Transactional Sex Work Research Articles

Subsistence and Survival: Strategies Women in the Republic of Barbados Engaged in Transactional Sex Work Employ to Stay Safe

ABSTRACT Women engaged in sex work (WESW) are at increased risk for exposure to work setting violence. This phenomenological study examines the experience of work setting violence and strategies utilized to maintain safety for WESW in Republic of Barbados in the Caribbean. In-depth, semi-structured interviews were conducted with 30 cis-gender WESW in Barbados. This study found participants experienced work-related violence that includes physical assault, rape, robbery, kidnapping, and attempted murder. Participants were actively engaged in strategies for maintaining safety that were central to their business practices. Moreover, local HIV prevention intervention efforts including condom assertiveness training, free condom distribution, and rapid, accessible STI testing further enabled participants to assert and enforce safe business practices. Unfortunately, poor economic conditions at the time of the study, which reduced the market of available customers who were willing to pay full price while increasing the number of WESW, diminished the participants’ power to insist on safe business practices. This has implications for interventions to prevent and counteract gender-based violence, as well as gender-based social and economic development efforts.

Predictors of Preexposure Prophylaxis Eligibility among Pregnant People with Opioid Use Disorder.

We seek to evaluate risk factors for eligibility for preexposure prophylaxis (PrEP) among pregnant people with opioid use disorder (OUD). This is a single-site retrospective cohort study of pregnant people admitted for management of OUD at an urban, tertiary care center from 2013 to 2022. PrEP eligibility was defined based on (1) modified American College of Obstetricians and Gynecologists' (ACOG) 2014 criteria: diagnosis of a sexually transmitted infection (STI), engagement in transactional sex work, intravenous drug use (IVDU), or incarceration and (2) modified 2021 Centers for Disease Control (CDC) criteria: diagnosis of bacterial STI (e.g., gonorrhea or syphilis) or transactional sex work. Risk factors associated with PrEP eligibility were evaluated using chi- square or Fischer's exact tests for categorical variables and t-tests or Wilcoxon rank-sum tests for continuous variables. Multivariable regression was used to control for confounding covariates, defined as p < 0.10 on bivariate analysis. p < 0.05 was used to indicate statistical significance. A total of 132 individuals met inclusion criteria, of whom 101 (76.5%) were deemed eligible for PrEP by meeting one or more modified 2014 ACOG criteria: 42 (31.8%) were incarcerated or had one or more STIs, while 30 (22.7%) endorsed engaging in transactional sex work and 68 (58.6%) endorsed IVDU. Using modified 2021 CDC criteria, 37 (28%) met PrEP eligibility, with 12 (9.1%) diagnosed specifically with a bacterial STI and 30 (22.7%) engaging in transactional sex work. Only comorbid psychiatric illness was associated with an increased risk for PrEP eligibility based on 2014 criteria, which persisted after controlling for maternal race/ethnicity (aRR 1.52, 95% confidence interval [CI] 1.24-1.86), and 2021 criteria, which persisted after controlling for nulliparity (aRR 2.12, 95% CI 1.30-3.57). A significant number of pregnant people with OUD meet one or more criteria for PrEP, with comorbid psychiatric conditions increasing the risk of meeting criteria. · Comorbid psychiatric illness is significantly associated with high risk of PrEP eligibility.. · A large proportion of pregnant individuals with active OUD meet criteria for PrEP prescribing.. · Risk-based screening algorithms for PrEP eligibility have limitations..

Implementing buprenorphine prolonged-release injection using a health at the margins approach for transactional sex-workers.

