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Women in the sex trade whose economic and social base are urban streets face multiple dangers of predation, isolation, and illness. A Mobile Access Project (MAP) to provide emergency medical help, peer counseling, condoms and clean needles, resource information and referral, and a place of respite and safety was initiated for sex trade workers in Vancouver, British Columbia, Canada. We conducted surveys with 100 women sex workers who accessed MAP services and reviewed MAP logbooks to document use of services. We assessed the impact of MAP through review of data from a concurrent cohort study of injection drug users and a survey of 97 women at a drop-in center in the Downtown Eastside. Over 90% of MAP clients reported that the van made them feel safer on the street. Sixteen percent of surveyed MAP clients recalled a specific incident in which the van’s presence protected them from a physical assault and 10% recalled an incident when its presence had prevented a sexual assault. Distribution of needles and condoms has increased steadily since the implementation of MAP. Eighty percent of women surveyed at a drop-in center in the Downtown Eastside had received services from MAP. The peer-led Mobile Access Project has emerged as a viable harm reduction strategy for serving the immediate health and trauma-related needs of women engaged in street-level sex work.
Women in the sex trade face multiple dangers associated with communicable disease, alienation from family and friends, lack of access to health services and police protection, random and partner violence, and even murder.1 Since the 1980s, over 60 female sex workers have disappeared from the infamous Downtown Eastside (DTES) of Vancouver, British Columbia (BC), Canada. Many of these women have fallen prey to sexual predators.2 In response, a coalition of local, provincial, and federal governments implemented the Mobile Access Project (MAP). The province of BC contributed an ambulance that was refurbished and stocked with first-aid supplies, condoms, clean needles, and information about community social services. Exterior doors were fitted with corkboards for posting of “bad-date” information. Start-up costs totaled $75,000.
The MAP van commenced operations on March 15, 2004. Staffed by a driver and two peer support workers, the van circulates through the DTES and surrounding areas every night from 10:30 p.m. to 5:30 a.m., stopping roughly every six blocks and spending about 15 min per stop. The route follows many of the “strolls” frequented by sex trade workers. The annual budget for operation of the van, including wages and training, is $294,000. To our knowledge, the MAP van is the first mobile outreach service staffed by peers to serve women in the sex trade. We evaluated the impact of MAP on safety and adoption of harm-reducing behaviors among sex workers.
Vancouver’s DTES is characterized by abject poverty, high crime rates, homelessness, prostitution, mental illness,3 and rampant alcohol and drug use.4 Women working in the DTES sex trade are subject to extreme violence and abuse.5 Of the area’s approximately 16,000 long-term residents, the majority are unemployed 6 and 4,700 are injection drug users.7 The Vancouver Injection Drug Users study (VIDUS) has estimated the prevalence of HIV–AIDS and hepatitis C at 35%8 and 90%,9 respectively.
We undertook a survey among sex workers using MAP services in January 2006. Survey items were generated by members of the research team. Agreement on face validity was achieved by consensus. We pretested our survey instrument on 30 sex workers and then simplified the vocabulary and sentence structure. The survey was divided into two parts. In the first survey, we asked nine questions, designed to determine how respondents learned about the van, when and why they used it and their sociodemographic status. On the second part of the survey, conducted 3 weeks later, we asked 17 questions, focused on support and services received at the van and perceived impact of the program on safety. Approval of our proposal was obtained from the University of British Columbia Behavioral Ethics Board.
To conduct the survey, two research assistants followed the van in a car and at each stop stood about 20 ft in front of the van. Women accessing services at the van were told by the staff that participation in a 3-min interview was requested (but not required) and that they would receive a $5.00 food coupon. Women who chose to participate then approached the researchers. In addition, we reviewed daily logs from the van to ascertain the number of clients served, clean needles and condoms distributed, and used needles turned in.
In order to assess the degree to which women in the DTES in general were aware of the van, we asked women at a drop-in center in the DTES in January, 2006, to complete a questionnaire on two consecutive days. It consisted of ten questions asking if they were aware of the van, how they learned about it, and what services they used. We inserted a question about MAP in the VIDUS questionnaire in order to both assess use of the van among this cohort and to compare risk status and behaviors among VIDUS participants who accessed the MAP van with those who did not. Statistically significant differences were denoted by a type I error, two-sided of 0.05 or less.
Survey participation among women approaching the van at each stop varied from 50% to 90% with higher rates in the more socioeconomically deprived stops. Ninety-seven MAP clients were interviewed for the first survey and 100 for the second. The age of participants ranged from 16 to 53 and 84% were between the ages of 22 and 45. The largest self-identified ethnic group was First Nations women (43%) followed by women of European descent (39%; Table 1).
