Risk sexual behaviors that expose female sex workers to HIV infections: a study among female sex workers attending the GHWP Clinic at Kibuye, Kampala City

BackgroundThere is little evidence on the need for differentiated HIV prevention services for men who have sex with men (MSM), female sex workers (FSW) and people who inject drugs (PWID in Nigeria. The aim of the study was to determine and compare the HIV sexual risk profiles of FSW, MSM and PWID resident in Nigeria; and identify factors associated with condom use among the groups. This will help identify if differentiated HIV prevention services are needed for MSM, FSW and PWID in Nigeria.MethodsThis is a cross-sectional study. Data on sexual practices (anal, vaginal and oral sex), history of alcohol and psychoactive substance use, and high risk sexual behaviors for HIV infection (inconsistent use of condom) was collected from study FSW, MSM and PWID resident in Enugu, Nassarawa, Benue, and Akwa-Ibom States of Nigeria between April and June, 2015. Association between sexual practices, alcohol and psychoactive substance use, and HIV sexual risk behaviors; and differences in sexual risk behaviors of MSM, FSW and PWID were determined using Pearson chi-square for categorical variables, and t-test for continuous variables. Determinants of condom use in the last 30 days were identified using logistic regression analysis.ResultsThe study population consisted of 188 (38.5%) FSW, 145 (29.7%) MSM and 155 (31.8%) PWID. MSM (AOR: 0.17; 95%CI: 0.05–0.67; p = 0.01) and PWID (AOR: 0.07; 95%CI: 0.02–0.21; p < 0.001) were significantly less likely than FSW to have used condom in the last 30 days. A lower proportion of FSW and PWID used condom during anal sex in the last 12 months when compared with MSM (p < 0.001 respectively). The proportion of MSM (23.5%) and FSW (23.4%) who had ever used psychoactive drugs was high. Of those who had ever used psychoactive drugs, 25.0% of FSW and 29.4% of MSM had injected drugs in the last 30 days of the survey. Also, 39.3% of PWID shared needles and syringes. The use of psychoactive substances (AOR: 5.01; 95%CI: 2.59–9.68; p < 0.001) and the ability to negotiate condom use (AOR: 2.04; 95%CI: 1.06–3.93; p = 0.03) were factors associated with condom use in the last 30 days of the survey.ConclusionHIV prevention programs designed for MSM, FSW and PWID need to address inconsistent condom use during sex by addressing condom negotation skills. This sexual risk behavior is common to the three groups.

In all regions of sub-Saharan Africa the predominant mode of transmission of HIV is through heterosexual intercourse however there are large variations in the rate and extent of the spread of HIV in different populations. This study was conducted to identify the factors that influence the rapid spread of HIV in four African cities namely Cotonou (Benin) Yaounde (Cameroon) Kisumu (Kenya) and Ndola (Zambia). Results demonstrated that high rates of partner change and being married are risk factors for HIV infection in men in at least one city but are risk factors for women in all four cities. In addition condom use among sex workers did not show a difference between the low and high prevalence cities. Furthermore no evidence of changes towards safer sexual behavior was identified in the high HIV prevalence cities. The only factors that were more common in the two high HIV prevalence cities than in the two low HIV prevalence cities were young age at first intercourse for women young age at first marriage and large age difference between the spouses. It was also noted that the high levels of HIV infection among young people especially among female adolescents in Kisumu and Ndola highlight the importance of interventions targeted at young people and their partners.

BackgroundThe HIV epidemic remains an important public health challenge for the sub-Saharan region. Female Sex Workers (FSW) in this region are among the most vulnerable of the key population groups with HIV prevalence as high as twice that of the general population. The aim of this study was to estimate HIV prevalence and explore sexual risk behaviors among FSW in Togo.MethodsA cross-sectional study using a Respondent Driven Sampling method was conducted across the six regions of country among FSW in 2017. A comprehensive questionnaire was used to explore socio-demographic characteristics, sexual history, HIV knowledge, and sexual behaviors. HIV rapid tests were used to assess HIV infection.ResultsA total of 1,036 FSW, with a median age of 26 years old [interquartile range (IQR): 22–33], participated in the study, with 49.2% (n = 510) of them having reached secondary school. Median age at first sexual intercourse was 20 years old [IQR: 17–25] and estimated number of clients per week was of 5 [IQR: 3–10]. A total of 936 (95.6%) reported the use of a condom during last sexual intercourse with a client and 493 (47.6%) reported the use of a condom during their last sexual intercourse with a partner or husband. HIV prevalence was 13.2% [95% CI: 11.2 – 15.4], and was associated with age (being between 26 and 32 years old; aOR = 4.5; 95% CI: [2.4 – 9.1], p < 0.0001) and ≥ 33 years old; aOR = 6.4; 95% CI [3.5 – 12.7], p < 0.0001), education level (being in primary school or less; aOR = 1.7; 95% CI: [1.1–2.6]; p = 0.012) and the number of partners per week (more than 2 and 3 partners; aOR = 2.5; 95% CI [1.2—5.2]; p = 0.014).ConclusionsHIV prevalence and sexual risk behaviors remain high among FSW in Togo, despite prevention efforts aimed at curbing this trend. Other factors, such as access and availability of condoms, the social and legal environment in which FSW operate, should be considered for HIV prevention strategies in this population.