Access to prescribed interventions and retention in treatment services are associated with improved health outcomes and reduced premature mortality rates for people living with opioid use disorder (OUD). In Leeds, transactional sex-workers frequently cycled in and out of treatment for OUD such that they never reached a level of engagement that permitted opportunities to meet their healthcare or housing needs. Barriers to accessing care provision include an itinerant lifestyle, difficulties with travel at unpredictable hours, impacting upon adherence to medication regimens including daily supervised consumption. To use a co-produced, "health at the margins" approach, to reach the sex-working population in Leeds, and support informed choices about the potential to receive buprenorphine prolonged-release injection (BPRI) as a treatment option for OUD. BPRI was introduced using a theory of change model and improvements in sex-worker care delivery was reviewed. Strategies included buprenorphine micro-induction, shared decision-making, collaborative multi-agency working and supporting a strengths-based and trauma-informed approach. Benefits of BPRI included removal of the need for daily pharmacy visits, reducing the risk of diversion, improved medication adherence, stability and engagement with treatment and supportive services. BPRI may offer an additional option for pharmacological interventions for people with OUD where there may be increased barriers to accessing treatment for example due to sex-working. Strategies for effective BPRI include micro-induction, shared decision-making, collaborative multi-agency working and supporting a strengths-based approach.

Employment as HIV Prevention: An Employment Support Intervention for Adolescent Men Who Have Sex With Men and Adolescent Transgender Women of Color.

Background:The purpose of this study was to adapt and pilot-test an employment support, primary HIV intervention tailored to the needs of adolescent men who have sex with men and adolescent transgender women of color.Setting:The intervention was implemented in 2 settings: controlled environment (Phase 1) and real-world community-based (Phase 2) setting in Chicago, IL.Methods:Eighty-seven adolescent men who have sex with men and adolescent transgender women of color ages 16–24 participated in Work2Prevent, a 4-session employment and HIV prevention intervention, designed to increase job-readiness and reduce HIV risk. Intervention sessions consisted of group activities: educational games, roleplaying/modeling behavior, and self-regulation exercises. Participants were assessed at baseline, postintervention, and 8-month (Phase 1) or 3-month follow-up (Phase 2).Results:Participants evaluated Work2Prevent as feasible and acceptable, rating intervention quality, usefulness, and satisfaction highly. Overall, 59.6% (Phase 1) and 85.0% (Phase 2) participants attended 2 or more sessions. At 8 months, Phase 1 participants reported a mean increase of 11.4 hours worked per week. Phase 2 participants reported a mean increase of 5.2 hours worked per week and an increase in job-seeking self-efficacy. Phase 2 participants also reported a decrease in transactional sex work.Conclusion:Work2Prevent is one of the first structural primary HIV interventions to specifically focus on adolescent employment readiness. Findings suggest Work2Prevent is feasible and acceptable, improved adolescent employment outcomes, and reduced HIV risk associated with transactional sex work. Our study underscores the need for alternative pathways, such as addressing socioeconomic determinants, to prevent adolescent HIV infection.

Transactional sex work and HIV among women in conflict-affected Northeastern Uganda: a population-based study

BackgroundArmed conflict and the HIV pandemic are significant global health issues. Evidence of the association between armed conflict and HIV infection has been conflicting. Our objective was to examine the role of mediating risk factors, such as engagement in transactional sex work, to elucidate the relation between armed conflict and HIV infection.MethodsWe used multistage sampling across three Northeastern Ugandan districts to randomly select 605 women aged 13 to 49 to answer cross-sectional surveys from January to May of 2016. We used multivariate logistic regression model with R 4.0.3 to examine if exposure to armed conflict has an indirect effect on reporting having an HIV-positive serostatus through engagement in transactional sex work. Age and district residence were included as covariates.ResultsExposure to armed conflict β = .16, SE = .04, p < .05, OR = 1.17, 95% [CI .08, .23] was significantly associated with reporting a HIV-positive serostatus. For each 1-unit increase in exposure to armed conflict (i.e., additional type of armed conflict exposure), there was a 17% increase in the odds of reporting a HIV-positive serostatus. Engagement in transactional sex work was not associated with reporting a HIV-positive serostatus β = .04, SE = .05, p = .37, 95% [CI − .051, .138]. We found district of residence, age, and interaction effects.ConclusionsAlthough exposure to armed was associated with reporting an HIV-positive serostatus, this relationship was not mediated by engagement in transactional sex. Further research is needed on risk factors that mediate this relationship. The likelihood of reporting a HIV-positive serostatus increased with each additional type of exposure to armed conflict. Thus, screening for exposure to multiple traumatic stressors should occur in HIV prevention settings. Healthcare services that are trauma-informed and consider mental distress would likely improve HIV outcomes.

