Sex workers perspectives on strategies to reduce sexual exploitation and HIV risk: a qualitative study in Tijuana, Mexico.

Globally, female sex workers are a population at greatly elevated risk of HIV infection, and the reasons for and context of sex industry involvement have key implications for HIV risk and prevention. Evidence suggests that experiences of sexual exploitation (i.e., forced/coerced sex exchange) contribute to health-related harms. However, public health interventions that address HIV vulnerability and sexual exploitation are lacking. Therefore, the objective of this study was to elicit recommendations for interventions to prevent sexual exploitation and reduce HIV risk from current female sex workers with a history of sexual exploitation or youth sex work. From 2010-2011, we conducted in-depth interviews with sex workers (n = 31) in Tijuana, Mexico who reported having previously experienced sexual exploitation or youth sex work. Participants recommended that interventions aim to (1) reduce susceptibility to sexual exploitation by providing social support and peer-based education; (2) mitigate harms by improving access to HIV prevention resources and psychological support, and reducing gender-based violence; and (3) provide opportunities to exit the sex industry via vocational supports and improved access to effective drug treatment. Structural interventions incorporating these strategies are recommended to reduce susceptibility to sexual exploitation and enhance capacities to prevent HIV infection among marginalized women and girls in Mexico and across international settings

Contraceptive Use, Unmet Need for Contraception, and Unintended Pregnancy in a Context of Mexico-U.S. Migration

This study examines the impact of migration on contraceptive use, unmet need for contraception, and unintended pregnancy among migrants from Tlacuitapa, Jalisco, a migrant-sending community in Mexico with a long history of out-migration to the United States. Our analysis found that after controlling for demographic factors, being born in the United States and having lived in the United States for at least one year during youth have a statistically significant positive effect on using medical contraception. We also found that having lived in the United States during youth has a negative influence on unmet need, suggesting that exposure to the United States during these formative years may facilitate access to contraception. In terms of migration and unintended pregnancy, our analysis yielded that being born in the United States and having lived in the United States during youth have a positive effect on unintended pregnancies, suggesting that U.S. experience may in fact be a risk factor for, rather than protective against, unintended pregnancy.Cette étude examine l’impact de l’immigration sur l’utilisation de contraceptifs, le besoin non satisfait de contraception, et les grossesses non désirées chez les migrants de Tlacuitapa, dans l’état de Jalisco, communauté du Mexique ayant une longue tradition d’immigration vers les Etats-Unis. Notre étude a montré, après contrôle des facteurs démographiques, que le fait d’être né aux Etats-Unis et d’avoir vécu dans ce pays pendant au moins un an pendant sa jeunesse avait un effet positif statistiquement significatif sur l’utilisation d’une contraception médicale. Nous avons également démontré que le fait d’avoir vécu aux Etats-Unis pendant sa jeunesse avait une influence négative sur le besoin non satisfait de contraception, laissant entendre que la présence aux Etats-Unis pendant ces années décisives de la vie peut faciliter l’accès à la contraception. En outre, notre analyse fait apparaître que le fait d’être né aux Etats-Unis et d'avoir vécu dans ce pays pendant sa jeunesse avait un effet positif sur les grossesses non désirées, ce qui laisse penser que la présence aux Etats-Unis peut en fait favoriser, et non limiter, les grossesses non désirées.Este estudio examina el impacto de la migración en el uso de anticonceptivos, la necesidad no cubierta de la anticoncepción y los embarazos no deseados entre emigrantes de Tlacuitapa, Jalisco, una comunidad emisora de emigrantes en México con una larga historia de emigración a los Estados Unidos. Nuestro análisis descubrió que tras controlar los factores demográficos, el hecho de haber nacido en los Estados Unidos y haber vivido en los Estados Unidos durante por lo menos un año durante la juventud tiene un efecto positivo estadísticamente significativo en el uso de anticonceptivos médicos. También descubrimos que vivir en los Estados Unidos durante la juventud tiene una influencia negativa en la necesidad no cubierta, lo que sugiere que la exposición a los Estados Unidos durante estos años de formación puede facilitar el acceso a los métodos anticonceptivos. En términos de migración y embarazos no deseados, nuestro análisis arrojó que nacer en los Estados Unidos y vivir en los Estados Unidos durante la juventud tiene un efecto positivo en embarazos no deseados, lo que sugiere que la experiencia de los EE. UU. puede ser de hecho un factor de riesgo para, en vez de ser protector contra, embarazos no deseados

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

Structural and Interpersonal Benefits and Risks of Participation in HIV Research: Perspectives of Female Sex Workers in Guatemala

This study explored perceived benefits and risks of participation in HIV research among 33 female sex workers in Tecun Uman, Guatemala. Stigma associated with sex work and HIV was a critical barrier to research participation. Key benefits of participation included access to HIV/STI prevention and testing, as well as positive and trusting relationships between sex workers and research teams. Control exerted by managers had mixed influences on perceived research risks and benefits. Results underscore the critical need for HIV investigators to develop population-tailored procedures to reduce stigma, engage managers, and reinforce trusting, reciprocal relationships between sex work communities and researchers

Gaps in the Hepatitis C Continuum of Care among Sex Workers in Vancouver, British Columbia: Implications for Voluntary Hepatitis C Virus Testing, Treatment and Care

