Female Entertainment And Sex Workers Research Articles

Joint effects of alcohol and stimulant use disorders on self-reported sexually transmitted infections in a prospective study of Cambodian female entertainment and sex workers.

Female entertainment and sex workers (FESW) have high rates of alcohol and amphetamine-type stimulant (ATS) use, increasing risk for HIV/sexually transmitted infections (STI), and other negative outcomes. A prospective cohort of 1,198 FESW in a HIV/ATS use prevention intervention in Cambodia was assessed for alcohol and stimulant use disorders (AUD and SUD) using the Alcohol and Substance Use Involvement (ASSIST) scale. STI history was measured by self-report at baseline and at quarterly follow-up visits. Participants were asked if they had been diagnosed with an STI by a medical provider in the past 3 months. Marginal structural models were used to estimate joint effects of AUD and SUD on recent STI. At baseline, one-in-four screened AUD positive and 7% screened positive for SUD. At 18-months, 26% reported ≥1 recent STI. Accounting for time-varying and other known confounders, the adjusted odds ratio (AOR) for recent STI associated with AUD alone and SUD alone were 2.8 (95% CI:1.5-5.1) and 3.5 (95% CI:1.1-11.3), respectively. The AOR for joint effects of AUD and SUD was 5.7 (95% CI:2.2-15.2). AUD and SUD are independently and jointly associated with greater odds of STI among Cambodian FESW. Further research is critical for understanding how AUD and SUD potentiate biological and behavioural pathways that influence STI acquisition and to inform HIV risk-reduction interventions in FESW.

Syndemic Psychosocial Health Conditions Associated with Recent Client-Perpetrated Violence Against Female Entertainment and Sex Workers in Cambodia.

Female entertainment and sex workers (FESW) are vulnerable to violence, which impedes safer sex behaviors and increases risk of HIV. FESW are also disproportionately affected by co-occurring psychosocial health conditions, including substance use, depression, and economic insecurity, which increased risk of exposure to violence. We used a syndemic framework to examine the effects of co-occurring psychosocial conditions on the risk of client-perpetrated physical and sexual violence against FESW. Data were collected among 1198 Cambodian FESW on recent client-perpetrated physical and sexual violence, and psychosocial conditions (psychological distress, alcohol consumption, amphetamine-type stimulant (ATS) use, debts, housing, and food insecurity). Bivariate and multivariate logistic regressions were conducted. Prevalence of physical and sexual violence from clients was 4.8% and 6.9%, respectively. Client-perpetrated physical violence was associated with housing insecurity, ATS use, and psychological distress. All psychosocial conditions, except ATS, were associated with exposure to sexual violence. In multivariable models, odds of client-perpetrated physical violence were twice higher among women with ≥ 4 compared to ≤ 3 psychosocial conditions. Risk of sexual violence increased with the number of psychosocial conditions. Compared to those with ≤ 1 condition, FESW with two psychosocial conditions had twice the odds (AOR = 2.08; 95% CI 1.00-4.31) and women with 5-6 psychosocial conditions had eightfold higher odds (AOR = 8.10; 95% CI 3.4-19.31) of sexual violence from clients. Our findings support a syndemic model of co-occurring psychosocial conditions among FESW that are associated with increased risk of violence. Violence prevention interventions targeting FESW should adopt comprehensive approaches that address co-occurring psychosocial conditions.

Who’s that SMARTgirl? Reaching Cambodian Female Entertainment and Sex Workers with HIV Prevention Services

Engagement in prevention services is crucial to reducing HIV risk among female entertainment and sex workers (FESW), and SMARTgirl is the national social marketing HIV prevention program for Cambodian women engaged in sex and entertainment work. Informed by the Behavioral Model of Vulnerable Populations, three multivariate logistic regression analyses examined correlates of three indices of engagement along the SMARTgirl HIV prevention continuum: (1) receipt of outreach services (past 3months); (2) being registered as a SMARTgirl member; and (3) SMARTgirl club attendance (past year). Among the 1077 FESW enrolled in nine Cambodian provinces, women working in a brothel or freelance (adjusted odds ratio [aOR] 2.48; 95% CI 1.44-4.26) and those exchanging sex for drugs during the past 3months (aOR 0.45; 95% CI 0.25-0.81) had significantly lower odds of contact with a SMARTgirl outreach worker. Women who reported having more than ten sexual partners in the past 3months (aOR 0.54; 95% CI 0.32-0.89) and those who reported binge alcohol use (aOR 0.53; 95% CI 0.29-0.98) had significantly lower odds of being registered as SMARTgirl members. Exchanging sex for drugs was also associated with increased odds of attending a SMARTgirl club (aOR 2.03; 95% CI 1.04-3.98). Novel methods to deliver HIV prevention services are warranted to more effectively reach FESW who exchange sex for drugs, engage in binge alcohol use, report a greater number of sexual partners, and those not working in established work venues.