The Intimate Relationship Experiences of Women Engaged in Transactional Sex Work in Barbados.

This phenomenological study, consisting of individual interviews with a sample of 30 women engaged in sex work, examines the intimate relationships of women engaged in sex work in Barbados. Participants often entered relationships with men they met while engaged in sex work. Most experienced relationships that became transactional, abusive, and exploitative. Intimate partner violence (IPV) challenged their ability to negotiate condom use with intimate partners placing them at risk for HIV. A cycle emerged of entering relationships to exit the violent conditions of sex work and then re-entering sex work to escape IPV. Implications for mental health, HIV prevention, IPV, and empowerment services are described.

Syringe Coverage Among People Who Inject Drugs in West Virginia, USA.

Ensuring people who inject drugs (PWID) have ≥ 100% sterile syringe coverage (i.e., persons have access to a sterile syringe for all injections) is optimal for HIV prevention. Existing syringe coverage literature is informative, yet little work has examined syringe coverage among PWID in rural communities. Using data from a 2018 PWID population estimation study conducted in a rural county in West Virginia, we used logistic regression to identify correlates of adequate sterile syringe coverage (at least 100%). A minority (37%) of PWID reported having adequate syringe coverage. Factors inversely associated with adequate syringe coverage included having recently (past 6months): engaged in transactional sex work, shared syringes, and injected fentanyl. Having exclusively acquired syringes from a syringe services program was associated with increased odds of adequate syringe coverage. Rural PWID may benefit from tailored interventions designed to increase sterile syringe access.

Intimate partner violence is a barrier to antiretroviral therapy adherence among HIV-positive women: Evidence from government facilities in Kenya.

Intimate Partner Violence (IPV) is linked to low engagement with HIV management services and adverse clinical outcomes, including poor ART adherence. In sub-Saharan Africa, studies on pregnant/postpartum women and transactional sex workers have produced divergent evidence regarding IPV's association with poor ART adherence. We investigate this association among a broad group of women. We sampled 408 HIV-positive women receiving free ART from different types of HIV clinics at government health facilities, assessing for IPV exposure by a current partner, ART adherence rate, and other factors that affect ART adherence (e.g. education, disclosure). ART adherence rates were measured using the Visual Analogue Scale (VAS); responses were dichotomised at a ≥95% cut-off. Multiple logistic regression models assessed the association between the independent variables and ART adherence. The participants' mean age was 38.6 (range: 18-69 years). The majority had ever attended school (94%, n = 382), were in monogamous marriages (70%, n = 282), and had disclosed status to partners (94%, n = 380). Overall, 60% (n = 242) reported optimal ART adherence (≥ 95%) in the previous 30 days. The prevalence of IPV by the current partner was 76% (CI95 = 72-80%). Experiencing physical IPV (AOR 0.57, CI95: 0.34-0.94, p = .028), sexual IPV (AOR 0.50, CI95: 0.31-0.82, p = .005), or controlling behaviour (AOR 0.56, CI95: 0.34-0.94, p = .027) reduced the odds of achieving optimal adherence, while a higher education level and having an HIV-positive partner increased the odds. IPV is common and is associated with suboptimal ART adherence rates among a broad group of HIV-positive women. ART programs could consider incorporating basic IPV interventions into regular clinic services to identify, monitor and support exposed women, as they might be at risk of poor ART adherence. Still, there is need for more research on how IPV affects ART adherence.

Work2Prevent, an Employment Intervention Program as HIV Prevention for Young Men Who Have Sex With Men and Transgender Youth of Color (Phase 3): Protocol for a Single-Arm Community-Based Trial to Assess Feasibility and Acceptability in a Real-World Setting.