Introduction Although anecdotal evidence suggests that HIV infections in Mexico were occurring in 1981, the first cases of AIDS in Mexico were documented in 1983. Since then, approximately 50 000 cases of AIDS have been reported nationwide and it is estimated that there are approximately 150 000 HIV-infected persons living in Mexico [1,2]. While it could be argued that there is some underreporting of AIDS in Mexico [2,3], the epidemic is still significantly less intense than that to the north (USA) or south (Central American countries, e.g. Honduras). One possible explanation for this is that, unlike in the countries surrounding it, the epidemic in Mexico has remained 'nuclear', primarily affecting men who have sex with men in urban areas of the country such as Mexico City, Guadalajara, Monterrey and Tijuana [4]. This relative containment of the epidemic is by no means accidental but rather the end result of many prevention efforts conducted by the government as well as by community-based organizations. The national response to AIDS in Mexico was early and strong, beginning shortly after the first cases were reported in 1983. HIV testing began the first year the test was available (1985) and in February of 1986 the National Committee for AIDS Prevention (CONASIDA) was founded. In 1988 a Presidential Decree transformed CONASIDA from a committee to a 'National Council', thus giving it a multisectorial composition that went beyond the scope of individual health sector response. While early national-level attention toward containing the epidemic has benefited the population at large, it is clear that prevention efforts of the Mexican government have been most successful in two areas: in the control of transfusion-transmitted HIV and in preventing infections among female commercial sex workers. Because HIV infection through blood and blood products represents only a small proportion of all cases of HIV/AIDS worldwide it has not received the attention this means of transmission merits [5]. Not only is it the most efficient way in which HIV can be transmitted, but transmission via blood and blood products is also the route most amenable to government control. As a result, devoting attention and resources to insuring the safety of the blood supply represents a unique opportunity and a cost-effective intervention for public health authorities to dramatically change the course of HIV infection in a given country. The changing epidemiology of AIDS in Mexico provides compelling proof of this conclusion. With the exception of patients with hemophilia, transfusion-transmitted HIV in developing countries primarily affects women – specifically women who receive blood for obstetric reasons [6]. Because of this observation, a country with a large proportion of infected women may overestimate the level of 'heterosexual' transmission, overlooking a hidden blood and blood products connection. For example, in 1986 there were 26 cases of AIDS in men for every one in women (26 : 1) in Mexico. Four years later, at the same time that the highest proportion of transfusion-transmitted cases were being reported nationwide, the number of infections among women had climbed so dramatically that the ratio dropped to five cases of AIDS in men for every one in women (5 : 1). Then, in 1999, the first year in which no transfusion-transmitted AIDS cases were reported in Mexico, the trend in male-to-female cases reversed direction ( for the first time ), with six cases of AIDS being reported in men for every one in women (6 : 1). In many countries, infection of the blood supply is chiefly an economic phenomenon. For example, prior to 1987, selling one's blood or plasma was such an attractive source of income for many impoverished Mexicans that commercial blood and plasma donors (who had, by definition, no inducement to know their HIV status prior to donation) formed a significant percentage of total blood suppliers. Thus, the control of transfusion-transmitted HIV in Mexico not only involved mandatory HIV testing but also banning the commercialization of blood and closing of commercial plasmapheresis centers. As noted above, this policy has all but eliminated HIV from the Mexican blood supply. Blood transmission of HIV in other countries continues to be a significant problem. Recent reports from China suggest that paid blood donors may be playing an important role in the spread of HIV there [7]. The impact of commercial sex on HIV transmission is well known and has long been considered a critical vector for the introduction of HIV infection into the general population [8,9]. As a result, interventions to limit the extent of HIV infection among commercial sex workers (CSW) are frequently viewed as a priority in many national prevention campaigns [10]. Perhaps the best-known of the successful interventions with CSW to date is the '100% condom use in brothels' initiative in Thailand [11]. This initiative has lead to a marked decrease in HIV incidence among Thai military recruits as well as to a decrease in the incidence of other sexually transmitted infections in that country. In contrast to Thailand and many other countries though, HIV seroprevalence among female CSW in Mexico has remained low since the beginning of epidemiological investigation, with seroprevalence averaging below 1% in large, repetitive serosurveillance studies. This finding suggests that many of the early interventions targeting CSW in Mexico might have limited the impact of HIV in this group. Yet, it could also be argued that the nuclear epidemiology of HIV in Mexico described above has simply meant that female CSW in Mexico are at less risk of exposure to infection than CSW in other countries. If this observation is so, the low seroprevalence among Mexican CSW may not be credited to public health intervention but rather reflect lack of opportunity to be exposed to HIV. In this article, we will review the major interventions conducted to date in Mexico as part of the National AIDS Prevention and Control Program. We will also review the available data published in journals or presented at the International AIDS Conferences for insights into Mexican HIV prevention successes and failures that may have implications for AIDS programs in other developing countries. The control of HIV transmission through blood and blood products When the AIDS epidemic began in Mexico in the early 1980s there was no coordinated system of blood procurement and a large proportion of the blood available in the country was obtained from paid donors. In addition, an unknown number of commercial plasma collection centers throughout the nation also obtained their products from paid donors. Evidence now suggests that these centers frequently re-used contaminated equipment during blood collection resulting in the introduction of HIV to previously healthy donors. As a result, not only did the centers collect and distribute infected blood products, but they also acted as an efficient means for accelerating that process by transmitting HIV to previously uninfected repeat clients during the plasmapheresis process. Until recently, the impact of transfusion-transmitted HIV on the AIDS epidemic in Mexico had been quite significant. In only 4 years (1984–1988) blood and blood product transfusion associated AIDS in Mexico went from being unheard of to comprising over 10% of all cases. Until 1987, paid blood and plasma donors provided approximately one-third of all blood products in Mexico [12]. Stereotypically, a paid donor would be a young man from a rural area who had migrated to one of the shanty towns that surround large cities like Mexico City, Guadalajara, Monterrey and Tijuana. He would be unemployed/underemployed, disenfranchised, and had no risk factors for HIV infection prior to his migration. After hearing about the opportunity from a friend or family member, he would become a regular customer at one of the local blood banks or plasmapheresis centers, being paid to donate as frequently as the individual center's policy allowed, perhaps as often as every 2 or 3 days. The more times he donated, the higher his risk became for becoming infected with HIV during the blood collection process. If he did become infected, he would almost certainly transmit that infection into the national blood supply – and to other donors at the same center as well – during his subsequent donations. Additionally, he might also transmit HIV to his wife or girlfriend during sex and, through them, to his children. In May of 1986, when HIV testing of all blood donors became mandatory in Mexico, the full extent of the tragedy of HIV among paid donors first began to surface. In two separate but concurrent studies carried out between 1986 and 1987, a prevalence of 7% was found among 9100 paid donors [12] compared to a seroprevalence of only 0.67% among 319 153 persons who donated blood without remuneration [13]. Further evidence of the extreme health risk disparity faced by paid donors in Mexico at that time is evident when their seroprevalence is compared to that of related donors (0.12%) or volunteer donors (0.09%) [12,14]. When the data were analyzed retrospectively, the scope of the risk faced by paid donors became dramatically clear. For example, the prevalence among paid donors at one plasmapheresis center increased in 5 months, from 6% in June 1986 to 9.2% in October of the same year [14]. Furthermore, seroconversion was documented in 22.1% of these subjects during this period. A case–control study of this population revealed that a history of four or more donations per month (odds ratio, 5.4; 95% confidence interval, 1.9–16.3) was associated with HIV infection. As described above, it is believed that donors were iatrogenically infected with HIV during the plasmapheresis process, probably as a result of improper infection control measures. The procedure included recycling of plasmapheresis equipment, reuse of needles or syringes, and even the injection of small amounts of infected plasma or blood. As the number of donations per month was as high as 12, it is feasible that once the infection was introduced into a specific blood or plasma bank, subsequent uninfected donors became infected at the blood or plasma facility at the time of donation. In 1989, the first case of AIDS in a Mexican paid plasmapheresis donor was reported [15] and by 1990 the reporting of this high-risk group became mandatory in Mexico [16]. Thus a new 'risk group' was defined in Mexico and later adopted by the Panamerican Health Organization: the professional blood donor. However, paid donor is not routinely reported as a risk group in many epidemiological reports and thus it may not be recognized as an important contributor to the spread of HIV in a given country (see Fig. 1).Fig. 1.: AIDS cases in Mexico in 1997 by risk group. Mexico versus WHO/UNAIDS.In May of 1987, as a consequence of poor compliance by blood and plasma banks with the 1986 law that mandated HIV screening of blood and blood products, the executive and legislative branches of the government approved a law prohibiting the sale of blood and blood products in Mexico [6,17]. This law was not without controversy and much opposition. Since Mexico lacked a culture of volunteer blood donation, ready sources of HIV testing, and an organized blood collection infrastructure, there was a major fear among public health officials that shutting down the blood and plasma industry would severely compromise the blood supply, prompting the emergence of a black market in blood and blood products. Because of this possibility, a two-pronged response was quickly approved and implemented. Campaigns promoting volunteer blood donations were begun all over the country while, at the same time, the necessary laboratory infrastructure for HIV testing was established. Within 4 months, a network of 70 laboratories capable of screening donors for HIV was set up in the country's 32 states. In addition, blood collection and distribution centers were established in collaboration with the Mexican Red Cross. Table 1 summarizes the steps taken by Mexico for the control of transfusion-transmitted HIV.Table 1: The Prevention of transfusion-transmitted HIV in Mexico. The implementation of the strategies described above has had dramatic consequences for public health in Mexico. Not only is the future health of the general public more assured – the number of transfusion- associated cases peaked within a year of the blood sale ban and no new cases of AIDS secondary to blood transfusion have been reported since 1999 (see Fig. 1) – but so is the future health of blood donors. After paid donors were banned in 1987 the HIV seroprevalence among donors decreased from 2.6% in 1986 to 0.7% in 1988 [6]. In 1989, HIV seroprevalence among blood donors in Mexico further decreased and has remained low (below 0.08% in all years). For example, only 385 out of 1 099 755 blood units tested positive for HIV in 1999 (0.04% prevalence) and 377 out of 1 140 632 were HIV infected in 2000 (0.03% prevalence), (see Figs 2 and 3). As a result of the change in government policy, it is estimated that over 8000 transfusion-transmitted infections have been prevented.Fig. 2.: AIDS cases associated with blood transfusion in Mexico (through July 2000, by date of diagnosis.Fig. 3.: HIV prevalence among blood donors, Mexico 1986–2000. From the National HIV Laboratory Network.This improvement is certainly a cause for relief but the true extent of the widespread damage caused by the paid donor system has yet to be calculated. Close to 400 cases of AIDS among paid donors were reported to the National AIDS Registry before this transmission of HIV was finally contained. This number of cases represents more than twice those reported among hemophiliacs in Mexico [17,18]. Close to 2500 cases of AIDS considered secondary to transfusion of HIV infected blood have been reported, and those account for only the primary infections [2,19,20]. As noted above, many of the paid donors, as well as the recipients of contaminated blood and blood products may have infected their sex partners (and subsequent children). This possibility is a key observation. Before the tragedy was contained, women in Mexico – particularly poor women – were at risk from contaminated blood from not one but two sources. They were at risk directly, via obstetric-related blood transfusions and they were at risk indirectly from sexual partners who were professional donors and who were infected at the time of blood or plasma collection. We believe that it is this 'double jeopardy' that Mexican women faced that led to the rapid transition in male : female ratio of AIDS cases in the mid 1980s and the apparent 'heterosexualization' of the AIDS epidemic. It is reasonable to suppose that without the now present safeguards placed on the blood supply in Mexico, this double jeopardy would have continued and the male : female ratio of infection would have continued to decrease until Mexico achieved a 'pattern 2' (primarily heterosexual) epidemic. Support for this assumption may be inferred by observing the rapid transition of the male : female case ratio in countries that continue to support a paid donor blood collection system. For example, in areas of India and China where epidemic HIV infection in paid donors has been noted, the epidemic has become overwhelmingly 'heterosexual' [21]. Support for this conclusion may also be found more concretely in the results of a study to determine the risk factors for HIV-infection among women in Mexico. Of 454 women who had an HIV test performed in 1992, multivariate analysis revealed that only a history of blood transfusion, low literacy and having sex with an HIV infected partner were associated with being HIV-infected [22]. In summary, the Mexican experience highlights the critical role that mandatory screening of all donors, prohibiting paid donations, and maintaining strict control of the plasma industry can have on the epidemiology of HIV/AIDS. Such simple control measures undoubtedly require resources but, above all, require political will for their implementation. The prevention of HIV infection among female commercial sex workers Commercial sex in Mexico takes place in the 32 federal states of Mexico under one of two legal frameworks: 'abolitionist' or 'reglamentarist' [23]. The abolitionist movement seeks to eliminate prostitution entirely by making its practice a misdemeanor. More commonly though, prostitution is allowed but controlled by legislation. The reglamentarist system restricts prostitutes' activities to certain areas of the city or establishments and requires them to be licensed and have periodic health exams. Most of Mexico (except for the Federal District where Mexico City is located, and the States of Mexico, Puebla and Guanajuato) functions under a reglamentarist system. The public health threat posed by the reglamentarist system – specifically the requirement for periodic health exams – is the potential for corruption (a sex worker might have the opportunity to 'buy' a clean record) and the potential for a false sense of security on the part of CSW clients. This false sense of security, which may lead some clients to request or insist on sex without a condom, is not just a product of political corruption. Unfortunately even periodic health exams are not sufficient to protect clients from recently acquired HIV infection or sexually transmitted infections (STI). There is continuing debate among public health experts about whether the abolitionist or reglamentarist legal framework provides a better system for preventing HIV infection among sex workers. Thailand's experience, however, would seem to suggest that strictly enforced rules and regulations governing both sex workers and their clients (such as 100% condom use in brothels) can be the cornerstone of a successful program of public health safety [11,24]. Commercial sex in Mexico City takes place under an abolitionist system that has been in place since 1940 when the practice of commercial sex was first banned in that city. In Mexico City, any individual who is found practicing commercial sex may be fined and arrested for 24–36 h [25]. Under this legislation the police are also permitted to detain women who are on the street simply because their personal appearance is considered 'offensive to modesty and good custom', even if there is no evidence that the women were actively engaging in prostitution. Nevertheless, patronizing the services of CSW is tolerated and excused, if not condoned. are arrested or This double is In the Mexico City of young health found that 6% of men reported having their first sexual with a CSW The proportion of men who have been clients of CSW during their is undoubtedly Unfortunately this system CSW in a status and them of health services and legal This in the corruption of police and other authorities who routinely from In 1986 an place CSW that, in may have been in the Mexican AIDS epidemic to its nuclear In that female CSW began at National AIDS (CONASIDA) and to request HIV testing and risk In these women provided an opportunity for public health officials to to an population that is and of with the CONASIDA began to to with these women and them into the public health process. Perhaps the most intervention that place during this time was a between the of in Mexico City and the of Health that allowed CONASIDA to a of and interventions with sex workers without the of the local In this way CONASIDA was to with sex workers and their without them to testing of early revealed that HIV incidence among female CSW in Mexico City was below 1% in the 1980s and has remained low since among 1997 women tested for HIV in This finding is in marked contrast to the prevalence of HIV among male CSW in Mexico or to the epidemic among male and female CSW in other countries. the same time interval, for example, the HIV seroprevalence for sex workers in Thailand increased from in 1988 to over in 1990 A of HIV among sex workers has been in India and [21]. on the seroprevalence of HIV found among CSW who are tested in a CONASIDA it is that factors described below may have a low prevalence of HIV among female CSW in Mexico, the that HIV prevalence has remained low to this could also be to increased condom use like other women in Mexico, are to HIV in one or more of four through the transfusion of contaminated blood or blood products during or for obstetric through the use of contaminated needles injection through infection at the time of blood or plasma professional blood plasma or through sex with a who is HIV For the to be – that low HIV prevalence in female CSW is not primarily to increased condom use – it would be necessary to evidence that the of transmission described above in a risk for HIV infection to female the result could that other or means of than transmission from of those In to and evidence be in to the at the of Health and CONASIDA was and was not known about the transmission from contaminated blood or blood products As noted above, transfusion-transmitted HIV primarily affects specifically women who receive blood for obstetric reasons [6]. There was no evidence that female CSW in Mexico were at less risk of blood transfusions than other the low prevalence of HIV among female CSW was probably to a risk from contaminated equipment There was no that HIV may be transmitted via contaminated needles by equipment or during was in was whether the low prevalence of use among female among those CONASIDA and in was sufficient to account for the low prevalence of HIV among them as For other countries with a low prevalence of use among female CSW have the incidence of HIV dramatically in their female CSW the low prevalence of use among female CSW in Mexico undoubtedly the of HIV in this it did not to be more than condom use for the continued low prevalence of HIV. infection at the time of blood or plasma As has been described above professional blood and plasma donors became infected with HIV until this practice was banned in It was thus possible that could also have been professional donors and thus be at risk for HIV infection through this However, of cases of AIDS among professional blood donors have been among which is by the that men were much more to be professional donors. from sex There are at in which sexual in the of may be with a continued low prevalence of HIV among female an HIV seroprevalence in the general population to a significant transmission if the prevalence of HIV is not spread throughout the population and infected clients not female and if the specific sexual in by CSW not HIV In the first the low prevalence of HIV in the general population of Mexico in 1986 six per meant that sex workers as a group faced risk of exposure from their clients The with this explanation was that had found a high prevalence of in many American countries It was that evidence would be before a could be that are less to female CSW than male CSW and that, the risk for infection from this group was than for female In the it was that female CSW did not practice sexual considered to be of high risk with their clients so the or of a For the of transmitting of transmission and evidence would be before a could be that female CSW in Mexico or only in HIV transmitting As a result of the in a major study was in observation, key and to a of commercial sex in the urban area of Mexico City This allowed the of street and where commercial sex From this it was estimated that approximately of the population of Mexico City were women in commercial sex 000 A of these women were to in a study which included sexual as well as testing for and The results of these studies a low prevalence of among female sex workers and the studies which that the HIV prevalence among these women was quite low (see Table A significant was also found between the risk of having an and the of a street have higher of In addition, a level and the number of years practicing commercial sex were associated with being for HIV and prevalence among female commercial sex workers in Mexico. from The results of the were also of major While all women reported having with their reported having sex and reporting having In addition, reported an in condom use since about However, in contrast to their with their reported with their or In multivariate risk factors for sex with clients included a low street no use of a to use clients of and use of services the years subsequent studies conducted in Mexico City as well as in other cities throughout the country have continued to a low prevalence of HIV among female commercial sex workers (see Table 3). As noted above, this finding is in marked contrast to the HIV seroprevalence among sex workers in other developing HIV prevalence studies among female commercial sex workers in Mexico. In an to further sexual and to risk factors for HIV infection among men in Mexico, a of studies have been conducted by group. studies that men at and had a higher seroprevalence of HIV infection than men versus and that reported condom use was quite with only reporting regular condom use As noted above, the practice of has been reported to be among American men in to a of men conducted in this practice to not be as in Mexico City in In that study of men reported that they had sex in their with reporting and The HIV prevalence in this was among men and among men This study also that men might be to the services of male or female CSW when not in a

