Violence and HIV Sexual Risk Behaviors Among Female Sex Partners of Male Drug Users

SUMMARY

Objective: Violence and HIV are emerging as interconnected public health hazards among drug users and their families. The purposes of this study are to (1) determine the prevalence of sexual and physical abuse of non-drug-using female sex partners of male drug users, and (2) ascertain the association between such violence and HIV-related risk behaviors. Methods: From 11/93 to 11/95, 208 female sex partners of injection drug or crack users in Collier County, FL, Tucson, AZ, and Portland, OR, were interviewed as part of a NIDA-funded HIV risk reduction project. Their mean age was 30 years (range 18–54); 21% were White, 6% African American, 7% Native American, and 63% Hispanic. Results: Of the 208 women, 28% reported being sexually molested and 20% raped before age 13; 41% reported being raped at least once in their lifetime. Forty-two percent of the women were physically assaulted by their sex partners; 36% had been threatened with assault by their sex partners. Those who were raped or threatened with assault were more likely to have multiple sex partners and engage in unprotected anal sex; there was a trend for women who had been physically assaulted to be more likely to engage in unprotected anal sex. Discussion: Rape, assault and the threat of assault are commonplace in the histories of female sex partners of male drug users. Experiences of violence and threats of violence are associated with heightened risk for the sexual transmission of HIV. Providers of HIV prevention need to understand the sequelae of violence, and design interventions which empower women to protect themselves from sexual transmission of HIV.     

Prevalence and Correlates of HIV and Sexually Transmitted Infections among Female Sex Workers and Their Non-commercial Male Partners in Two Mexico-USA Border Cities

Female sex workers (FSWs) acquire HIV and other sexually transmitted infections (STIs) through unprotected sex with commercial and non-commercial (intimate) male partners. Little research has focused on FSWs'' intimate relationships, within which condom use is rare. We sought to determine the prevalence and correlates of HIV/STIs within FSWs'' intimate relationships in Northern Mexico. From 2010 to 2011, we conducted a cross-sectional survey of FSWs and their non-commercial male partners in Tijuana and Ciudad Juárez, Mexico. Eligible FSWs and their verified male partners were aged ≥18 years; FSWs reported lifetime use of heroin, cocaine, crack, or methamphetamine and recently exchanged sex (past month). Participants completed baseline questionnaires and testing for HIV, chlamydia, gonorrhea, and syphilis. We determined the prevalence and correlates of individuals'' HIV/STI positivity using bivariate probit regression. Among 212 couples (n = 424), prevalence of HIV was 2.6 % (n = 11). Forty-two (9.9 %) tested positive for any HIV/STIs, which was more prevalent among women than men (12.7 % vs. 7.1 %, p < 0.05). FSWs with regular sex work clients were less likely to test positive for HIV/STIs than those without regular clients. Similarly, male partners of FSWs who had regular clients were 9 % less likely to have HIV/STIs. Higher sexual decision-making power was protective against HIV/STIs for women. Men who recently used methamphetamine or reported perpetrating any conflict within steady relationships were more likely to test positive for HIV/STIs. Within FSWs'' intimate relationships in two Mexican-US border cities, nearly one in ten partners tested positive for HIV/STIs. Couple-based prevention interventions should recognize how intimate relationship factors and social contexts influence HIV/STI vulnerability.     

Venue-Mediated Weak Ties in Multiplex HIV Transmission Risk Networks Among Drug-Using Male Sex Workers and Associates