BackgroundIn the United States, young cisgender men who have sex with men (YMSM), young transgender women (YTW), and gender nonconforming (GNC) youth face elevated rates of HIV infection. However, racial and ethnic disparities in adolescent HIV infection cannot be attributed to individual-level factors alone and are situated within larger social and structural contexts that marginalize and predispose sexual and gender minority youth of color to HIV. Addressing broader ecological factors that drive transmission requires interventions that focus on the distal drivers of HIV infection, including violence exposure, housing, food insecurity, educational attainment, and employment. Given the ways that economic instability may make YMSM, YTW, and GNC youth of color vulnerable to HIV exposure, this study focuses on employment as an HIV prevention intervention. More specifically, the intervention, called Work2Prevent (W2P), targets economic stability through job readiness and employment as a means of preventing behaviors and factors associated with adolescent and young adult HIV, such as transactional sex work and homelessness. The intervention was adapted from iFOUR, an evidence-based employment program for HIV-positive adults in phase 1 of this study, and pilot tested in a university-based setting in phase 2.ObjectiveThis paper aims to describe the protocol for the community-based test phase of W2P. The purpose of this phase was to pilot test a tailored, theoretically informed employment intervention program among YMSM, YTW, and GNC youth of color within a lesbian, gay, bisexual, transgender, and queer (LGBTQ) community setting.MethodsThe employment intervention was pilot tested using a single-arm pretest-posttest trial design implemented among a sample of vulnerable YMSM, YTW, and GNC youth of color using services within a community-based LGBTQ center. Assessments will examine intervention feasibility, acceptability, and preliminary estimates of efficacy.ResultsPhase 3 of W2P research activities began in May 2019 and was completed in December 2019. Overall, 41 participants were enrolled in the community-based pilot.ConclusionsThis study will assess intervention feasibility and acceptability in the target populations and determine preliminary efficacy of the intervention to increase employment and reduce vulnerability to HIV when implemented in a community-based setting serving LGBTQ youth of color. Testing the intervention in a community setting is an opportunity to evaluate how recruitment, retention, and other outcomes are impacted by delivery in a venue akin to where this intervention could eventually be used by nonresearchers. If W2P demonstrates feasibility and acceptability, a larger multisite trial implemented in multiple community settings serving YMSM, YTW, and GNC youth of color is planned.Trial RegistrationClinicalTrials.gov NCT03313310; https://clinicaltrials.gov/ct2/show/NCT03313310International Registered Report Identifier (IRRID)DERR1-10.2196/18051

Prevalence and correlates of receptive syringe‐sharing among people who inject drugs in rural Appalachia

Syringe-sharing significantly increases the risk of HIV and viral hepatitis acquisition among people who inject drugs (PWID). Clearer understanding of the correlates of receptive syringe-sharing (RSS) is a critical step in preventing bloodborne infectious disease transmission among PWID in rural communities throughout the United States. This study aimed to measure the prevalence and correlates of RSS among PWID in a rural county in Appalachia. Observational, cross-sectional sample from a capture-recapture parent study. Cabell County, West Virginia (WV), USA, June-July 2018. The sample was restricted to people who reported injecting drugs in the past 6months (n=420). A total of 180 participants (43%) reported recent (past 6months) RSS. Participants reported high levels of homelessness (56.0%), food insecurity (64.8%) and unemployment (66.0%). The main outcome was recent re-use of syringes that participants knew someone else had used before them. Key explanatory variables of interest, selected from the risk environment framework, included: unemployment, arrest and receipt of sterile syringes from a syringe services program (SSP). Logistic regression was used to determine correlates of recent RSS. PWID reporting recent RSS also reported higher prevalence of homelessness, food insecurity and unemployment than their non-RSS-engaging counterparts. In adjusted analyses, correlates of RSS included: engagement in transactional sex work [adjusted odds ratio (aOR) =2.27, 95% confidence interval (CI)=1.26-4.09], unemployment (aOR=1.67, 95% CI=1.03-1.72), number of drug types injected (aOR=1.33, 95% CI=1.15-1.53) and injection in a public location (aOR=2.59, 95% CI=1.64-4.08). Having accessed sterile syringes at an SSP was protective against RSS (aOR=0.57, 95% CI=0.35-0.92). The prevalence of receptive syringe-sharing among people who inject drugs in a rural US county appears to be high and comparable to urban-based populations. Receptive syringe-sharing among people who inject drugs in a rural setting appears to be associated with several structural and substance use factors, including unemployment and engaging in public injection drug use. Having recently acquired sterile syringes at a syringe services program appears to be protective against receptive syringe sharing.