This study examined the associations between minority stressors, poor mental health, and sexual risk behaviors, and whether there were interactive effects of minority stress and mental health factors in their associations with sexual risk behaviors in a sample of Chinese transgender women sex workers (TGSW). A cross-sectional study was conducted in 204 TGSW in Shenyang, China (mean age 33.4years and 18.1% self-reported as HIV positive). We found a high prevalence of condomless anal intercourse (CAI) with male clients (27.9%) and CAI with male regular partners (49.5%) in the past three months among TGSW. Multivariate logistic regression analysis showed that discrimination, victimization, and life dissatisfaction were significantly associated with higher odds of CAI with male clients (AOR range: 1.05-1.42, all p < 0.05). Likewise, CAI with male regular partners was more frequently reported by participants who experienced higher levels of victimization, rejection, and anxiety (AOR range: 1.37-2.88, all p < 0.05). No significant interaction effects of gender minority stress and mental health on sexual behaviors were observed. Interventions addressing the multiple psychosocial risks are warranted to prevent behavioral risks of TGSW.

Female sex workers (FSWs) and their male clients are vulnerable to HIV infection and serve as a bridge in HIV transmission from the high-risk population to the general, low-risk population. To examine the factors of FSWs and male clients that correlate with the prevalence of HIV infection in the Chinese-Vietnamese border region, a cross-sectional survey was conducted in 2014 in the Hekou county of the Yunnan province of China. We performed a questionnaire survey to collect data on demographics, sexual behavior, and drug use. Blood and urine samples were collected for testing of HIV/sexually transmitted infections and drug use. We found that the prevalence of HIV infection among FSWs was 2.74%, and 15 male clients (2.62%) were HIV-positive. Multivariate logistic regression analysis revealed that herpes simplex virus type 2 infection was a risk factor for HIV infection in FSWs and male clients, suggesting the increased role of sexual transmission in the HIV epidemic in the Chinese-Vietnamese border region. Positive urinalysis result for amphetamine-type stimulants was observed in FSWs with HIV infection. History of drug use was correlated with HIV infection, which increased the HIV infection risk of male clients, confirming that drug use is an important target in future interventions for HIV prevention.

