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1.  Surveillance-Based Program Planning 
Objective
to analyze the Integrated Behavioral & Biological Surveillance (IBBS) 2011 data for designing a condom utilization program.
Introduction
The IBBS is part of the Indonesian MoH HIV Surveillance System, which include Serological Surveillance, Behavioral Surveillance, Reproductive Tract Infection Survey, and monthly HIV/AIDS facility-based (hospitals, HCs, VCT Sites) monthly reports. The IBBS 2011 was conducted in 11 provinces (22 districts/municipalities) encompassing eight Most At Risk Populations (MARPs) – injection drug users, transsexuals, men who have sex with men, youths, inmates, mobile men, direct female sex workers (FSWs), and indirect FSWs. Data of 442 direct FSWs of the Jayapura Municipality and Jayawijaya District (Papua Province) showed that 406 (91.85%) have sex with partners who did not use condoms. Of these 406 FSWs 60 (14.78%) were HIV positive and 231 (56.89%) were STD positive.
Methods
Items of the Direct FSW Questionnaire, IBBS 2011, were examined and items that would yield information regarding content and method of HIV prevention interventions by means of condoms were identified. The Stata12 software was used to inspect/codebook the variables related to the selected items, to recode numeric data into categorical data, to generate one-way and two-way tables, and to produce pairwise correlations (and their significance levels).
Results
The Direct FSWs IBBS 2011 data of the Jayapura Municipality and Jayawijaya District showed that there are significant positive correlations between condom use behavior variables of FSWs (i.e., to know, to possess, to buy, and to offer male condoms) and variables of last-sex encounter condom use by customers, and between the latter and HIV and STD lab results. The correlations were low, however, of the condom use behavior variables and variables that are related to comprehensive knowledge of HIV prevention, condom use by more steady sex partners (e.g., husbands, boyfriends, other males) and female condom utilization, and during last-week and last-month sex transactions. The data analyses also indicated details of the distribution of the FSWs, with their condom use behaviors, according to individual characteristics, CIE (communication, information & education) intervention utilization, condom acquirement, and sexual behavior.
Conclusions
The condom utilization campaigns ought to focus on continuous reminders (instead of education programs) about how to persuade customers and other sex partners to use condoms, or to allow FSWs to use female condoms, and about where to go for HIV/STD testing and treatment. The condom promotion drives should use posters, TV ads, and field/health workers, The program should also make certain that good quality condoms be made avaible by local managers (of brothels, hotels, bars, etc.) and local vendors (drugists, stands, mobile carts).
PMCID: PMC3692826
IBBS; condom use; HIV; FSWs; Papua
2.  High prevalence of syphilis among street-based female sex workers in Nanchang, China 
Background:
Female sex workers (FSWs) play a critical role in the heterosexual transmission of human immunodeficiency virus (HIV)/sexually transmitted infections (STIs) in China. Several studies reported that street-based FSWs have higher risk behaviors than establishment-based FSWs. Therefore, street-based FSWs should be specifically targeted for HIV and STIs intervention programs.
Objectives:
This study aims to investigate the prevalence rates and risk factors of HIV and syphilis among FSWs in Nanchang, China.
Materials and Methods:
Using convenience sampling methods, 361 street-based FSWs were recruited from August 2011 to February 2012. All participants completed an anonymous questionnaire on socioeconomic and sex behavioral information and were tested for HIV and syphilis. Risk for HIV and syphilis infection was assessed using univariate and multivariate logistic regression analyses.
Results:
No HIV infections were found. The prevalence rate of syphilis was 43.5%. Nearly 46.1% of street-based FSWs reported having education for no more than 6 years. Having reproductive tract infections at current visit, duration of sex work more than 5 years, indulgence in unprotected sex trade in the last time, unprotected sex trade in the last month, and unprotected sex with boyfriend or spouse in the last month were reported by 35.2%, 43.5%, 33.8%, 60.4%, and 93.1% street-based FSWs, respectively. In multivariate logistic regression analysis, having reproductive tract infections at current visit [odds ratio (OR), 12.10; 95% confidence interval (CI), 6.01-24.37], duration of sex work more than five years (OR, 4.26; 95% CI, 2.40-7.54), and unprotected sex trade in the last month (OR, 1.85; 95% CI, 1.06-3.22) were independently associated with syphilis infection.