Parenting and child-caretaking among black men who have sex with men and associated sexual and reproductive health factors: a brief report

The purpose of this exploratory study was to examine the prevalence of parenting and child-caretaking among a sample of black men who have sex with men (MSM), as well as associations between parenting roles and sexual and reproductive health (SRH) factors. Parenting and SRH data were derived from a survey of 199 black MSM. Nearly half of the sample reported being a father or father-figure (44.4%), almost a third indicated serving as caretaker of a child (29.1%), and one in five have a biological child (20.1%). Over half of the sample reported at least one of these three parenting/child-caretaking roles (52.5%). Two significant differences were observed for sexual health variables: men with biological children were significantly more likely to report using condoms inconsistently (55.0% vs. 35.7%, p = .026) and engaging in transactional sex work (36.8% vs. 21.0%, p = .041). Given the observed prevalence, parenting and child-caretaking among black MSM warrant further inquiry as factors that may influence SRH outcomes and care utilization. Services and interventions tailored to black MSM should consider these men’s potential roles and responsibilities as parents and caretakers of children.

The World’s Oldest Profession? Employment-Age Profiles from the Transactional Sex Market

Abstract Standard labor market models predict that the likelihood of employment increases, hours worked increase, and individuals transition from less-skilled and temporary jobs to more skilled and more stable employment as they age. I examine the association between age and transactional sex work using national household surveys from Zambia, one of the few settings with general population surveys asking women about transactional sex and a relatively high documented prevalence of employment in transactional sex. My results indicate that the likelihood of employment in transactional sex sharply falls with age. Increased employment opportunities outside of transactional sex do not appear to explain the transactional sex employment-age profile and marital status appears to explain only a portion of it. These findings are consistent with the hypothesis that clients prefer younger transactional sex workers and suggest that policymakers implement interventions designed to reduce client demand for younger females.

Liminal Masculinity: Narratives of Class and Sexuality in Post-authoritarian Indonesia

ABSTRACTIn contemporary Indonesia, the fragmentation of a collectively-imagined future has generated ambivalent and contradictory ways of being and becoming a man. This article investigates this tension by drawing on interviews and ethnographic data collected from young men aged 18–30 who engage in transactional sex work in the capital city Jakarta. The narratives of these young men suggest that transactional sex is a choice linked to the cultivation of an appropriate form of masculinity. This understanding, however, is complicated by mobility in two ways. First, geographical mobility tied to migration is understood to be necessary to becoming a man who is independent from family. Second, temporal mobility involves future aspirations to marry a woman and become a father, a powerful template for joining middle-class society. Young men find the intersection of geographical and temporal mobility as a source of open-ended liminality in the midst of acute economic precarity and perpetually flexible employment. Serving as narrative accounts of the plasticity of the most widely-held assumptions about the immutable nature of gender, liminal masculinity helps to illuminate the ambiguous effects of global economic forces on forms of moral self-cultivation.

Human T-cell lymphotropic virus 1/2 and human immunodeficiency virus antibodies identification among transactional sex workers and drug users in the Dominican Republic.

Human immunodeficiency virus (HIV) increases the risk of acquiring human T-cell lymphotropic virus (HTLV) and subsequently HTLV's progression to tropical spastic paraparesis/HTLV-1-associated myelopathy (TSP/HAM). Existing data have exclusively reported generalized rates of HIV and HTLV-1 chronic viral infections in the Dominican Republic. To our knowledge, no published studies have focused on the rates of HTLV-1/2 in transactional sex workers and drug users, both higher risk groups, in the Dominican Republic. From December 2012 to April 2013 we conducted a study to estimate the seroprevalence of HTLV-1/2 immunoglobulin G (IgG) and HIV antibodies among transactional sex workers and intravenous drug users in Santo Domingo, Dominican Republic. Serological status was analysed with behaviour and demographic data. We collected and analysed plasma from 200 participants with a mean age of 27.4 y in men and 25.2 y in women. The overall weighted seroprevalence of HTLV-1/2 IgG antibodies was 13.91% (95% CI 7.59 to 20.23) in men and 10.59% (95% CI 4.05 to 17.13) in women. The overall weighted seroprevalence of HIV-1 was 13.91% (95% CI 7.59 to 20.23%) in men and 17.65% (95% CI 9.55 to 25.75) in women. Male intravenous drug users had an exceptionally high rate of HTLV-positive HIV co-infection, at 75% (95% CI 44.99 to 105.01). Although there an association has been found between HTLV/HIV co-infections and sex work, the adjusted odds revealed a confounding role of HIV infection. The results highlight the urgent need for enhanced public health preventive strategies among high-risk populations in the Dominican Republic and other resource-constrained Caribbean settings, as well as global adoption of routine screening for HTLV-associated infections, particularly in these high-risk, underserved populations.