IntroductionHIV self‐testing (HIVST) and oral pre‐exposure prophylaxis (PrEP) are complementary, evidence‐based, self‐controlled HIV prevention tools that may be particularly appealing to sex workers. Understanding how HIVST and PrEP are perceived and used by sex workers and their intimate partners could inform prevention delivery for this population. We conducted qualitative interviews to examine ways in which HIVST and PrEP use influence prevention choices among sex workers in Uganda.MethodsWithin a randomized trial of HIVST and PrEP among 110 HIV‐negative cisgender women, cisgender men and transgender women sex workers (NCT03426670), we conducted 40 qualitative interviews with 30 sex workers and 10 intimate partners (June 2018 to January 2020). Sex worker interviews explored (a) experiences of using HIVST kits; (b) how HIVST was performed with sexual partners; (c) impact of HIVST on PrEP pill taking; and (d) sexual risk behaviours after HIVST. Partner interviews covered (i) introduction of HIVST; (ii) experiences of using HIVST; (iii) HIV status disclosure; and (iv) HIVST's effect on sexual behaviours. Data were analysed using an inductive content analytic approach centering on descriptive category development. Together, these categories detail the meaning of HIVST and PrEP for these qualitative participants.ResultsUsing HIVST and PrEP was empowering for this group of sex workers and their partners. Three types of empowerment were observed: (a) economic; (b) relational; and (c) sexual health. (i) Using HIVST and PrEP made sex without condoms safer. Sex workers could charge more for condomless sex, which was empowering economically. (ii) Self‐testing restored trust in partners’ fidelity upon being reunited after a separation. This trust, in combination with condomless sex made possible by PrEP use, restored intimacy, empowering partnered relationships. (iii) HIVST and PrEP enabled sex workers to take control of their HIV prevention efforts and avoid the stigma of public clinic visits. In this way they were empowered to protect their sexual health.ConclusionsIn this sample, sex workers’ use of HIVST and PrEP benefitted not only prevention efforts, but also economic and relational empowerment. Understanding these larger benefits and communicating them to stakeholders could strengthen uptake and use of combination prevention interventions in this marginalized population.