Objectives. We investigated the structural characteristics of a multiplex HIV transmission risk network of drug-using male sex workers and their associates.Methods. Using a sample of 387 drug-using male sex workers and their male and female associates in Houston, Texas, we estimated an exponential random graph model to examine the venue-mediated relationships between individuals, the structural characteristics of relationships not linked to social venues, and homophily. We collected data in 2003 to 2004. The network comprised social, sexual, and drug-using relationships and affiliations with social venues.Results. Individuals affiliated with the same social venues, bars, or street intersections were more likely to have nonreciprocated (weak) ties with others. Sex workers were less likely than were other associates to have reciprocated (strong) ties to other sex workers with the same venues. Individuals tended to have reciprocated ties not linked to venues. Partner choice tended to be predicated on homophily.Conclusions. Social venues may provide a milieu for forming weak ties in HIV transmission risk networks centered on male sex workers, which may foster the efficient diffusion of prevention messages as diverse information is obtained and information redundancy is avoided.Sex work increases the risk of contracting and transmitting HIV and other sexually transmitted infections through unprotected sexual behaviors or substance use.1 Male sex workers (MSWs) experience high rates of HIV infection, both globally and domestically.2–4 In North America, HIV prevalence among MSWs is estimated to range from 5% to 31%.4 MSWs have high rates of risky sexual behavior and substance use, including drug injection.5–7 However, public health issues related to MSWs have been understudied, and current HIV prevention programs underserve MSWs.4MSWs are not homogeneous nor are the contexts of male sex work uniform.4,8 Because male sex work takes diverse forms in a variety of contexts,8,9 HIV risks may also vary by context. MSWs who solicit sex on the streets are at high risk for HIV infection, and the context of the street may increase the risk. MSWs working in street venues are more likely to have few financial resources, be undereducated, live in unstable housing or on the streets, be unemployed or disabled, and engage in sex work as a means of survival.8 Numerous MSWs and their clients self-identify as heterosexual.10 Men who have sex with men and women (MSMW) have higher rates of both transactional sex and concurrent illicit drug use and sex than do men who have sex with men only, and, among MSMW, both transactional sex and concurrent illicit drug use predict risky sexual behavior.11Although sociodemographic characteristics, HIV infection, and risk behaviors of MSWs have been documented,12,13 relatively few studies have provided a relational account of HIV risk within male sex work networks. It is known, for example, that networks of MSWs are connected to networks of other high-risk groups.2,8,10,14,15 Through these network ties, MSWs may bridge with men who have sex with men (MSM), female sex workers, drug users, and other less risky groups.2,16 MSMW are more likely to engage in sex for drugs or money than are other MSM, and MSMW occupy a central position in the network of HIV-infected males.17 However, because of the diversity of male sex work, it may be inappropriate to conceptualize MSWs as a core group.18Social networks are the structures within which norms are developed and implemented and social support occurs.19,20 Most risk-potential linkages within networks are social,20 and sex ties are often formed through social circles.21 MSWs form unique social networks,9,22 most likely involving risky drug-use and sexual behaviors. The networks are often hierarchical structures in which network leaders control areas for soliciting sex, and the network structure provides mutual support for soliciting sex.9Rarely do studies on HIV risk networks that involve MSWs regard the network as composed of “persons, places, and the relevant links connecting them.”23^(p684) Social venues are an important part of the network structure, forming the setting for MSWs’ social life and facilitating the formation of “sexual affiliation networks.”24 Our previous study25 underscored the duality of people and places26 by focusing on affiliation networks between MSWs and social venues. We found centralized affiliation patterns around a small number of highly interdependent venues. Although interdependent, the venues presented distinct patterns of venue-based clustering.25 These findings, however, were limited because the study focused on venue affiliation. Non–venue-based direct ties also may be important because they are expected to occur within social, drug-using, and sexual relationships. These types of relationships may have different emotional and interpersonal contexts27 that would tend to result in different patterns and types of ties.We defined a multiplex transmission risk network as composed of multifaceted social contexts that comprise a mix of social, sexual, and drug-using ties and affiliation ties to social venues. The social network perspective informs relational mechanisms of information diffusion and social influence at the entire network and personal network levels. Granovettor’s theory of the strength of weak ties posits, “The weak tie between ego and his acquaintance, therefore, becomes not merely a trivial acquaintance tie but rather a crucial bridge between the two densely knit clumps of close friends.”28^(p202) Weak ties avoid information redundancy by enabling individuals to access diverse information and to facilitate the diffusion of information throughout the entire network.29 Although weak ties facilitate information diffusion, they may not be sufficiently powerful to change behavior because of the ties’ transient and passive nature.Rarely have network studies focused on the role that affiliation ties play in forming direct ties between individuals. We defined venue-mediated weak or strong ties as 1-mode social, sexual, and drug-using ties formed through jointly affiliating in the same venues. We examined and statistically tested local relational features of venue-mediated weak or strong ties among MSWs and their associates. On the basis of the effect of bar-based social influence interventions led by opinion leaders on HIV risk reduction,30,31 HIV prevention messages disseminated within venues are expected to facilitate the diffusion of information, and, thus, weak ties are more likely than are strong ties to be observed linked to social venues.In personal networks, reciprocated ties suggest higher levels of trust and intimacy and, in some cases, a strong tendency to engage in risky behaviors.32 The risk of engaging in behaviors that transmit HIV are also heightened during sex for money exchanges, particularly if there is a strong economic incentive for doing so. This suggests that risk is related to the multiple types of ties determined by context. Additionally, homophily affects network ties by influencing the information that people receive, the attitudes formed, and the social interactions experienced.33 We also sought to examine the tendency of reciprocity and the effect of homophily on HIV status and sociodemographic and behavioral factors when forming risk-potential relationships that comprise social, sexual, or drug-using ties but are not linked to social venues. The likelihood of engaging in risk-taking behavior is greater in relationships with a high degree of homophily, as information flows and persuasion tend to be more frequent among like pairs.32 We tested these relational features using a stochastic network modeling approach.     