Structural interventions and social suffering: Responding to amphetamine-type stimulant use among female entertainment and sex workers in Cambodia

BackgroundIn Cambodia, HIV infection remains high among female entertainment and sex workers (FESW) and the use of amphetamine-type stimulants (ATS) is an independent risk factor for unprotected sex and sexually transmitted infections among this group. For decades public health approaches to HIV prevention in low and middle income countries (LMIC) have attempted to target the macro-power relations that shape risk behaviour with structural interventions. Recent research has highlighted that interventions that combine ATS risk reduction, in the form of financial incentives for abstinence, with existing HIV prevention programmes, may also play an important role. However, whether this approach goes far enough as a response to structural drivers of risk requires further examination. MethodsSemi-structured in-depth interviews were conducted with 30 FESW (mean age 25 years) from five provinces in Cambodia, as part of formative research for the implementation of the Cambodia Integrated HIV and Drug Prevention (CIPI) trial. The aim was to explore the contexts and drivers of ATS use. Data were analysed using grounded theory. ResultsIn addition to increasing occupational functionality, ATS were used to control pervasive feelings of ‘sadness’ in relation to the lived experience of poverty, family and relationship problems. Feeling sad could be viewed as an expression of social suffering, in response to competing priorities and seemingly inescapable constraints imposed by a lack of options for income generation, gender inequalities and stigma. Participants expressed interest in microenterprise (ME) opportunities, particularly vocational training, that could create new work opportunities beyond sex work and ATS use. ConclusionIn addition to reducing ATS use, HIV prevention interventions need to target sources of sadness and social suffering as drivers of risk among FESW in this context. The inclusion of ME opportunities in HIV prevention, to alleviate social suffering, warrants further investigation through qualitative and ethnographic research.

Proportion and predictors of loss to follow-up in a longitudinal cohort study of female entertainment and sex workers in Cambodia.

We examined the proportion and correlates of loss to follow-up (LTFU) among female entertainment and sex workers (FESWs) in a longitudinal HIV prevention intervention trial in Cambodia. The Cambodia Integrated HIV and Drug Prevention Intervention trial tested a comprehensive package of interventions aimed at reducing amphetamine-type stimulant use and HIV risk among FESWs in ten provinces. The present study estimated the proportion of women LTFU and assessed factors associated with LTFU. Logistic regression analyses were used. Of a total 596 women enrolled, the cumulative proportion of LTFU was 29.5% (n = 176) between zero- and 12-month follow-up. In multivariate analyses, women with no living children (adjusted odds ratio [AOR] 1.6; 95% confidence interval [CI]: 1.1, 2.3) and those who experienced recent food insecurity (AOR 1.7; 95%CI: 1.1, 2.7) were more likely to be LTFU. Women who were members of the SMARTgirl HIV prevention programme for ≥ 6 months compared to non-members were less likely to be LTFU (AOR 0.3; 95%CI: 0.2, 0.6). LTFU was moderately high in this study and similar to other studies, indicating a need for strategies to retain this population in HIV prevention programmes and research. Interventions aimed at stabilizing women's lives, including reducing food insecurity and creating communities of engagement for FESWs, should be considered.

High pregnancy incidence and low contraceptive use among a prospective cohort of female entertainment and sex workers in Phnom Penh, Cambodia