Searching for modifiable perceptions that are associated with sexual risk behaviors among female sex workers (FSWs) are considered a priority in HIV/sexually transmitted disease preventions. Perception of peers' involvement in risk behaviors, a key correlate of individual risk behaviors, has barely been studied among FSWs. A self-administered questionnaire was completed by 1022 FSWs in Guangxi, China, a country with rapid growth in both HIV epidemic and commercial sex. Multiple imputation using chained equation (MICE) was applied to handle missing values (1–10%) in the data-set. Regression analysis that focused on relationship between perceived peers' risk involvement and FSWs' risk-taking was performed on full data-sets generated by MICE. FSWs who perceived more peer alcohol use was significantly more likely to have sex under the influence of alcohol. Those who perceived more unprotected sex among peers had a higher likelihood to use condom inconsistently with both stable and casual partners. Perceiving more peers engaging in sex after using alcohol was positively associated with having sex with clients who were intoxicated and/or high on drugs, and with having sex under the influence of alcohol. Perceived peer promiscuity, defined as having sex with any types of clients at any price offered, was positively associated with inconsistent condom use with casual partners, but negatively associated with having sex under the influence of alcohol. These data suggest that the potential for intervention programs to address behavioral change among FSWs through modifying perceptions of peer involvement in sexual risk behaviors. Longitudinal studies are needed to confirm these findings and qualitative researches will be essential for the clarification of mechanisms behind associations found in the current study and for the actual design of effective norm-based interventions among FSWs.

