Summary of main findings
Thirty-four street sex workers were successfully engaged with GP-led primary care drug treatment services in Derby for over a year — a significant number for such individuals that are both vulnerable and hard to access.
The clinic and its access to targeted primary care services was effective in significantly improving the health and wellbeing of the sample, as measured by the Christo score.
All responders were actively sex working at the beginning of the study, whereas, after a year of prescribed treatment for their heroin addiction, the proportion reporting involvement in sex work had dropped to 33%. There is no apparent reason or incentive for participants to be less honest about this after 1 year than at entry, as their treatment was unaffected.
Heroin use, as reflected in urine samples, had reduced overall in the cohort, from 87% at entry to the study (the negative 13% of samples were taken after the start of treatment), to 72% at 1 year. The reduction to 72% at 1 year compares with around 50% still positive in studies undertaken with general, less chaotic populations.6
As urine sampling for illicit opiates is not quantitative and it was known that all participants were taking maintenance medication, it is likely that actual amounts of heroin used may have fallen much more than numbers of positive samples, as suggested in another study.6
In the context of an abstinence-based government treatment policy, it is pertinent to note that total abstinence from heroin use does not appear to be a precondition for stopping street sex work.
Strengths and limitations of the study
This study recruits a group of individuals that are notoriously hard to access and for which there is very little published data. It is also unusual in looking at outcomes for a GP-led primary care-based UK drug treatment service.
Retention in the study at 1 year was 100%; as such, the study did not suffer from bias due to failure to track those who dropped out. On the other hand, it relies, to a large extent, on self-reported data. It is also important to note that, in this field, it is very difficult to carry out a randomised controlled study, as control participants are not available. This study, therefore, relies on repeated measures for a single self-selected cohort and confounding variables, such as readiness to change, cannot be excluded.
Regression to the mean would tend to reduce the number of sex workers and heroin users over time; it has not been possible to control for this effect. However, the results from this study are encouraging and suggest that further research in this field would be fruitful.
Comparison with existing literature
There are very few studies in this field. An observational study by DeBeck et al7
pointed to the economic relationship between intravenous drug use and income generation by prostitution, and noted that intervention to relieve financial pressure by involvement in treatment programmes should, on the face of it, be successful. A further study8
pointed to the improved take-up of a wider range of health promotion interventions, which is likely if these are embedded in a drug treatment programme and continued untreated illicit drug use is a barrier to exiting prostitution.9
Implications for clinical practice
The Home Office prostitution strategy1
recognises the range of health issues arising from prostitution and suggests an integrated approach to managing sex workers. However, the 2007 Department of Health guidelines on drug misuse management10
give no explicit advice for treating sex workers as a separate population that is vulnerable. This study indicates that GP-led primary care interventions, targeted specifically at treating opiate addiction in this group, can be effective not only in improving health and wellbeing, but also in achieving an end to working on the streets for some women.