2% (372) faced 702 events of client condom refusal. In multivariable GEE confounder models, seeing mostly regulars was associated with reduced odds of sexual violence (AOR 0.73, 95%CI 0.53-1.02, p=0.067) and client condom refusal (AOR 0.70, 95%CI 0.57-0.86). In multivariable GEE confounder models examining the additive interaction between seeing mostly regulars and work environment, participants who saw mostly regulars and primarily worked in outdoor or informal indoor venues faced significantly lower odds of experiencing workplace sexual violence (AOR 0.69, 95%CI 0.49-0.95) and client condom refusal (AOR 0.64, 95%CI 0.52 -0.80) relative to those who worked in the same venues and did not see mostly regulars. Conclusion Our findings highlight protective effects of seeing pre-screened regulars within a criminalized setting. Removal of ‘end-demand’ client criminalization is needed to enable sex workers to effectively screen clients, support HIV/STI prevention, and advance sex workers’ human rights.Medicine, Faculty ofNon UBCReviewedFacultyResearche

The impact of end-demand legislation on sex workers' access to health and sex worker-led services: A community-based prospective cohort study in Canada.

BackgroundFollowing a global wave of end-demand criminalization of sex work, the Protection of Communities and Exploited Persons Act (PCEPA) was implemented in Canada, which has implications for the health and safety of sex workers. This study aimed to evaluate the impact of the PCEPA on sex workers' access to health, violence, and sex worker-led services.MethodsLongitudinal data were drawn from a community-based cohort of ~900 cis and trans women sex workers in Vancouver, Canada. Multivariable logistic regression examined the independent effect of the post-PCEPA period (2015-2017) versus the pre-PCEPA period (2010-2013) on time-updated measures of sex workers' access to health, violence supports, and sex worker/community-led services.ResultsThe PCEPA was independently correlated with reduced odds of having access to health services when needed (AOR 0.59; 95%CI: 0.45-0.78) and community-led services (AOR 0.77; 95%CI: 0.62-0.95). Among sex workers who experienced physical violence/sexual violence or trauma, there was no significant difference in access to counseling supports post-PCEPA (AOR 1.24; 95%CI: 0.93-1.64).ConclusionSex workers experienced significantly reduced access to critical health and sex worker/community-led services following implementation of the new laws. Findings suggest end-demand laws may exacerbate and reproduce harms of previous criminalized approaches to sex work in Canada. This study is one of the first globally to evaluate the impact of end-demand approaches to sex work. There is a critical evidence-based need to move away from criminalization of sex work worldwide to ensure full labor and human rights for sex workers. Findings warn against adopting end-demand approaches in other cities or jurisdictions

Violence, trauma and living with HIV: Longitudinal predictors of initiating crystal methamphetamine injection among sex workers.

BACKGROUND: Despite rapid increases in crystal methamphetamine (CM) use worldwide and established gendered patterns of use, empirical research on CM injection initiation among sex workers is limited. Given the wide range of harms associated with CM, alongside stimulant effects including sexual dis-inhibition and prolonged awake-ness, this study aimed to longitudinally investigate socio-structural predictors of initiating CM injection among sex workers in Vancouver, Canada. METHODS: Data (2010-2014) were drawn from a community-based cohort of women sex workers: AESHA (An Evaluation of Sex Workers Health Access). Participants completed bi-annual interviewer-administered questionnaires and HIV/STI testing. Kaplan Meier methods and Cox proportional hazards regression were used to model predictors of CM injection initiation among CM injection-naïve participants. RESULTS: Of 455 participants eligible at baseline, 14.3% (n=65) injected CM for the first time over follow-up, with an incidence density of 6.79 per 100 person-years (95% Confidence Interval [CI] 5.30-8.69). In multivariable analysis, injection heroin use (Adjusted Hazard Ratio [AHR] 6.11; 95%CI 3.24-11.52), having an intimate partner who injects drugs (AHR 2.93; 95%CI 1.57-5.46), workplace violence (AHR 2.85; 95%CI 1.74-4.67), HIV seropositivity (AHR 2.69; 95%CI 1.45-5.00), and childhood abuse (AHR 1.86; 95%CI 0.99-3.49) were independently associated with initiating CM injection. CONCLUSIONS: Findings underscore the gendered and social risk environment of CM injection initiation among sex workers. The strong influences of historical/workplace violence, coupled with heroin injection (known to be self-medicating for post-traumatic stress) as a primary risk pathway, emphasize the urgency of increasing access to integrated, trauma-informed addiction treatment and HIV care for marginalized women