To understand the illegal sidenafil use among middle-aged and elderly male clients of female sex workers (FSWs) in central region of Guangxi as well as on related risk factors. Initial evaluation regarding the effect of illegal sidenafil use on HIV infection among the middle-aged and elderly men was also conducted. A survey was conducted among the over 50-year-olds male clients of low-grade prostitutions in central areas of Guangxi. Information on demographics, related behavior, and illegal sidenafil use was collected. 5 ml blood sample were taken to test antibodies of HIV and syphilis. PASW Statistics 18.0 was used for data analysis. 2 056 questionnaires were completed. 23.1% of the participants said they had ever used illegal sidenafil. The risk of sildenafil use was low among the male clients who were not over 60 years old (OR = 0.586, 95% CI:0.459-0.749). The risks of sildenafil use among the male clients with frequencies(in the past 30 days) of having commercial sex behavior were:only once (OR = 0.184, 95%CI:0.090- 0.378), twice (OR = 0.187, 95%CI:0.089-0.378) or three times (OR = 0.181, 95%CI: 0.085-0.384) lower than those with more than five times. Being single (OR = 0.608, 95% CI: 0.396-0.933), married/cohabiting (OR = 0.533, 95% CI:0.391-0.727), having unstable partners (OR = 0.558, 95%CI:0.393-0.792) seemed to be protective on those who used sildenafil, among the study population. Factors as 'never use the condom (OR = 1.642, 95%CI:1.125-2.397) or 'seldom use as condom (OR = 1.840, 95%CI:1.278-2.648) when having commercial sex, were under high risk among the sildenafil users. Forty-seven subjects were HIV positive, with the prevalence as 2.29% in this study population. Male clients of the FSWs who used sidenafil were under 60 years of age and with higher risk of HIV infection. people who were ≥60 years old, divorced/widowed/ separated, with frequencies (in the past 30 days) of having commercial sex more than 5 times, never or occasionally using a condom when having commercial sex etc., appeared at high risk. Middle-aged and elderly male clients who used sildenafil or sildenafil-like drugs were under high risk of contracting HIV infection.

Background: An adequate perception of the degree to which one is at risk of having or contracting HIV is necessary for behavioural change and the adoption of safe behaviours. There are limited data regarding HIV risk perceptions among female sex workers in Iran. This study aimed to determine the HIV risk perception status and its association with sexual behaviours among female sex workers in Tehran. Methods: A cross sectional study was conducted among 170 female sex workers in Tehran. Participants were recruited using a combination of snowball, purposeful, and convenience sampling methods. Multiple logistic regression was used to identify adjusted associations between background factors, sexual behaviours, and HIV risk perception. The analysis was conducted by the "logistf" package in the R statistical system. P-value less than .05 was considered as statistically significant.Results: Among the participants, 122 (77%) reported high HIV risk perception. Most female sex workers with high HIV risk perception reported that they did not consistently use condoms (n=120, 98%. Female sex workers with a higher frequency of sex work (AOR=1.18, 95% CI: 1.08, 1.31), inconsistent condom use (AOR=0.15, 95% CI: 0.02, 0.66), a history of HIV testing (AOR=5.1, 95% CI: 1.2, 26.0), and low HIV knowledge (AOR=0.97, 95% CI=0.95, 0.996) were more likely to report high HIV risk perception. Conclusion: Most female sex workers with risky sexual behaviours had a high HIV risk perception. Effective educational programs are suggested to enable female sex workers to correctly assess their own HIV risk and change risk behaviors based on self-assessment of actual risk.

ObjectivesFor migrant female sex workers (FSWs) at the Sino-Vietnamese border, the impact of work time in their current location on the spread of HIV/AIDS is not clear.MethodsData were collected from the Sino-Vietnamese border cities of Guangxi, China. Migrant FSWs working in these cities were studied. FSWs who worked less than 6 months in their current location were assigned to the short-term work group (ST FSWs), and FSWs who worked equal to or longer than 6 months in their current location were assigned to the long-term work group (LT FSWs). Logistic regression was performed to examine the impact of work time in the current location and factors associated with HIV infection.ResultsAmong the 1667 migrant FSWs, 586 (35.2%) and 1081 (64.9%) were assigned to the ST FSW and LT FSW groups, respectively. Compared to LT FSWs, ST FSWs were more likely to be of Vietnamese nationality, be less than 18 years old when they first engaged in commercial sex work, and have a low-level of HIV-related knowledge and had higher odds of using condoms inconsistently, having more male clients, having no regular male clients, and having a history of male clients who used aphrodisiacs but lower odds of receiving free condoms distribution and education/HIV counselling and testing programme. The analysis of factors associated with HIV infection revealed that Vietnamese FSWs, less than 18 years old when they first engaged in commercial sex work, having no regular male clients, and having lower average charge per sex transaction were correlated with HIV infection.ConclusionFSWs with short-term work at the Sino-Vietnamese border had a higher risk of risky sex and were correlated with HIV risk factors. Vietnamese FSWs were at higher risk of HIV infection, and they were more likely to have short-term work. More targeted HIV prevention should be designed for new FSWs who recently began working in a locality to further control the spread of HIV, particularly cross-border FSWs.

