This study demonstrates how various HIV risk factors of migrant FSWs are situated, grouped, and varied in different types of sex work environments in a low- to middle-income neighborhood in Beijing. Overall, the FSWs in this study differed on key demographic characteristics from those reported in previous studies of FSWs in Beijing and other parts of China. Compared to most FSWs in other studies who were young in their 20s and unmarried (Hong & Li, 2008
; Rou et al., 2007
; Yang et al., 2005a
), the FSWs in this study were relatively older and were married with children. Such differences may reflect the characteristics of the migrant FSWs in this study community. While two-thirds of the participants always used a condom with clients, the majority experienced clients' refusal of condom use. The finding that when clients refused condom use, some FSWs' safer sex decisions were dependent upon situations (often by higher economic gain) or took risk (“didn't care”) suggests the need to raise collective awareness of HIV/STI prevention as a primary concern for them. FSWs were also at risk of HIV/STIs in their sexual relationships outside of sex work. As found in other studies among FSWs (see Hong & Li, 2008
), inconsistent condom use in this study sample was higher with non-paid regular partners than with paid clients. Therefore, interventions promoting gender empowerment for safer sex needs to be developed and targeted to both clients and partners.
Importantly, various forms of sex work-related violence and harms, in particular STI symptoms, were highly prevalent among the participants. Less than half of them, however, had access to protection supports or health care systems; most dealt with those problems by themselves. The frequent policing of the sex work industry marginalizes FSWs, compounding FSWs' difficulties in obtaining peer support and accessing HIV/STI prevention and treatment/care services (Tucker & Ren, 2008
). The low rates of drug use in this sample might be due to regional factors as most participants came from regions where injection drug use has not been reported as a major HIV transmission mode. The low rates of drug use suggest an opportunity for early intervention before FSWs begin to use drugs as maladaptive coping with sex work-related social-psychological stressors. Thus, in order to intervene to reduce such cumulative risk factors, multi-level prevention strategies must be implemented.
Different risk profiles were found across the three groups. Coming from a rural area with less education, Sb-FSWs appeared to be the most marginalized – they had the least access to HIV prevention resources and the lowest HIV knowledge scores. While migrant women might choose sex work as a way to achieve rapid financial gains to support their families in their home towns, Sb-FSWs, who earned less income than those in the other sex work environments, were also at risk for being arrested by police. Sb-FSWs' higher exposure to those exogenous risk factors (e.g., lower educational attainment, lack of access to health services, and frequent arrest by police) might increase psychosocial distress, which in turn, might increase their HIV risk behaviors. In contrast, Et-FSWs were more likely to have been exposed to risk factors that might occur in transactional sex – physical and verbal abuse and other harms by their clients while providing sex services. These context-dependent risk factors may disempower FSWs in safer sex negotiations that are under the control of clients: Clients who are drunk, violent, or lose control often humiliate FSWs. The unequal nature of the relationship between clients and FSWs can heighten situationally-induced HIV risks (Rekart, 2005
). As noted in the literature on HIV vulnerability in women (Lin, McElmurry, & Christiansen, 2007
; Logan, Cole, & Leukefeld, 2002
) and structural-level HIV protective and risk factors among FSWs (Morisky et al., 2002
), neither condom promotion nor HIV prevention self-efficacy will ensure actual condom use unless FSWs' unequal power relationships with men and policies toward condom use in the sex work environment are addressed. Thus, effective HIV prevention interventions should include male clients as well as owners and managers/mommies of sex work establishments.
The findings from the MDA suggest that there are different clusters of risk factors situated among the three types of sex work environments; therefore, prevention needs to be tailored to the context of sex work environments. One profile of risk reflects structural risk factors resulting from criminalization, lack of access to protection, community-based prevention services, and health care; this profile was highly scored in Sb-FSWs. The other risk profile indicates sex work-related violence and power imbalance with clients; this profile was highly scored in Et-FSWs. Ps-FSWs reported lowest on those two profiles compared to the other groups. The first clustered risk profile suggests the need for structural interventions focused on the 3As – availability, accessibility/affordability, and acceptability – combined with strengthening community-based prevention capacity for FSWs (Blankenship, Bray, & Merson, 2000
). The second profile suggests the importance of incorporating sex work harm-reduction, in particular occupational safety, where sex workers and owners/managers together have control over reducing exposure to violence and contextual risk and ensuring FSWs' health and rights.
Although existing socio-structural research of sex work supports our findings, there are limitations in this study. First, the study was conducted from a drop-in center in a low- to middle-income neighborhood in a northwestern district of Beijing and participants were recruited through target and chain-referral sampling rather than random sampling. Therefore, the study sample might be not representative of all FSWs in Beijing, limiting the generalizability of study findings to other FSW populations. Second, this study was designed as a needs assessment to identify proxy risk factors of HIV/STIs and violence; assessment of sexual behavior, including characteristics of clients and non-paid sex partners, was limited. The complexity of transactional sex exchanges between FSWs and clients should be explored further to improve understanding of the contextual risk factors (e.g., intimacy and trust of clients) and migration process. Sex worker identity is another important area for research. As suggested by our study findings, the perception of sex work (identity) as occupational resiliency from hardship as a protective factor needs to be explored. Discriminant analysis is a useful method to examine variables that discriminate between groups for profiling, but there are limitations of this analytic approach. Unlike exploratory factor analysis or cluster analysis, a variable of group is determined beforehand, and the number of functions is driven from that of the group. It is possible that different profiles (e.g., factor structures or clusters) might result if an independent variable is not specified or other dependent variables are added. In principle, MDA in the study is a post-hoc, not a prior prediction; therefore, prediction of classification is unknown. Future research needs to cross-validate the clusters of risk factors from this study with diverse FSW populations and settings (e.g., rural areas and places of high HIV prevalence).
Despite study limitations, this descriptive study has important public health implications. Sex work is a fluid occupation influenced by economic conditions. Due to the illegal nature of sex work and FSWs' geographical mobility, it is difficult to sustain outreach, education, and counseling programs targeted at the individual level among these mobile populations. This is all the more reason to focus on the context of HIV risk and develop structural interventions for the sex work industry. Environmental-based interventions might be more effective and feasible among FSWs since structural interventions aim to change the foundations of social structure of HIV vulnerability and socio-cultural norms of prevention rather than focus on individual behavioral change (Gupta et al., 2008
). Thus, when a sex worker comes to a sex work venue where a structural intervention is being implemented, she will be exposed to HIV prevention.
Research also needs to focus on migrant FSWs' networks in terms of kinship, origin of migration, social ties, and protective resources so as to better deliver HIV prevention programs (Liao, Schensul, & Wolffers, 2003
; Wong & Leung, 2008
). While migrants would have easier access to health care systems in their rural hometowns than in their urban workplaces, health care systems for sexual health might not be well-established in their hometowns. To overcome inadequate health promotion resources in rural areas, effective structural HIV prevention interventions and sexual training should be integrated into existing social welfare and medical systems (Wu et al., 2007
). This type of effort would facilitate a harm-reduction approach to HIV/STI prevention among FSWs. HIV prevention interventions among FSWs need to be incorporated into comprehensive reproductive health promotion programs rather than only for disease prevention. To achieve the sustainability of policy-driven effective interventions, there should be a coordinated approach among all sectors, including civil society, community-based organizations, and FSWs, to implement women's rights-based structural interventions. Otherwise, we will continue to promote and reinforce an ecology of risk that enhances FSWs' vulnerability to HIV and other STIs.