High rates of Unintended Pregnancies among Young Women Sex Workers in Conflict-affected Northern Uganda: The Social Contexts of Brothels/Lodges and Substance Use

This study aimed to examine the correlates of unintended pregnancies among young women sex workers in conflict-affected northern Uganda. Data were drawn from the Gulu Sexual Health Study, a cross-sectional study of young women engaged in sex work. Bivariable and multivariable logistic regression was used to examine the correlates of ever having an  unintended pregnancy. Among 400 sex workers (median age=20 years; IQR 19-25), 175 (43.8%) reported at least one unintended pregnancy. In multivariable analysis, primarily servicing clients in lodges/brothels [Adjusted Odds Ratio (AOR= 2.24; 95% Confidence Interval: 1.03-4.84)], hormonal contraceptive usage [AOR=1.68; 95%CI 1.11-2.59] and drug/alcohol use while working [AOR= 1.64; 95%CI 1.04-2.60] were positively correlated with previous unintended pregnancy. Given that unintended pregnancy is an indicator of unmet reproductive health need, these findings highlight a need for improved access to integrated reproductive health and HIV services, catered to sex workers‘ needs. Sex work-led strategies (e.g., peer outreach) should be considered, alongside structural strategies and education targeting brothel/lodge owners and managers.  Key words: sex work, reproductive health, HIV, Uganda, post-conflic

Thriving beyond survival: Understanding utilization of perinatal health services as predictors of birth registration: A cross-sectional study

There are an estimated 35 million unregistered children in Indonesia. To understand ways to best leverage existing health system-related resources and ensure greater protective measures for these vulnerable children, this study explores the predictive relationship between the utilization of perinatal health services and birth certificate ownership in two Indonesian provinces. This study employed a cross-sectional design with interviewer-administered household surveys to heads of households in West Nusa Tenggara and East Nusa Tenggara from May to July of 2013. The primary outcome of interest was birth certificate ownership among children under the age of 5 years old. Bivariate and multivariable regression analyses using Generalized Estimating Equations (GEE) considered a set of covariates that represented child and household socio-demographic characteristics along with health services utilization variables during pregnancy and post-pregnancy periods. 389 heads of households were interviewed, yielding data on a sample of 451 children under the age of 5. Fewer than 28% of children in this sample possessed a birth certificate. Nearly 57% (n = 259) of children were delivered in a clinical facility, though only 36% (n = 93) of these were legally registered. Of children born in the home (n = 194), registration dropped to 16% (n = 31). Adjusted analyses accounting for socio-demographic factors suggest that children born in a clinic facility (AOR = 2.33, 95% CI: 1.27, 4.33), hospital (AOR = 2.38, 95% CI: 1.12, 5.09), or in the presence of a skilled birth attendant (AOR = 2.35, 95% CI: 1.31, 4.23) were significantly more likely to be registered. Children whose mothers sought post-natal care were 2.99 times more likely to possess a birth certificate (AOR = 2.99, 95% CI: 1.1, 7.57). Pre-natal care was not associated with birth registration. These findings suggest that use of perinatal health services increases the likelihood of registering a child’s birth despite a lack of formal integration of vital registration with the health sector. Formally leveraging existing community-based health workers and perinatal services may serve to further increase registration rates in hard to reach areas of Indonesia

Investigating the role of structural determinants in shaping sex workers' reproductive health access and outcomes

Background and objectives: While sex workers are disproportionately impacted by reproductive health inequities, a significant knowledge gap regarding the contextual drivers of sex workers’ broader reproductive health access and outcomes remains. This dissertation therefore sought to disentangle the role of multiple, and intersecting structural factors on sex workers’ ability to exercise their reproductive rights. Specifically, this dissertation’s objectives were to: explore the structural correlates of sex workers’ pregnancy intentions; investigate the influences of community organization and venue-based features on indoor sex workers’ ability to negotiate and use contraceptives; and examine the structural correlates of accessing cervical screening. Methods: This dissertation drew on data collected from AESHA (An Evaluation of Sex Workers’ Health Access), an open prospective cohort of street- and off-street sex workers across Metro Vancouver, Canada. Bivariable and multivariable regression methods, using generalized estimating equations for longitudinal data, were employed to examine the associations between intersecting structural, community organization, venue-based, interpersonal and individual-level factors and various reproductive health access and outcomes. Spatial analysis using geographical information systems (GIS) were used to examine geographical correlates of reproductive health services access. Results: This dissertation found that sex workers exhibited pregnancy desires similar to that of the general population, with access to off-street venues, inconsistent condom use by clients and intimate partner violence among the important factors shaping these desires. The availability of supportive indoor work features and increased social cohesion increased sex workers’ ability to negotiate for and use condoms. Finally, this dissertation documented suboptimal cervical cancer screening access among HIV seropositive and sero-negative sex workers. While barriers to health care services in general reduced odds of cervical cancer screening, access to screening via outreach models increased odds of screening. Conclusion: Structural factors play a pivotal role in shaping access to reproductive health services and sex workers’ negotiation of their sexual and reproductive health. Given the Canadian government is in the process of revising its sex work legislation, this study offers critical insights into how structural interventions including safer workplace models, sex worker-led integrated HIV/sexual and reproductive health services within a decriminalized legal framework can promote positive sexual and reproductive health.Medicine, Faculty ofPopulation and Public Health (SPPH), School ofGraduat

