Abstract
BackgroundWhile crack cocaine has been associated with elevated sexual risks and transmission of HIV/STIs, particularly in the context of street-based sex work, few empirical studies have examined correlates of direct sex-for-crack exchanges. This study longitudinally examined the correlates of sex-for-crack exchanges and associated effects on sexual risk outcomes among street-based female sex workers (SW) who use drugs in Vancouver, Canada.MethodsData were drawn from a prospective cohort of street-based SWs (2006–2008), restricted to those who smoke crack cocaine. Multivariable generalized estimating equations (GEE) were employed to examine the correlates of exchanging sex for crack. A confounding model using GEE quasi-Poisson regression modeled the independent effect of exchanging sex for crack on number of clients/week.ResultsOf 206 SWs, 101 (49%) reported sex-for-crack exchanges over 18 months of follow-up. In multivariable GEE analyses, sharing a crack pipe with a client (aOR = 1.98; 95%CI: 1.27-3.08) and smoking crack in a group of strangers (e.g., in an alley or crackhouse) (aOR = 1.70; 95% CI: 1.13-2.58) were independently correlated with sex-for-crack exchanges. In our confounding model, exchanging sex for crack (aIRR = 1.34; 95% CI: 1.07-1.69) remained significantly associated with servicing a greater number (>10) of clients/week.ConclusionsThese findings reveal elevated sexual- and drug- risk patterns among those who exchange sex for crack. The physical and social environment featured prominently in our results as a driver of sex-for-crack exchanges, highlighting the need for gender-sensitive multilevel approaches to harm reduction, STI and HIV prevention that address SWs’ environment, individual level factors, and the interplay between them.
Highlights
The advent of widespread use of crack cocaine in North America in the 1980s and 1990s has been directly linked to elevated rates for sexually transmitted infections (STIs), including HIV transmission [1,2,3], through increased sexual risk pathways [4,5]
Similar trends have been reported in the Vancouver context; the reported prevalence of daily crack use among street-involved women was found to be 9.7% compared to 5.6% among men [1]
Of a total of 252 participants enrolled in our open prospective cohort between 2006–2008, 206 (82%) had reported smoking crack within the follow-up period
Summary
The advent of widespread use of crack cocaine in North America in the 1980s and 1990s has been directly linked to elevated rates for sexually transmitted infections (STIs), including HIV transmission [1,2,3], through increased sexual risk pathways (e.g. higher number of sexual partners and unprotected sex) [4,5]. Similar trends have been reported in the Vancouver context; the reported prevalence of daily crack use among street-involved women was found to be 9.7% compared to 5.6% among men [1]. Though it is unclear whether the higher prevalence among street-involved women is related to sex work, studies elsewhere have noted high levels of crack cocaine among sex workers [5,13]. While crack cocaine has been associated with elevated sexual risks and transmission of HIV/STIs, in the context of street-based sex work, few empirical studies have examined correlates of direct sex-forcrack exchanges. This study longitudinally examined the correlates of sex-for-crack exchanges and associated effects on sexual risk outcomes among street-based female sex workers (SW) who use drugs in Vancouver, Canada
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