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Prostituted women report disempowerment-related barriers to condom use, extensive violence victimization and trafficking experiences; findings indicate that disempowerment must be addressed within STI/HIV prevention efforts.
The prevention of sexually transmitted infection (STI) and HIV among prostituted women worldwide is consistently challenged by violence victimization in this context. Other manifestations of coercion, such as sex trafficking as an entry mechanism, and pressure or more money offered for unprotected sex, may similarly compromise agency to refuse sex and ensure condom use among this vulnerable population. Although prostitution is widespread in Latin America, to date, little study exists concerning disempowerment-related STI/HIV vulnerabilities among prostituted women and girls in the region.
Prostituted women (n=92) seeking health care at a non-governmental organization in Managua, Nicaragua completed a brief assessment as part of intake data collection in November 2008, pending 9 their verbal consent. Developed to track the service delivery population, items were designed to assess experiences thought common among the population. The assessment was administered by the intake health provider to overcome potential literacy concerns. All items were self-reported; single items assessed condom use, barriers to condom use, and violence victimization. Consistent with UN guidelines, trafficking was defined based on 2 items regarding having been coerced, forced, or involuntarily entering sex work at any age or reporting age at first paid sex before age 18. The current investigation consists of secondary analysis of service delivery data, provided in a de-identified form, and was deemed exempt from review by the Harvard School of Public Health Human Subjects Committee.
Two in five (41%) reported not using condoms ‘always’ or ‘most of the time’ over the past month, suggesting tremendous opportunity for unintended pregnancy and STI/HIV. While over one third of the sample (38%) reported condom use barriers related to access or knowledge, 61% reported barriers to condom use that reflected coercion, such as being offered more money for unprotected sex or other pressure for unprotected sex, and fear of client anger. These data suggest that efforts to increase access to, and knowledge about, condoms may be insufficient to fully reduce condom non-use amongst this group.
Slightly less than half of the sample (46%) had experienced physical or sexual violence from a client in the month prior to the survey; such experiences likely similarly compromise sexual and condom negotiation. Over two thirds (70%) entered prostitution via mechanisms consistent with sex-trafficking, i.e., entering under conditions of force, coercion or deception, and/or under the age of 18 years; current findings suggest that trafficking may be pervasive within this context. STI risks unique to sex-trafficking have been well-articulated in other settings.
The current investigation concerning disempowerment-related STI/HIV vulnerabilities among prostituted women in Central America identified extensive experiences of trafficking, as well as violence and power-related threats to condom use. Findings strongly indicate the need for further efforts to evaluate and address these forms of disempowerment and their implications for STI/HIV risk among prostituted women in the region.
Support was provided to Drs. Silverman & Decker from the Office of Trafficking in Persons, US Department of State and to Dr. Decker via the Harvard University Center for AIDS Research (HU CFAR NIH/NIAID fund P30-AI060354).