HIV Risk Among Homosexual, Bisexual, and Heterosexual Male and Female Youths

Variations in sexual risk acts and thesocial-cognitive mediators of sexual acts were examinedamong young homosexual, bisexual, and heterosexual malesand females (N = 478; 13-21 Years of age) from four community-based agencies in New York City, SanFrancisco, and Los Angeles (29% African American, 36%Latino, 36% White/other). The prevalence and frequencyof sexual risk acts varied by gender but were similar across youth of different sexualorientations, ethnicities, and ages. Condom use and thesocial-cognitive mediators of risk varied by sexualorientation and gender. Homosexual youths reported a gap between their positive attitudes toward HIVprevention and their skills to implement safer sex acts,particularly under social pressure. Bisexual youthsappeared at greatest risk; their reports of sexual risk were the highest, yet their perceived riskfor HIV was relatively low and skills and knowledge weremoderate (relative to their peers). Heterosexual youthsappear at high risk for HIV based on reports of low rates of condom use and HIV-relatedbeliefs and attitudes. However, heterosexual youthsdemonstrated the highestlevelofcondom skills. The numberofsexual partners was not associated with anyHIV-related social cognitive mediator, suggesting thatalternative theoretical models must be proposed forpartner selection. Longitudinal research with similarsubgroups of youths is needed.     

HIV Prevention Needs Among Street-Based Male Sex Workers in Providence,Rhode Island

We examined data derived from a needs assessment of the personal and social characteristics and HIV risk behavior of street-based male sex workers, in Providence, Rhode Island, who engage in transactional sexual intercourse with other men. Substance use, injected drugs, needle sharing, and psychosocial distress were highly prevalent among the sample. History of physical, sexual, and emotional abuse was associated with increased risk of condomless anal sexual intercourse with paying male clients.In the United States, studies show that male sex workers (MSWs) engage in sexual and drug-using risk behaviors that put themselves and their partners at risk for HIV acquisition. Male sex workers have a significantly higher HIV prevalence (7.3% vs 1.1%) and incidence (4.7% vs 0.9%) than do men who have sex with men but who do not engage in transactional sexual intercourse.1–6 Street-based MSWs have been shown to have the highest rates of HIV risk behavior both with clients and nontransactional partners.5,7 Several psychosocial factors, including sexual abuse, homelessness, and substance use (particularly injecting), are known to heighten sexual risk behavior among street-based MSWs.8–13Given the clandestine nature of sex work, there are limited surveillance data on MSWs in the United States. Project Weber (http://www.projectweber.org), a nonprofit health service organization serving MSWs in Providence, Rhode Island, estimates that there are between 300 and 500 street-based MSWs in the city. Collected by Project Weber as part of a needs assessment of street-based MSWs in Providence, the data reported here detail the personal and social characteristics and HIV risk behavior among this group.     

