Abstract
BackgroundStigma in health services may be detrimental to health seeking attitudes and practices. This study investigates non-disclosure of sex work to health care providers among female sex workers (FSW) in Brazil and its association with the utilization of health care services.MethodsThis study used cross-sectional respondent-driven sampling, carried out in 12 Brazilian cities to identify HIV risk behaviors among FSW. We first assessed statistical associations of sociodemographic, human right violations, health service access and utilization, and discrimination variables with non-disclosure of FSW status to health care providers as outcome. Secondly, we investigated the association of non-disclosure of FSW status with selected preventive health care outcomes: HIV testing, PAP smear exam, and post-exposure prophylaxis (PEP). Adjusted odds ratio with 95% confidence intervals were calculated by multivariable logistic regressions.ResultsAmong 4245 recruited FSW, a high percentage received free condoms (82%) but only 24.4% were counseled on STI. Most FSW used non-specialized public healthcare routinely (62.6%), but only 51.5% had a Pap smear exam in the last two years and less than 40% were tested for HIV in the last 12 months. Among FSW who engaged in risky behavior (49.6%), only 8.3% used PEP. Regarding human rights violations, approximately 15% were required to give part of their earnings to owners of workplace establishments, 38% started sex work under 18 years old and 6% were required to periodically present their HIV test results. 21.3% reported having faced discrimination in health services, and 24.3% always disclosed their FSW status. Multivariable logistic models indicated significant associations of non-disclosure on the four healthcare outcomes, with lower odds of using preventive health services among women who did not disclose their sex work status, even after controlling for age, educational level, NGO affiliation, and type of health care routinely used.ConclusionsOur results indicate that sex work stigmatization within health services may be one of the main barriers to STI control and HIV response among FSW. It is essential to combat stigmatization and discrimination against FSW in health services to guarantee the appropriate uptake of preventive services available in the public health system in Brazil.
Highlights
Stigma in health services may be detrimental to health seeking attitudes and practices
Study design This study reports results of a cross-sectional Biological and Behavioral Surveillance Survey (BBSS) among female sex workers (FSW) conducted in 12 Brazilian cities, in 2016
50.0% were younger than 30 years old, 48.0% had not completed high school, 52.3% self-reported as brown, and only 8.0% belonged to an non-governmental organizations (NGO) (Table 1)
Summary
Stigma in health services may be detrimental to health seeking attitudes and practices. The human rights approach proposes that “the provision of health services should be ensured to all population groups on the basis of equality and freedom from discrimination, paying particular attention to vulnerable and marginalized groups” [11], which include FSW. The core principles of the Brazilian National Health System or Sistema Único de Saúde (SUS) ─ integrality (integrated prevention, treatment and care), equity, public accountability and funding ─ resulted from a long period of advocacy for governmental responsibility for health promotion [12, 13] Despite these principles, many FSW suffer barriers to access health services because of stigma and discrimination related to the nature of their work
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