Conclusion:
The prevalence rate of syphilis among street-based FSWs is very high. Most street-based FSWs in our survey had low education, long experience of commercial sex, and high rate of inconsistent condom use. Comprehensive interventions targeting this high-risk group, especially scaling up screening and ensuring consistent use of condoms during sex are needed.
doi:10.4103/2229-5178.142491
PMCID: PMC4228639  PMID: 25396127
Epidemiology; female sex worker; human immunodeficiency virus; prevalence; risk factor; syphilis
3.  High Burden of Prevalent and Recently Acquired HIV among Female Sex Workers and Female HIV Voluntary Testing Center Clients in Kigali, Rwanda 
PLoS ONE  2011;6(9):e24321.
Objectives
To estimate HIV prevalence and risk factors in population-based samples of female sex workers (FSW) and female voluntary counseling and testing (VCT) clients in Rwanda.
Methods
We conducted a cross-sectional survey of 800 FSW and 1,250 female VCT clients in Rwanda, which included interviewing and testing for HIV-1/2, HSV-2 and pregnancy, and BED-CEIA and Avidity Index (AI) to identify recent infections among HIV-infected women.
Results
Prevalence of HIV-1, HSV-2, and pregnancy were 24% (95% CI: 21.0–27.0), 59.8% (56.4–63.2), and 7.6% (5.8–9.5) among FSW, and 12.8% (10.9–14.6), 43.2% (40.4–46.0), and 11.4% (9.7–13.3) among VCT clients, respectively. Thirty-five percent of FSW and 25% of VCT clients had never been HIV tested. Per national guidelines, 33% of newly HIV-diagnosed FSW and 36% of VCT clients were already eligible for ART based on CD4<350 cells/µl. Condom use at last sex was higher among FSW (74%) than VCT clients (12%). In age and district of residence-adjusted models, HIV-1 seropositivity was associated with HSV-2 co-infection; recent treatment for sexually transmitted infection (STI); genital symptoms; forced sex; imprisonment; widowhood; and alcohol consumption. Eleven percent of FSW and 12% of VCT clients had recently acquired HIV-1 per BED-CEIA and AI. HSV-2 infection and recent STI treatment were associated with recent HIV infection in both groups, and being married and vaginal cleansing were associated with recent infection before last sex among VCT clients.
Conclusions
This population-based survey reveals a high HIV prevalence and incidence among FSW and female VCT clients in Kigali, the scale of which is masked by the low general-population HIV prevalence in Rwanda. HIV/STI and family planning services should be strengthened.
doi:10.1371/journal.pone.0024321
PMCID: PMC3176231  PMID: 21949704
4.  Prevalence of HIV and Other Sexually Transmitted Infections among Female Sex Workers in Kisumu, Western Kenya, 1997 and 2008 
PLoS ONE  2013;8(1):e54953.
Background
In 1997, a survey in Kisumu found a prevalence of HIV infection among female sex workers (FSW) of 75%. Only 50% reported using a condom with the last client. In 2008, we conducted another survey to collect data to inform an intervention targeting FSW in Kisumu.
Methods
In 2008 FSW were recruited by respondent-driven sampling. Women completed a questionnaire and were tested for HIV and other sexually transmitted infections (STIs). Multiple logistic regression analysis was done to explore factors associated with HIV-infection, and with condom use. Prevalence of HIV infection was compared in the two surveys from 1997 and 2008. Multivariate analysis was used to assess whether a change in HIV prevalence between the two surveys could be explained by changes in socio-demographic characteristics and/or behavioral factors.
Results
481 FSW participated in the 2008 study. HIV prevalence was 56.5% (95% CI 52.0–61.6). Factors independently associated with HIV were age older than 29 years; being a widow; STI treatment in the past year; herpes simplex virus Type-2 infection; bacterial vaginosis; and trichomoniasis. Condom use with last client was reported by 75.0% (95% CI 70.9–78.9). Predictors of condom use with the last client were age older than 29 years; higher price paid by last client; ever having been tested for HIV. Predictors of unprotected sex were being drunk during last sex act; usually having sex during menses; and STI treatment in the past year. The odds ratio of HIV infection associated with year of survey was 0.49 (95% CI 0.33–0.75) after adjusting for socio-demographic and behavioral factors.