Assessment of risk factors for sexually transmitted infections in high-risk communities in Santo Domingo and La Romana, Dominican Republic

Abstract Background This study assesses the prevalence of sexually transmitted infections and risk factors among key populations living in La Romana and Santo Domingo, Dominican Republic: pregnant adolescents, men who have sex with men, trans women, sugar cane field (batey) residents, transactional sex workers, and people living with HIV. This work is based on a preliminary analysis of batey data collected in La Romana. Methods In 2017, 203 participants, aged 18–60 years, were recruited from eight bateys systematically selected using time-location sampling. Informed consent was obtained, and a 40 min questionnaire was administered. Blood, urine, Papanicolaou samples, and oral/anal swabs were used to test for HIV, syphilis, hepatitis B virus (HBV), hepatitis C virus (HCV), gonorrhoea, chlamydia, Trichomonas vaginalis, Ureaplasma spp, and Mycoplasma genitalium , and Papanicolaou (cervical) samples were collected. Participants with positive results received free treatment, when available, follow-up and education. Findings Of 203 participants, 131 (65%) were women and 161 (79%) were Spanish-speaking. One ( T vaginalis , and 60 (30%) participants were positive for Ureaplasma spp. 116 (88%) of 132 women underwent Papanicolaou testing. 21 (18%) women had abnormal Papanicolaou results, and 36 (31%) women were positive for human papillomavirus (HPV); of those, 25% of women had HPV16, 8% of women had HPV18/45, and 67% of women had indeterminate high-risk type. 19 (9%) participants were HBV positive. Two bateys were disproportionately affected: nine (33%) of 27 participants in Batey 1 and eight (32%) of 25 participants in Batey 2. Interpretation The prevalence of HBV infection was disproportionately higher than those found in Central and Latin America. In response, Clinica de Familia La Romana and the Dominican Ministry of Health established an HBV vaccination and prevention programme for affected bateys, and this is underway. In terms of HIV, the prevalence was lower ( vs 3%) when compared to that previously reported in bateys. Targeted HIV prevention programmes conducted by Clinica de Familia La Romana and others might have helped curb HIV infection. The prevalence of high-risk HPV and other sexually transmitted infections in this study needs to be further explored. Overall, these results highlight the need for more research, for targeted prevention initiatives, and improved access to testing and treatment for sexually transmitted infections. Funding David E Rogers Fellowship, NY Academy of Medicine Bioreference Laboratories.

Factors Associated with Use of Short-Term Pre-Exposure Prophylaxis for HIV Among Female Partners of Migrant Miners in Mozambique.

Effective interventions tailored to specific types of behaviors and contexts are needed for women at risk for HIV acquisition. Oral pre-exposure prophylaxis (PrEP) is an efficacious HIV prevention intervention that uses antiretroviral drugs to reduce the risk of acquiring HIV infection. In Mozambique, HIV remains a major public health concern, with a national prevalence of 13%. Studies have demonstrated that the migration of male miners between southern provinces of Mozambique and South Africa is contributing to the HIV epidemic in Mozambique. This increased risk is associated with the engagement of male miners, while separated from their partners, in sexual relationships with other women, including transactional sex workers, in a hyperendemic setting in South Africa. We conducted 25 in-depth interviews with a subset of female partners in a stable relationship with migrant miners participating in a prospective cohort study to assess the feasibility, acceptability, and adherence to daily oral short-term PrEP. Drug levels were available for the participants, as reported in an earlier study. Interviews were recorded, transcribed, and submitted for qualitative thematic analysis. The major themes identified were the benefits of taking PrEP, the ease of taking daily PrEP, the reluctance to disclose PrEP use to partners, the lack of changes in sexual behavior, and prevailing gender dynamics and how they impact women's ability to access PrEP and other HIV prevention interventions.