Burnout Among Female Indoor Sex Workers

This study examined levels of “burnout” and associated factors among a sample of female indoor sex workers in the Netherlands (N=96). Levels of burnout on 3 dimensions (emotional exhaustion, depersonalization, and personal competence) were assessed. Only sex workers' mean score on depersonalization was significantly higher than that of a comparison group of female nurses and comparable to those of another comparison group of patients with work-related psychological problems. Evidence was provided for the importance of experiential and context-related factors in burnout among indoor sex workers. For instance, 42% of the variance in depersonalization was explained by not working by choice, negative social reactions, experiences of violence, and lack of control in interaction with clients. Depersonalization may be a strategy to cope with negative conditions and experiences in sex work, but was significantly related to indicators of stress and emotional exhaustion. More than half (53%) of the variance in emotional exhaustion was explained by lack of management support, negative social reactions, not working by choice, and negative working motivation. Personal competence was highest among sex workers with a professional attitude, who started sex work at a relatively older age, and who were well supported by colleagues and management. It is concluded that burnout is not as much associated with sex work per se, but with sex work under certain conditions, among which stigma (notably negative social reactions) and stigma-related experiences (such as role conflict, experiences with violence, and lack of a worker-supportive organizational context) are important.     

女用安全套在女性性工作者中可接受性研究

目的了解女用安全套在女性性工作者（FSW）中的可接受性及其影响因素。方法采用定性调查方法评估FSW人群对女用安全套的可接受性。结果大多数（25/27）FSW认为女用避孕套质量较好,多数FSW认为女用避孕套外观难看（19/27）,使用不方便（11/27）,有不适感（24/27）。结论认为女用避孕套使用不方便比例较高,女用避孕套推广有一定困难。     

不同档次场所暗娼人群艾滋病/性病感染状况和高危行为调查

目的 了解不同场所中暗娼艾滋病病毒/性病感染(HIV/STI)的感染状况,为制定针对暗娼的综合干预措施提供科学依据.方法 对广西某县各城区、乡镇、村屯各类场所的暗娼进行流行病学调查,收集人口学和高危行为信息,并采集静脉血检测HIV、梅毒,采用SPSS11.5软件进行统计分析.结果 326名暗娼中,中高档场所占60.7％(198/326),低档场所占39.3％(128/326).两组相比,在年龄、职业、文化程度、婚姻、高危行为、艾滋病认知和艾滋病感染率等方面,中高档和低档暗娼相比差异有统计学意义(P＜0.001).低档暗娼年龄较大,农民占的比例更高,文化程度较低,对艾滋病的认知较差,已婚占的比例更多;低档暗娼服务的客人为中老年为主,安全套使用率低,服务收费低廉,首次从事性交易年龄较大,低档暗娼最近一个月平均每天服务客人的数量更多,而她们获得的艾滋病服务较少;低档暗娼HIV阳性感染率为3.9％,明显高于中高档暗娼,梅毒感染率为12.5％,与中高档暗娼相比差异无统计学意义.结论 低档暗娼比中高档暗娼存在更高的艾滋病高危行为,传播艾滋病的几率更大,应作为监测和干预的重点人群.     

Sexual Coercion,HIV-Related Risk,and Mental Health Among Female Sex Workers in China

We performed this study to examine the association of sexual coercion with HIV-related risk behaviors and suicidal thoughts and attempts among female sex workers (FSWs) in Guangxi, China. Four hundred fifty-four FSWs in 57 entertainment establishments (including shampooing salons, massage parlors, and restaurants) were interviewed between March and May 2004. Fifteen percent of the women reported having been coerced into sex in the last 6 months. The prevalence of suicidal thoughts and suicide attempts in the last 6 months were 14.3% and 8.4%, respectively. Sexual coercion was significantly associated with both an increased rate of HIV-related risk behavior, and suicidal thoughts and attempts among FSWs. Therefore, along with the awareness and intervention programs, efforts should be taken to reduce the exposure of FSWs to sexual coercion and to improve the mental health of FSWs.     