The majority of women surveyed used van services once (44.8%) or twice (20.9%) each night. The remainder of the women reported accessing the van twice weekly (17.9%), once weekly (11.9%), or less frequently (3.0%). Log books indicated that MAP was rapidly adopted. The average number of monthly contacts increased from 963 in 2004 to 1,269 in 2005 and 1,496 in 2006.
Ninety-seven women participated in the survey conducted at the drop-in center, among which 81% had obtained services from MAP. Of the 107 female sex workers interviewed as part of the VIDUS study, 20% had used MAP.
MAP clients described a frightening array of violence perpetrated against them, such as being brutally beaten, punched in the face, strangled, and dragged down the street by cars. More than half of the women accessing the van had used it to receive first aid or to facilitate access to medical care elsewhere. Sixteen percent recalled a specific incident when the van had prevented them from being injured. Ten percent recalled a specific incident when the van had prevented them from being sexually assaulted. When asked if the van made them feel safer, 93.7% of respondents indicated that it did. Reasons for accessing the van are listed in Table 1.
The mean number of condom packs distributed per month doubled in the first year—from 531 in 2004 to 1,074 in 2005 and increased to 1,432 in 2006. The number of clean needles dispensed per month almost tripled during the MAP’s first 3 years of operations from 1,240 in 2004 to 3,241 in 2006.
During our study period, 107 female sex workers in the VIDUS cohort responded to a question related to their use of the MAP van and we were able to compare women who used MAP with those who did not. A higher proportion of MAP users were injecting cocaine one or more times daily (31% vs. 19%), but rates of daily heroin injection at about 50% were similar. A higher proportion of MAP users were smoking crack (81% vs. 72%). Rates of borrowing used needles were similar (10%) but none of the MAP users, compared to 10.5% of the non-MAP users, had lent used needles. Differences were not statistically significant.
Fear and uncertainty were constant companions on the job. Among the eight peer support workers, all but one reported feeling unsafe at times. They were threatened by van clients who were intoxicated and by men who either wanted supplies from the van themselves or who did not want their female associates to use the van. On occasions where the staff called the police for assistance, they reported a rapid response. In general, however, van staff reported that police were inadequately informed about MAP and did not share information with them about bad dates and other hazards.
The Mobile Access Project was designed to promote the health and safety of sex workers. Over 90% of a cohort of 97 sex workers indicated that the MAP van made them feel safer on the street. It prevented both physical and sexual assault.
Lack of respectful nonjudgmental health care services and providers knowledgeable about the specific health care needs of sex workers are gaps cited in the literature that have been addressed by MAP.10 The quasicriminal status of sex work undermines the ability of sex workers to seek protection from police.10 A report on victimization of sex workers by police has called for the use of peer leaders to educate sex workers about the laws related to their work, and their rights as citizens.11
The large and increasing number of needles exchanged suggests that MAP could play a decisive role in prevention of HIV–AIDS and hepatitis C among sex workers. Detailed data from VIDUS indicate that MAP reached a high-risk population, including women injecting drugs on a daily basis. None of the VIDUS participants who accessed MAP had lent used needles. A key reason for the success of the needle program may be that women can access the van without leaving the corner they are working on for more than a few minutes. Another reason may be the social support provided by peers who staff the MAP van.
A recent major review of harm reduction strategies for sex workers advocates mobility in provision of services and the opportunity for sex workers to rest and talk with peer support workers.12 In New York, a van supported by a private foundation was staffed with health care workers to dispense clean needles, condoms, bleach kits, and HIV prevention information during day and evening hours.13 This study emphasized the need to reach sex workers through outreach programs. The use of peer counselors was advocated. Other studies have described the potential for women in the sex trade to influence sex workers’ decisions to practice safe sex.14
Our study is limited by our inability to assume that women who use MAP are representative of all DTES sex workers and because 50–90% of women at each survey location participated in the survey.
We used a “sample–resample” approach to estimate the proportion of women working on the street that answered our survey.15 Since 30 women out of our sample of 90 answered both questions, we believe that our participants represented about one third of the population of sex workers on the MAP route.
MAP holds much promise as a relatively low-cost method of meeting the immediate needs of women engaged in street-level sex work, including shelter from imminent danger, first aid, condoms and clean needles, information about predators, and access to health and other community services. Our study demonstrates the utility of using peer support for this especially vulnerable group of women. Our findings should encourage other large urban centers to consider the implementation of a mobile access service to monitor and enhance the safety of women in the sex trade.
Status of Women Canada, The Public Health Agency of Canada, Western Economic Diversification Canada, Service Canada-Aboriginal Community Career and Employment Services Society (ACCESS), Government of BC Ministry of Community Aboriginal and Women’s Services, Vancouver Foundation, Van City Credit Union, City of Vancouver