Barriers and opportunities for sexual health services for key populations in the Dominican Republic: provider, government, and community-leader perspectives

36 www.thelancet.com/lancetgh Published Online April 8, 2016 Columbia University Medical Center, New York, NY, USA (A Gomes BA, C Nicholas BA, S Amesty MD, R Perez-Figueroa MD, S Nicholas MD, B Taylor MD); Instituto Dermatologico y Cirugia de Piel “Dr. Humberto Bogaert Diaz”, Santo Domingo, Dominican Republic (Y Donastorg MD, M Perez MS); University of Texas Health Science Center San Antonio, San Antonio, TX, USA (B Taylor MD) Correspondence to Angelina Gomes amg2272@cumc.columbia.edu Barriers and opportunities for sexual health services for key populations in the Dominican Republic: provider, government, and community-leader perspectives Angelina Gomes, Catherine Nicholas, Yeycy Donastorg, Martha Perez, Silvia Amesty, Rafael Perez-Figueroa, Stephen W Nicholas, Barbara S Taylor Abstract Background Sexually transmitted infections (STIs) are an important health issue in developing countries. Key populations, including people living with HIV, men who have sex with men, trans women, transactional sex workers, pregnant adolescents, and migrants, are at high risk of STIs and have barriers to sexual health services. In this study, we aim to understand capacities and barriers to access for key populations in the Dominican Republic, and to identify opportunities to improve services.Background Sexually transmitted infections (STIs) are an important health issue in developing countries. Key populations, including people living with HIV, men who have sex with men, trans women, transactional sex workers, pregnant adolescents, and migrants, are at high risk of STIs and have barriers to sexual health services. In this study, we aim to understand capacities and barriers to access for key populations in the Dominican Republic, and to identify opportunities to improve services. Methods We used purposive sampling to solicit views from stakeholders in Santo Domingo, Dominican Republic, including health-care agencies, community-based organisations, and government entities that guide STI screening policy. We conducted 19 semi-structured interviews between February, 2015, and May, 2015, with: nine health providers, seven community leaders, and three government authorities, asking questions about STI services for key populations, gaps in services, and barriers to access. Comprehensive notes and audio recordings were iteratively reviewed by two investigators to defi ne barriers and opportunities for STI screening. Findings Respondents identifi ed barriers to access at individual, community, organisational, and policy levels. Individual barriers include poor risk perception and health knowledge, drug use in transactional sex workers and trans women, inability to negotiate condom use in sex worker and adolescent groups, and poverty. Community barriers include: discrimination against sex workers, trans women, people living with HIV, men who have sex with men, and migrants; and a culture of self-medicating in all populations. Organisational barriers include a lack of centres off ering STI testing, unavailability of medications in centres accessed by key population, and poor knowledge of available resources in the community. Policy barriers include poor access to insurance in populations; low resource allocation to STIs, other than HIV; and inconsistent supply of materials and funds. Despite these barriers, local organisations that work with key populations expressed interest in increasing capacity to screen and treat STIs. Interpretation There are many barriers to STI services for key populations in the Dominican Republic. Communitybased organisations working with such populations could leverage their expertise to increase STI awareness, screening, and treatment. Our fi ndings can help generate sustainable interventions to reduce the burden of STIs in these key populations. Funding NIAID (K23AI081538 to B Taylor); Columbia University IFAP Global Health. Copyright © Gomes et al. Open Access article distributed under the terms of CC BY. Declaration of interests We declare no competing interests.

Populations at increased risk for HIV infection in Kenya: results from a national population-based household survey, 2012.