BACKGROUND: Hepatitis C virus (HCV) eradication leads to reduced morbidity, mortality and transmission. Despite the disproportionate burden of HCV among sex workers, data regarding the HCV care continuum in this population remain negligible. METHODS: Using baseline data from an ongoing cohort of women sex workers in Vancouver (An Evaluation of Sex Workers’ Health Access, January 2010 to August 2013), the authors assessed HCV prevalence and engagement in the HCV care continuum within the past year. Multivariable logistic regression analyses were used to evaluate associations with recent (ie, in the past year) HCV testing. RESULTS: Among 705 sex workers, 302 (42.8%) were HCV seropositive. Of these, 22.5% were previously unaware of their HCV status, 41.7% had accessed HCV-related care, 13.9% were offered treatment and only 1.0% received treatment. Among 552 HCV-seronegative sex workers, only one-half (52.9%) reported a recent HCV test. In multivariable analysis, women who self-identified as a sexual/gender minority (adjusted OR [aOR] 1.89 [95% CI 1.11 to 3.24]), resided in the inner city drug use epicentre (aOR 3.19 [95%CI 1.78 to 5.73]) and used injection (aOR 2.00 [95% CI 1.19 to 3.34]) or noninjection drugs (aOR 1.95 [95% CI 1.00 to 3.78]) had increased odds of undergoing a recent HCV test, while immigrant participants (aOR 0.24 [95% CI 0.12 to 0.48]) had decreased odds. CONCLUSIONS: Despite a high burden of HCV among sex workers, large gaps in the HCV care continuum remain. Particularly concerning are the low access to HCV testing, with one-fifth of women living with HCV being previously unaware of their status, and the exceptionally low prevalence of HCV treatment. There is a critical need for further research to better understand and address barriers to engage in the HCV continuum for sex workers

Structural Determinants of Health among Im/Migrants in the Indoor Sex Industry: Experiences of Workers and Managers/Owners in Metropolitan Vancouver

Background Globally, im/migrant women are overrepresented in the sex industry and experience disproportionate health inequities. Despite evidence that the health impacts of migration may vary according to the timing and stage of migration (e.g., early arrival vs. long-term migration), limited evidence exists regarding social and structural determinants of health across different stages of migration, especially among im/migrants engaged in sex work. Our aim was to describe and analyze the evolving social and structural determinants of health and safety across the arrival and settlement process for im/migrants in the indoor sex industry. Methods We analyzed qualitative interviews conducted with 44 im/migrant sex workers and managers/owners working in indoor sex establishments (e.g., massage parlours, micro-brothels) in Metropolitan Vancouver, Canada in 2011; quantitative data from AESHA, a larger community-based cohort, were used to describe socio-demographic and social and structural characteristics of im/migrant sex workers. Results Based on quantitative data among 198 im/migrant workers in AESHA, 78.3% were Chinese-born, the median duration in Canada was 6 years, and most (86.4%) serviced clients in formal indoor establishments. Qualitative narratives revealed diverse pathways into sex work upon arrival to Canada, including language barriers to conventional labour markets and the higher pay and relative flexibility of sex work. Once engaged in sex work, fear associated with police raids (e.g., immigration concerns, sex work disclosure) and language barriers to sexual negotiation and health, social and legal supports posed pervasive challenges to health, safety and human rights during long-term settlement in Canada. Conclusions Findings highlight the critical influences of criminalization, language barriers, and stigma and discrimination related to sex work and im/migrant status in shaping occupational health and safety for im/migrants engaged in sex work. Interventions and policy reforms that emphasize human rights and occupational health are needed to promote health and wellbeing across the arrival and settlement process

Qualitative Evaluation of a Mandatory Health Insurance ‘Wait Period’ in a Publicly Funded Health System: Understanding Health Inequities for Newcomer Im/Migrant Women

Objectives To evaluate impacts of a residency-based waiting period for health insurance coverage on lived experiences of health and settlement for im/migrant women in British Columbia, Canada. Design The IRIS study is a mixed-methods, community-based, qualitative evaluation of recently arrived im/migrant women’s access to sexual and reproductive care. In-depth, semistructured interviews were conducted by trained multilingual and multicultural interviewers with lived migration experience in the participant’s preferred language. Setting Metro Vancouver, British Columbia, Canada from July 2018 to January 2020. Participants Data collected from community focus groups (four groups, n=29) of both service providers and im/migrant women was used. Following this, qualitative interviews with service providers (n=10) and im/migrant women (n=47) were conducted. Eligible participants self-identified as women; were aged 18–49 and had arrived in Canada from another country. Eligible providers were employed in the health, social or legal sectors working with im/migrant women. Results The wait period resulted in mistrust and internalised stigma for racialised im/migrant women, for whom the policy resulted in feeling ‘undeserving’ of care. Resulting administrative burden produced delays and unmet need for care, particularly related to sexual and reproductive healthcare and children’s health. Unexpected costs meant difficult choices between survival and care. Negative health outcomes included the inability to family plan, difficulties during pregnancy, as well as hardships related not being able to seek help for sick children. Community-based organisations provided support in many areas but could not fill all gaps produced by this policy. Conclusions Findings highlight severe, yet commonly overlooked, health inequities produced by a mandatory health coverage wait period within a purportedly ‘universal’ healthcare system. Health system policies such as mandatory ‘waiting periods’ produce discriminatory and inequitable outcomes for im/migrant women. Policy reforms towards full ‘healthcare for all’ are urgently needed to affirm the health and human rights of all im/migrants

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

Examining negative effects of early life experiences on reproductive and sexual health among female sex workers in Tijuana, Mexico

To explore experiences during childhood and adolescence that influenced reproductive and sexual health among women who had entered the sex industry in adolescence