Mass Media and HIV/AIDS Prevention Among Female Sex Workers in Beijing,China

The current study aimed to identify the sources of HIV prevention information for female sex workers in Beijing and assess the associations between levels of mass media exposure of HIV/AIDS prevention information and HIV/AIDS knowledge as well as condom use–related attitudes, beliefs, and behaviors. Cross-sectional data were collected from 359 female sex workers in Beijing, China. Chi-square tests and one-way ANOVA tests were employed. Female sex workers sampled in Beijing were more likely to obtain HIV/AIDS prevention information from television and street posters than radio and the Internet. However, a higher level of exposure to and a lasting impression on online information were significantly associated with a higher level of condom use self-efficacy and more consistent condom use among the participants. Exposure to HIV/AIDS prevention information delivered by radio, street posters, and the Internet was found to be associated with sexual communication about HIV or condom use with sexual partners. Overall, this study provides preliminary evidence of the utility of various mass media outlets in delivering HIV/AIDS prevention information among female sex workers in China. Future studies are needed to systematically examine the effectiveness of mass media–based prevention education on HIV/AIDS related attitudes and behaviors among female sex workers and other populations in China.     

兰州市城关区暗娼人群艾滋病和梅毒流行病学分析

目的了解兰州市城关区暗娼人群(FSW)艾滋病和梅毒流行特征及相关影响因素,为有针对性地开展健康教育和行为干预提供科学依据。方法在知情同意的原则下,采用两阶段整群抽样的方法,对城关区娱乐场所从事商业性交易的女性,进行面对面问卷调查。调查内容包括人口学状况、艾滋病相关知识、安全套的使用和求医行为等。血液采集进行艾滋病、梅毒抗体检测。结果共调查FSW1200人,未检出HIV感染者,检出梅毒108例,检出率为9.00%;最近1个月商业性性行为安全套每次使用率为78.33%,最近一次商业性性行为安全套使用率为92.50%。49.66%的调查对象有固定性伴,其最近1个月安全套每次使用率为43.50%,最近一次安全套使用率为51.25%。结论暗娼人群安全套使用率低,存在艾滋病/梅毒感染的潜在危险,应继续加大健康教育和行为干预力度,促进其建立良好的行为和生活方式。     

308名性乱妇女HIV监测及性行为调查

目的 了解性乱妇女HIV感染情况及相关性行为特征，为制定预防策略提供依据。方法 对308名性乱妇女，采取匿名调查方法进行问卷调查和HIV抗体检测。结果 调查对象HIV抗体检测结果1人为阳性，年龄最小为15岁，21．4％性乱时从不使用安全套，1人既性乱又吸毒。结论 性乱妇女HIV相关危险行为发生率高，应加强宣传教育和安全套的推广使用，以减少HIV经性传播。     

低档站桩性服务小姐艾滋病相关知识行为

目的了解某市低档站桩性服务小姐艾滋病相关知识、行为等生存状况,为进一步干预提供依据。方法采用非概率抽样中的目的抽样方法,个人深入定性访谈调查14名低档站桩性服务小姐,并采集血样进行HIV、梅毒抗体检测。结果14名小姐年龄在20～50岁之间,平均年龄41岁,以文盲为主。艾滋病及其预防的知识较匮乏,发生无安全套保护性行为的情况比较严重。普遍不知道或认为没有可能感染艾滋病,大部分自己买药治疗生殖器异常症状。14名小姐中,HIV抗体阳性2例,梅毒抗体阳性9例,其中2例HIV抗体阳性感染者合并感染梅毒。结论低档性服务小姐文化水平低,对感染艾滋病的风险意识不足,不安全性行为比例大,应加强针对该人群的干预措施,遏制艾滋病的传播。     