Lack of full citizenship rights linked to heightened client condom refusal among im/migrant sex workers in Metro Vancouver (2010–2018)

In Canada, im/migrant sex workers face stigma, health access barriers, and overlapping marginalisation, with end-demand law reforms in 2014 postulated to exacerbate these inequities. Yet, little quantitative evidence on how immigration status shapes HIV/STI risk exists. Drawing on community-based longitudinal cohort data (AESHA, 2010–2018), we used multivariable confounder models with logistic regression to model (1) the independent effect of precarious immigration status (any status revocable under criminal charges: permanent residency/temporary residency/undocumented) on client condom refusal, and (2) the moderating effect of precarious status on the relationship between condom refusal and exposure to end-demand law reform (2015–2018). Over this 8-year study involving 758 sex workers in Metro Vancouver, 16.0% were im/migrants, of whom 57% had precarious immigration status at baseline. 16.5% of participants experienced client condom refusal. Precarious immigration was associated with increased odds of facing condom refusal (adjusted odds ratio [AOR] 2.53, 95% confidence interval [CI] 1.37–4.68), and these odds were heightened post-end-demand law reforms (AOR 4.35, 95%CI 1.21–15.66). Our findings suggest that lack of citizenship rights may enhance barriers to safer sex negotiation and increase HIV/STI risk among sex workers, highlighting the need for sex work and immigration policy reforms

Correlates of Suicidality Among A Community-Based Cohort of Women Sex Workers: The Protective Effect of Social Cohesion

Suicide is a critical public health concern globally. Sex workers experience a disproportionate burden of social and health inequities driven by forms of violence, stigma, and criminalization, yet empirical research on suicidality is limited. This study longitudinally investigated the burden and socio-structural correlates of recent suicidality among women sex workers in Vancouver, Canada. Data (2010-2017) were drawn from a community-based, prospective cohort of cis and trans women sex workers across Metro Vancouver. Women completed biannual interviewer-administered questionnaires, and correlates of suicidality in the last 6 months were analyzed using bivariate and multivariable logistic regression with generalized estimating equations (GEE). Of 867 women at baseline, 48% (n = 413) reported lifetime suicidality, 16% (n = 141) reported suicidality in the last 6 months, and 29% reported suicidality at some point during the study. In multivariable analysis, factors independently associated with suicidality included physical/sexual childhood abuse (adjusted odds ratio [AOR]: 2.99; 95% confidence interval [CI] = [1.75, 5.10]), mental health issues (depression/anxiety/posttraumatic stress disorder; AOR = 2.19; 95% CI = [1.63, 2.95]), intimate partner violence (AOR: 2.11; 95% CI = [1.60, 2.80]), physical/sexual client violence (AOR: 1.82; 95% CI = [1.33, 2.50]), and homelessness (AOR: 1.44; 95% CI = [1.10, 1.89]). Older age (AOR: 0.97; 95% CI = [0.95, 0.99]) and higher social cohesion (AOR: 0.88; 95% CI = [0.78, 0.99]) were significantly associated with reduced odds of suicidality. Findings reveal key socio-structural correlates of suicidality among sex workers including experiences of historical and interpersonal violence, trauma/mental health issues, and homelessness. Strengthening social cohesion may have a protective effect on suicidality. Trauma-informed community-led structural interventions tailored to sex workers are urgently needed alongside a legal framework that enables collectivization and connectedness