Conclusions
The prevalence of HIV among FSW in Kisumu was found to be lower in 2008 than in 1997, while reported condom use was higher. However, access to HIV/STI prevention and care services needs to improve to further decrease HIV transmission between FSW and their clients.
doi:10.1371/journal.pone.0054953
PMCID: PMC3553007  PMID: 23372801
5.  Systematic review of facility-based sexual and reproductive health services for female sex workers in Africa 
Background
Several biological, behavioural, and structural risk factors place female sex workers (FSWs) at heightened risk of HIV, sexually transmitted infections (STIs), and other adverse sexual and reproductive health (SRH) outcomes. FSW projects in many settings have demonstrated effective ways of altering this risk, improving the health and wellbeing of these women. Yet the optimum delivery model of FSW projects in Africa is unclear. This systematic review describes intervention packages, service-delivery models, and extent of government involvement in these services in Africa.
Methods
On 22 November 2012, we searched Web of Science and MEDLINE, without date restrictions, for studies describing clinical and non-clinical facility-based SRH prevention and care services for FSWs in low- and middle-income countries in Africa. We also identified articles in key non-indexed journals and on websites of international organizations. A single reviewer screened titles and abstracts, and extracted data from articles using standardised tools.
Results
We located 149 articles, which described 54 projects. Most were localised and small-scale; focused on research activities (rather than on large-scale service delivery); operated with little coordination, either nationally or regionally; and had scanty government support (instead a range of international donors generally funded services). Almost all sites only addressed HIV prevention and STIs. Most services distributed male condoms, but only 10% provided female condoms. HIV services mainly encompassed HIV counselling and testing; few offered HIV care and treatment such as CD4 testing or antiretroviral therapy (ART). While STI services were more comprehensive, periodic presumptive treatment was only provided in 11 instances. Services often ignored broader SRH needs such as family planning, cervical cancer screening, and gender-based violence services.
Conclusions
Sex work programmes in Africa have limited coverage and a narrow scope of services and are poorly coordinated with broader HIV and SRH services. To improve FSWs’ health and reduce onward HIV transmission, access to ART needs to be addressed urgently. Nevertheless, HIV prevention should remain the mainstay of services. Service delivery models that integrate broader SRH services and address structural risk factors are much needed. Government-led FSW services of high quality and scale would markedly reduce SRH vulnerabilities of FSWs in Africa.
doi:10.1186/1744-8603-10-46
PMCID: PMC4070634  PMID: 24916010
Female sex workers; Sub-saharan Africa; Health services; Sexual and reproductive health; HIV prevention
6.  Prevention of sexually transmitted infections in urban communities (Peru PREVEN): a multicomponent community-randomised controlled trial 
Lancet  2012;379(9821):1120-1128.
Summary
Background
Previous community-randomised trials of interventions to control sexually transmitted infections (STIs) have involved rural settings, were rarely multicomponent, and had varying results. We aimed to assess the effect of a multicomponent intervention on curable STIs in urban young adults and female sex workers (FSWs).
Methods
In this community-randomised trial, baseline STI screening was done between August, and November, 2002, in random household samples of young adults (aged 18–29 years) and in FSWs in Peruvian cities with more than 50 000 inhabitants. Geographically separate cities were selected, matched into pairs, and randomly allocated to intervention or control groups with an S-PLUS program. Follow-up surveys of random samples were done after 2 years and 3 years. The intervention comprised four modalities: strengthened STI syndromic management by pharmacy workers and clinicians; mobile-team outreach to FSWs for STI screening and pathogen-specific treatment; periodic presumptive treatment of FSWs for trichomoniasis; and condom promotion for FSWs and the general population. Individuals in control cities received standard care. The composite primary endpoint was infection of young adults with Chlamydia trachomatis, Trichomonas vaginalis, or Neisseria gonorrhoeae, or syphilis seroreactivity. Laboratory workers and the data analyst were masked, but fieldworkers, the Peruvian study team, and participants in the outcome surveys were not. All analyses were done by intention to treat. This trial is registered, ISRCTN43722548.
Findings
We did baseline surveys of 15 261 young adults in 24 Peruvian cities. Of those, 20 geographically separate cities were matched into pairs, in each of which one city was assigned to intervention and the other to standard of care. In the 2006 follow-up survey, data for the composite primary outcome were available for 12 930 young adults. We report a non-significant reduction in prevalence of STIs in young adults, adjusted for baseline prevalence, in intervention cities compared with control cities (relative risk 0·84, 95% CI 0·69–1·02; p=0·096). In subgroup analyses, significant reductions were noted in intervention cities in young adult women and FSWs.