Work environments and HIV prevention: a qualitative review and meta-synthesis of sex worker narratives

Background: Sex workers (SWs) experience a disproportionately high burden of HIV, with evidence indicating that complex and dynamic factors within work environments play a critical role in mitigating or producing HIV risks in sex work. In light of sweeping policy efforts to further criminalize sex work globally, coupled with emerging calls for structural responses situated in labour and human-rights frameworks, this meta-synthesis of the qualitative and ethnographic literature sought to examine SWs’ narratives to elucidate the ways in which physical, social and policy features of diverse work environments influence SWs’ agency to engage in HIV prevention. Methods We conducted a meta-synthesis of qualitative and ethnographic studies published from 2008 to 2014 to elucidate SWs’ narratives and lived experiences of the complex and nuanced ways in which physical, social, and policy features of indoor and outdoor work environments shape HIV prevention in the sex industry. Results Twenty-four qualitative and/or ethnographic studies were included in this meta-synthesis. SWs’ narratives revealed the nuanced ways that physical, social, and policy features of work environments shaped HIV risk and interacted with macrostructural constraints (e.g., criminalization, stigma) and community determinants (e.g., sex worker empowerment initiatives) to shape SWs’ agency in negotiating condom use. SWs’ narratives revealed the ways in which the existence of occupational health and safety standards in indoor establishments, as well as protective practices of third parties (e.g., condom promotion) and other SWs/peers were critical ways of enhancing safety and sexual risk negotiation within indoor work environments. Additionally, working in settings where negative interactions with law enforcement were minimized (e.g., working in decriminalized contexts or environments in which peers/managers successfully deterred unjust policing practices) was critical for supporting SWs’ agency to negotiate HIV prevention. Conclusions Policy reforms to remove punitive approaches to sex work, ensure supportive workplace standards and policies, and foster SWs’ ability to work collectively are recommended to foster the realization of SWs’ health and human rights across diverse settings. Future qualitative and mixed-methods research is recommended to ensure that HIV policies and programmes are grounded in SWs’ voices and realities, particularly in more under-represented regions such as Eastern Europe and Sub-Saharan Africa.Medicine, Faculty ofOther UBCNon UBCMedicine, Department ofReviewedFacult

Thriving beyond survival: Understanding utilization of perinatal health services as predictors of birth registration: A cross-sectional study

Abstract Background: There are an estimated 35 million unregistered children in Indonesia. To understand ways to best leverage existing health system-related resources and ensure greater protective measures for these vulnerable children, this study explores the predictive relationship between the utilization of perinatal health services and birth certificate ownership in two Indonesian provinces

Youth, violence and non-injection drug use: Nexus of vulnerabilities among lesbian and bisexual sex workers

Despite increasing evidence of enhanced HIV risk among sexual minority populations, and sex workers in particular, there remains a paucity of epidemiological data on the risk environments of sex workers who identify as lesbian or bisexual. Therefore, this short report describes a study that examined the individual, interpersonal and structural associations with lesbian or bisexual identity among sex workers in Vancouver, Canada. Analysis drew on data from an open prospective cohort of street and hidden off-street sex workers in Vancouver. Bivariate and multivariable logistic regression were used to examine the independent relationships between individual-, interpersonal, work environment- and structural-factors and lesbian or bisexual identity. Of the 510 individuals in our sample, 95 [18.6%] identified as lesbian or bisexual. In multivariable analysis, reporting non-injection drug use in the last 6 months (adjusted odds ratio [AOR]= 2.89; 95% confidence intervals [CI]= 1.42, 5.75), youth ≤ 24 years of age (AOR= 2.43; 95% CI = 1.24, 4.73) and experiencing client-perpetrated verbal, physical and/or sexual violence in the last 6 months (AOR= 1.85; 95% CI= 1.15, 2.98) remained independently associated with lesbian/ bisexual identity, after adjusting for potential confounders. The findings demonstrate an urgent need for evidence-based social and structural HIV prevention interventions. In particular, policies and programs tailored to lesbian and bisexual youth and women working in sex work, including those that prevent violence and address issues of non-injection stimulant use are required. lesbian; bisexual; sex work; violence; youth; substance use Send correspondenceMedicine, Faculty ofOther UBCMedicine, Department ofPopulation and Public Health (SPPH), School ofReviewedFacultyResearche