In Vietnam's concentrated HIV epidemic, female sex workers (FSWs) are at increased risk for acquiring and transmitting HIV, largely through their male clients. A high proportion of males in Vietnam report being clients of FSWs. Studying HIV-related risk factors and prevalence among male clients is important, particularly given the potential for male clients to be a 'bridge' of HIV transmission to the more general population or to sex workers. Time-location sampling was used to identify FSW in Hanoi and Ho Chi Minh City, Vietnam's largest cities, in 2013-2014. Recruited FSWs were asked to refer one male client to the study. Demographic and risk behavior data were collected from FSWs and male clients by administered questionnaires. Biologic specimens collected from male clients were tested for HIV and opiates. Sampling weights, calculated based on the FSWs probability of being selected for enrolment, were applied to prevalence estimates for both FSWs and male clients. Logistic regression models were developed to obtain odds ratios for HIV infection among male clients. A total of 804 male clients were enrolled. Overall, HIV prevalence among male clients was 10.2%; HIV prevalence was 20.7% (95% confidence interval (CI) 15.0-27.9%) among those reporting a history of illegal drug use and 32.4% (95% CI 20.2-47.7%) among those with opioids detected in urine. HIV prevalence among male clients did not differ across 'bridging' categories defined by condom use with FSWs and regular partners over the previous 6months. HIV among male clients was associated with a reported history of illegal drug use (OR 3.76; 95% CI 1.87-7.56), current opioid use (OR 2.55; 95% CI 1.02-6.36), and being referred by an FSW who self-reported as HIV-positive (OR 5.37; 95% CI 1.46-19.75). Self-reported HIV prevalence among enrolled FSWs was 2.8%. Based on HIV test results of male clients and self-reported status from FSWs, an estimated 12.1% of male client-FSW pairs were sero-discordant. These results indicate high HIV prevalence among male clients of FSWs, particularly among those with a history of drug use. Programs to expand HIV testing, drug-use harm reduction, and HIV treatment for HIV-infected male clients of FSWs should be considered as key interventions for controlling the HIV epidemic in Vietnam.

Sex workers health: time to act

Female sex workers (FSWs) account for about 20% of new HIV infections in Nigeria. We estimated the change in HIV prevalence and sexual risk behaviors between 2 consecutive rounds of integrated biological and behavioral surveillance surveys (IBBSSs) and determined correlates of HIV transmission among FSWs. In 2007 and 2010, HIV prevalence and risk behavior data on brothel-based (BB) and non-brothel-based (NBB) FSWs from the integrated biological and behavioral surveillance survey were evaluated in 6 Nigerian states. Logistic regression was used to identify correlates of HIV infection. A total of 2897 and 2963 FSWs were surveyed in 2007 and 2010, respectively. Overall HIV prevalence decreased in 2010 compared to 2007 (20% vs. 33%; P < 0.001), with similar magnitude of declines among BB-FSW (23% vs. 37%; P < 0.0001) and NBB-FSW (16% vs. 28%; P < 0.0001). Consistent condom use with boyfriends in the last 12 months was lower in 2010 compared to 2007 overall (23% vs. 25%; P = 0.02) and among BB-FSWs (17% vs. 23%; P < 0.01] while NBB-FSWs showed a marginal increase (30% vs. 27%; P = 0.08). FSWs residing in the Federal Capital Territory [adjusted odds ratio (AOR): 1.74 (1.34 - 2.27)] and Kano state [AOR: 2.07 (1.59 - 2.70)] were more likely to be HIV-positive while FSWs recruited in 2010 [AOR: 0.81 (0.77-0.85)] and those who had completed secondary education [AOR: 0.70 (0.60-0.80)] were less likely to be HIV-positive. Results suggest significant progress in reducing the burden of HIV among FSWs in Nigeria, although low condom use with boyfriends continued to be a potential bridge between FSWs and the general population. Venue-based prevention programs are needed to improve safer sex practices among BB-FSWs.

ABSTRACTBackground: Alcohol use is pervasive among female sex workers (FSW) placing them at increased risk of violence and sexual risk behaviors. FSW often live and work where alcohol is highly normative. Objective: To understand the socioecological influences on hazardous alcohol use among FSW in Malawi. Methods: In 2014, 200 FSW identified through venue-based sampling in Lilongwe, Malawi, completed a quantitative behavioral survey, with a sub-sample participating in qualitative interviews. Multivariable log-binomial regression was used to identify associations between hazardous alcohol use (AUDIT score ≥ 7) and time in sex work, clients per week, unprotected sex, alcohol use with clients, and living environment. Qualitative interviews enhanced findings from quantitative data and identify emergent themes around socioecological influences on alcohol use. Results: Over 50% reported hazardous alcohol use and lived in an alcohol-serving venue. Hazardous alcohol use was associated with sex work duration of ≥2 years (aPR: 1.30; 95%CI: 1.02,1.65) and alcohol use at last sex with a client (aPR: 1.29; 95%CI: 1.06,1.57). FSW perceived alcohol as a facilitator for sex work by reducing inhibitions and attracting clients, but acknowledged alcohol leads to violence and/or unprotected sex. Despite these risks and a motivation to reduce use, FSW feared that refusing to drink would be tantamount to turning away clients. Conclusions: Although FSW recognized alcohol-related risks, the norms and power dynamics of sex work perpetuated hazardous alcohol use. Multilevel interventions are needed to collectively change norms around drinking and sex work that will enable FSW to reduce alcohol consumption when engaging in their work.