BackgroundWhile HIV and unintended pregnancies are both occupational risks faced by female sex workers, the epidemiology of pregnancy and its drivers in this population remains understudied. This includes Cambodia, where the drivers of pregnancy among female entertainment and sex workers (FESW) remain unknown. The current study aimed to examine factors associated with incident pregnancy, as well as describe contraceptive use among FESW in Phnom Penh, Cambodia.MethodsThis analysis drew from the Young Women’s Health Study (YWHS)-2, a 12-month observational cohort of 220 FESW aged 15–29 years, conducted between August 2009 and August 2010. Interviewer-administered questionnaires were conducted at baseline and quarterly thereafter, alongside HIV and pregnancy testing. Bivariate and multivariable extended Cox regression analysis was used to examine correlates of incident pregnancy.ResultsAt baseline, 6.8% of participants were pregnant, and only 10.8% reported using hormonal contraceptives, with 11.3% reporting an abortion in the past 3 months. Pregnancy incidence was high, at 22/100 person-years (95% CI: 16.3–30.1). In multivariable analysis, younger age (19–24 years versus 25–29 years) (Adjusted Hazards Ratio (AHR): 2.28; 95% Confidence Interval (CI) 1.22–4.27), lower income (400,000–600,000 Riel (≤150$USD) versus > 600,000 Riel (> 150$USD)) (AHR 2.63; 95% CI 1.02–6.77) positively predicted pregnancy, while higher self-reported condom self-efficacy were associated with reduced pregnancy incidence (AHR 0.89; 95% CI 0.81–0.98).ConclusionsResults document high incidence of pregnancy and unmet reproductive health needs among FESWs in Cambodia. Findings point to an urgent need for multi-level interventions, including venue-based HIV/STI and violence prevention interventions, in the context of legal and policy reform. High pregnancy incidence in this population may also undermine recruitment and retention into HIV prevention intervention trials. The exploration of innovative and comprehensive sex worker-tailored sexual and reproductive health service models, also as part of HIV prevention intervention trials, is warranted.

HIV treatment cascade among female entertainment and sex workers in Cambodia: impact of amphetamine use and an HIV prevention program

BackgroundHIV prevalence remains high in Cambodia among female entertainment and sex workers (FESW), and amphetamine-type stimulant (ATS) use significantly increases risk of infection. A successful continuum of care (CoC) is key to effective clinical care and prevention. This study aimed to describe the HIV CoC in HIV-positive FESW. We examined CoC outcomes among HIV-positive FESW participating in the Cambodia Integrated HIV and Drug Prevention Implementation (CIPI) study, being implemented in ten provinces. CIPI is a trial aimed at reducing ATS use concomitant with the SMARTgirl HIV prevention program.MethodsFrom 2013 to 2016, 1198 FESW ≥ 18 years old who reported multiple sex partners and/or transactional sex were recruited. We identified 88 HIV-positive women at baseline. We described linkage to care as 12-month retention and viral suppression (<1000 copies/mL). Logistic regression analyses were conducted to examine correlates of retention in care at 12 months, and viral suppression.ResultsMedian age of the 88 HIV-positive women was 32 years [interquartile range (IQR) 28, 35]; 50% were working in entertainment venues and 50% as freelance sex workers; 70% reported SMARTgirl membership. In the past 3 months, women reported a median of 15 sex partners, 38% reported unprotected sex, and 55% reported using ATS. Overall, 88% were receiving HIV care, 83% were on antiretroviral therapy, 39% were retained in care at 12 months, and 23% were virally suppressed. SMARTgirl membership was independently associated with fourfold greater odds of 12-month retention in care (AOR = 4.16, 95% CI 1.38, 12.56). Those at high risk for an ATS use disorder had 91% lower odds of 12-month retention in care (AOR = 0.09, 95% CI 0.01, 0.72). Viral suppression was independently associated with SMARTgirl membership, older age, reporting of STI symptoms, worse symptoms of psychological distress, and greater numbers of sex partners.ConclusionsThis is the first study to characterize the HIV CoC in Cambodian FESW. While most women were successfully linked to HIV care, retention and viral suppression were low. Tailored programs like SMARTgirl, targeting the broader population of HIV-positive FESW as well as interventions to reduce ATS use could optimize the clinical and population health benefits of HIV treatment.Trial registration This work reports data collected as part of a trial: NCT01835574. This work does not present trial results

Protocol of a cluster randomised stepped-wedge trial of behavioural interventions targeting amphetamine-type stimulant use and sexual risk among female entertainment and sex workers in Cambodia

IntroductionHIV risk among female entertainment and sex workers (FESW) remains high and use of amphetamine-type stimulants (ATS) significantly increases this risk. We designed a cluster randomised stepped wedge trial (The...