Syphilis Infection Among Female Sex Workers in Colombia

Objective To study the epidemiology of Treponema pallidum (syphilis) among female sex workers (FSW) in Santa Fe de Bogotá, Colombia. Design A cross-sectional study was conducted. Participants were interviewed using a standardized questionnaire, which collected socio-demographic characteristics and risk behavior information. Blood samples were screened for syphilis using the VDRL test and the MHATP assay. Results The prevalence of syphilis was 10.3% (53/514). Adjusted risk factors significantly associated with syphilis were: age (linear increase), education (primary or no education), monthly income (<US$ 180), time in sex work (≥4 years), number of clients per week (≥22), main workplace (street), inconsistent (never) condom use in sex work, previous STI history, and use of illegal drugs. Conclusions Effective health education programs for improving the level of knowledge of STI and the promotion of consistent condom use activities along with other appropriate harm reduction activities are urgently required among FSW in Colombia. Human Use Statement: The study protocol was approved by the Instituto Nacional de Salud of the Colombian Ministry of Health.     

Violence Against Chinese Female Sex Workers From Their Stable Partners: A Hierarchical Multiple Regression Analysis

Limited data are available regarding risk factors that are related to intimate partner violence (IPV) against female sex workers (FSWs) in the context of stable partnerships. Out of the 1,022 FSWs, 743 reported ever having a stable partnership and 430 (more than half) of those reported experiencing IPV. Hierarchical multivariate regression revealed that some characteristics of stable partners (e.g., low education, alcohol use) and relationship stressors (e.g., frequent friction, concurrent partnerships) were independently predictive of IPV against FSWs. Public health professionals who design future violence prevention interventions targeting FSWs need to consider the influence of their stable partners.     

Correlates of Self-Efficacy for Condom Use Among Male Clients of Female Sex Workers in Tijuana,Mexico

Male clients of female sex workers (FSWs) in Tijuana, Mexico engage in high levels of unprotected sex. While behavioral change theories posit that self-efficacy predicts condom use, correlates of self-efficacy for condom use remain largely unstudied. We examined these correlates among male clients of FSWs in Tijuana. Eligible male clients were at least 18 years of age, HIV-negative, lived in Tijuana or San Diego, reported unprotected sex with a Tijuana FSW at least once in the past 4 months, and agreed to be treated for sexually transmitted infections (STIs). Participants completed an interviewer-administered questionnaire including demographics, substance use, psychosocial and psychosexual characteristics (e.g., outcome expectancies for negotiation of safer sex, social support, and sexual sensation seeking), and sexual behaviors. Participants also underwent HIV/STI testing. A stepwise hierarchical multiple regression analysis identified correlates of self-efficacy for condom use. Of 393 male clients, median age was 37 years. Participants were mostly Spanish-speaking and employed. Factors independently associated with higher self-efficacy for condom use were higher positive outcome expectancies for negotiation of safer sex, lower sexual sensation seeking scores, and higher social support scores. Both psychosocial and psychosexual factors may influence self-efficacy for condom use among male clients of FSWs. These factors represent central constructs in sociocognitive models that explain behavioral change and could be intervention targets for improving self-efficacy for condom use and, ultimately, safer sex behavior.     

Female Migrant Sex Workers in Moscow: Gender and Power Factors and HIV Risk

This study aimed to build formative knowledge regarding HIV risks in female migrant sex workers in Moscow, focusing on gender and power. This was a collaborative ethnographic study, informed by the theory of gender and power, in which researchers conducted minimally structured interviews with 24 female sex workers who were migrants to Moscow and who provided sexual services to male migrant laborers. Overall, the female migrant sex workers engaged in HIV risk behaviors and practiced inadequate HIV protection with their clients. These behaviors were shaped by gender and power factors in the realms of labor, behavior, and cathexis. In the labor realm, because some female migrants were unable to earn enough money to support their families, they were pushed or pulled into sex work providing service to male migrants. In the behavior realm, many female migrant sex workers were intimidated by their male clients, feared violence, and lacked access to women's health care and prevention. In the cathexis realm, many had a sense of shame, social isolation, emotional distress, and lacked basic HIV knowledge and prevention skills. To prevent HIV transmission requires addressing the gender and power factors that shape HIV/AIDS risks among female migrant sex workers through multilevel intervention strategies.