Populations with higher risks for HIV exposure contribute to the HIV epidemic in Kenya. We present data from the second Kenya AIDS Indicator Survey to estimate the size and HIV prevalence of populations with high-risk characteristics. The Kenya AIDS Indicator Survey 2012 was a national survey of Kenyans aged 18 months to 64 years which linked demographic and behavioral information with HIV results. Data were weighted to account for sampling probability. This analysis was restricted to adults aged 18 years and older. Of 5088 men and 6745 women, 0.1% [95% confidence interval (CI): 0.03 to 0.14] were persons who inject drugs (PWID). Among men, 0.6% (CI: 0.3 to 0.8) had ever had sex with other men, and 3.1% (CI: 2.4 to 3.7) were males who had ever engaged in transactional sex work (MTSW). Among women, 1.9% (CI: 1.3 to 2.5) had ever had anal sex, and 4.1% (CI: 3.5 to 4.8) were women who had ever engaged in transactional sex work (FTSW). Among men, 17.6% (CI: 15.7 to 19.6) had been male clients of transactional sex workers (TSW). HIV prevalence was 0% among men who have sex with men, 6.3% (CI: 0 to 18.1) among persons who injected drugs, 7.1% (CI: 4.8 to 9.4) among male clients of TSW, 7.6% (CI: 1.8 to 13.4) among MTSW, 12.1% (CI: 7.1 to 17.1) among FTSW, and 12.1% (CI: 5.0 to 19.2) among females who ever had engaged in anal sex. Population-based data on high-risk populations can be used to set realistic targets for HIV prevention, care, and treatment for these groups. These data should inform priorities for high-risk populations in the upcoming Kenyan strategic plan on HIV/AIDS.

Profiling the HIV/AIDS Risk Sexual Behavior of Male Transactional Sex Workers in Manila, Philippines

The Philippine Health Department sounded the alarm on the steady increase of Human Immunodeficiency Virus- Acquired Immunodeficiency Syndrome (HIV-AIDS) cases in the Philippines particularly in the male to male sexual contact transmission. There is a dearth of academic work regarding male transactional sex workers in the country thus the need for this study. This study identified the HIV/AIDS risk sexual behavior of male transactional sex workers in Manila and correlated the behavior with selected demographic variables. A two-week cross-sectional survey in Malate using snowball sampling technique was used to recruit 30 respondents – male transactional sex workers. Face to face interviews were conducted. Chi-square determined how selected demographic information of the respondents correlated with HIV/AIDS risk sexual behavior. Respondents were 16-31 years old, mostly single and high school graduates who live with their families. Many perceived that their job is essential for their families’ survival. Almost all denied using drugs. Most engaged in bisexual acts without using condom. Many denied having sexually transmitted infections (STIs). Perceived economic value of the job was significantly related to condom use and experience with STIs. Drug use significantly correlated with age. Swift action is needed to address the increase of HIV/AIDS cases. It is necessary to understand the risk sexual behavior of men who have sex with men so prevention programs could be designed. KEYWORDS - Health Education, HIV/AIDS, risk sexual behavior, male transactional sex workers, condom use, STIs, descriptive cross-sectional survey, Philippines

Sexuality, Sexual Practices, and HIV Risk Among Incarcerated African-American Women in North Carolina

BackgroundWomen who have been in prison carry a greater lifetime risk of HIV for reasons that are not well understood. This effect is amplified in the Southeastern United States, where HIV incidence and prevalence is especially high among African-American (AA) women. The role of consensual sexual partnerships in the context of HIV risk, especially same-sex partnerships, merits further exploration. MethodsWe conducted digitally recorded qualitative interviews with 29 AA women (15 HIV positive, 14 HIV negative) within 3 months after entry into the state prison system. We explored potential pre-incarceration HIV risk factors, including personal sexual practices. Two researchers thematically coded interview transcripts and a consensus committee reviewed coding. ResultsWomen reported complex sexual risk profiles during the 6 months before incarceration, including sex with women as well as prior sexual partnerships with both men and women. Condom use with primary male partners was low and a history of transactional sex work was prevalent. These behaviors were linked with substance use, particularly among HIV-positive women. ConclusionsAlthough women may not formally identify as bisexual or lesbian, sex with women was an important component of this cohort's sexuality. Addressing condom use, heterogeneity of sexual practices, and partner concurrency among at-risk women should be considered for reducing HIV acquisition and preventing forward transmission in women with a history of incarceration.