The impact of violence on sex risk and drug use behaviors among women engaged in sex work in Phnom Penh, Cambodia

BackgroundViolence, substance use, and HIV disproportionately impact female entertainment and sex workers (FESW), but causal pathways remain unclear. MethodsWe examined data from an observational cohort of FESW age 15–29 in Phnom Penh, Cambodia for associations between violence exposure and sexual risk and drug use. Validated measures of physical and sexual violence were assessed at baseline. Self-reported outcomes measured quarterly over the next 12-months included past month sexual partners, consistent condom use by partner type, sex while high, and amphetamine type stimulant (ATS) use. Biomarkers measured quarterly included prostate specific antigen (PSA) and urine toxicology. Generalized estimating equations were fit adjusting for age, education, marital status and sex work venue. ResultsOf 220 women, 48% reported physical or sexual violence in the preceding 12-months. Physical violence was associated with increased number of sex partners (adjusted incidence rate ratio [aIRR] 1.33; 95% CI: 1.04–1.71), greater odds of sex while high (adjusted odds ratio [aOR] 2.42; 95% CI: 1.10–5.33), increased days of ATS use (aIRR 2.74; 95% CI: 1.29–5.84) and increased odds of an ATS+ urine screen (aOR 2.80, 95%CI: 1.38–5.66). Sexual violence predicted decreased odds of consistent condom use with non-paying partners (aOR 0.24; 95% CI: 0.10–0.59) and greater odds of a PSA+ vaginal swab (aOR 1.83; 95% CI: 1.13–2.93). ConclusionsPhysical and sexual violence are prevalent among Cambodian FESW and associated with subsequent sexual risk and drug use behaviors. Clinical research examining interventions targeting structural and interpersonal factors impacting violence is needed to optimize HIV/AIDS prevention among FESW.

Behavioral interventions for Cambodian female entertainment and sex workers who use amphetamine-type stimulants.

Conditional cash transfer (CCT) and cognitive-behavioral treatments are evidence-based approaches to reduce stimulant use and sexual risk taking. We describe the adaptation and implementation of sequential behavioral interventions for Cambodian female entertainment and sex workers (FESW) who use amphetamine-type stimulants (ATS): (1) a 12-week CCT intervention; and (2) a 4-week cognitive-behavioral aftercare (AC) group. An ongoing cluster randomized stepped wedge trial in 10 Cambodian provinces is enrolling FESW with confirmed recent ATS use to examine the effectiveness of CCT+AC. In the first six provinces, 138 of the 183 eligible FESW (75%) enrolled in CCT and completed a median of 25 (interquartile range 9-32) of the 36 urine screening visits. Of the 84 participants who were eligible for AC, 79 completed at least one session (94%) and 57 completed three or more sessions (68%). Culturally tailored behavioral interventions to reduce ATS use and optimize HIV prevention are feasible in resource-limited settings.

Pharmacology, physiology and performance: occupational drug use and HIV risk among female entertainment and sex workers in Cambodia.

BackgroundIn Cambodia, HIV prevalence among female entertainment and sex workers (FESW) is up to twenty times higher than in the general population. Use of amphetamine-type stimulants (ATS) has been associated with increased risk of HIV and other sexually transmitted infections in key populations, including FESW. While one in four Cambodian FESW report recent ATS use, little attention has been paid to how the occupational contexts of sex work shape patterns of use. Currently, no HIV prevention interventions target ATS use in this population.MethodsWe conducted in-depth interviews with FESW (n = 30) with the goal of exploring experiences and motivations for ATS use and informing the development of a conditional cash transfer (CCT) intervention designed to reduce ATS use and HIV risk. Interviews were conducted and transcribed in Khmer and translated into English. Interview narratives were read and re-read and emerging themes reviewed and refined to develop an initial coding scheme. Data were formally coded using both open and axial coding to clarify and consolidate initial themes.ResultsThe most common driver of ATS use among FESW was increased functionality. ATS was seen as a performance enhancer, acting as an appetite suppressant and enabling women to meet the physiological demands of sex work, including long working hours, multiple clients and extended sexual transactions. While our results are consistent with studies linking ATS use to heightened sexual risk, via unprotected and/or prolonged sex, for women in the current study, the negative consequences of ATS use were outweighed by perceived functional benefits.ConclusionsFESW in Cambodia harness the pharmacological properties of ATS to meet the physiological demands of sex work in a context of limited economic opportunities. There is an urgent need to both provide Cambodian women with options for income generation that do not risk their health and to better regulate the conditions of sex work to provide safer working environments. Structural and economic interventions, including CCT programmes, combined with awareness and enforcement of sex workers’ rights, are also necessary to facilitate harm reduction and occupational health and work safety within the Cambodian sex and entertainment industry.