Interpretation
Syndromic management of STIs, mobile-team outreach to FSWs, presumptive treatment for trichomoniasis in FSWs, and condom promotion might reduce the composite prevalence of any of the four curable STIs investigated in this trial.
Funding
Wellcome Trust and Burroughs Wellcome Fund, National Institutes of Health, Center for AIDS Research, CIPRA, and USAID-Peru.
doi:10.1016/S0140-6736(11)61846-1
PMCID: PMC3315635  PMID: 22341824
7.  Female sex workers incarcerated in New York City jails: prevalence of sexually transmitted infections and associated risk behaviors 
Sexually Transmitted Infections  2013;89(4):280-284.
Objectives
Sexually transmitted infections (STIs) are an important cause of morbidity among incarcerated women and female sex workers (FSW). Little is known about FSW incarcerated in New York City (NYC) jails. We reviewed jail health records to identify the STI and HIV prevalence among newly incarcerated FSW in NYC jails. We also examined the relationship of demographics and self-reported clinical and risk behaviour history with FSW status and compared FSW with non-FSW incarcerated women to identify FSW predictors and, guide NYC jail programme planning and policy.
Methods
We retrospectively reviewed routinely collected jail health record data to identify the prevalence of chlamydia (Ct), gonorrhoea (Ng) and HIV infection among women newly incarcerated in NYC jails in 2009–2010 (study period) and studied the relationship of STIs, demographics and self-reported clinical and risk behaviour history with FSW status.
Results
During the study period, 10 828 women were newly incarcerated in NYC jails. Of these, 10 115 (93%) women were tested for Ct and Ng; positivity was 6.2% (95% CI 5.7% to 6.7%) and 1.7% (95% CI 1.4% to 1.9%), respectively. Nine percent had HIV infection. Seven hundred (6.5%) were defined as FSW. FSW were more likely to have Ct (adjusted OR (AOR): 1.55; 95% CI 1.17 to 2.05; p<0.0001) but not Ng or HIV. FSW were more likely to report age 20–24 years, reside in boroughs other than Manhattan, ≥6 prior incarcerations, ≥2 incarcerations during the study period, condom use with current sex partners, multiple sex partners and current drug use.
Conclusions
Women incarcerated in NYC jails had high rates of Ct, Ng, and HIV infection. FSW were at higher risk for Ct than non-FSW incarcerated women. These findings are being used to design targeted interventions to identify FSW, provide clinical and preventive services in jail and coordinate care with community partners.
doi:10.1136/sextrans-2012-050977
PMCID: PMC3664364  PMID: 23687128
Sexual Health; Prostitution; Public Health
8.  Prevalence and predictors of cervicitis in female sex workers in Peru: an observational study 
BMC Infectious Diseases  2013;13:195.
Background
Cervicitis is a syndrome of cervical inflammation and a common condition in female sex workers (FSW), a subpopulation vulnerable to sexually transmitted infections. Local data is essential for guiding syndromic management of cervicitis in FSW working in Peru. We sought to describe the prevalence and etiologies of cervicitis in this population. We also aimed to identify sociodemographic, behavioral and biological factors associated with cervicitis, including bacterial vaginosis (BV), a condition with a possible role in cervicitis.
Methods
FSW 18 years of age or older presenting to a free public sexual health clinic in Callao-Lima, Peru were eligible for inclusion upon consent. 467 participants completed a face-to-face questionnaire and underwent genital examination. Vaginal, endocervical and blood samples were collected and tested for C. trachomatis (CT), N. gonorrhea (GC), T. vaginalis (TV), BV, HIV and Human T-Cell Lymphotropic Virus −1. Logistic regression was used to determine whether sociodemographic, behavioral, or other sexual health related characteristics were associated with the diagnosis of cervicitis.
Results
Cervicitis was detected in 99 (24.9%) of 397 FSW. The presence of cervicitis was unable to be determined in 70 participants. In women with cervicitis, CT was present in 4.6% (4/87), TV in 4.0% (4/99), GC in 0% (0/87) and no pathogen was detected on cervical microbiology in 91.9% (91/99). BV was detected on vaginal microbiology in 36.9% (31/84) of cervicitis cases. BV was more common in women with cervicitis, however this association did not reach statistical significance (aOR = 1.47 [0.87, 2.48], p = 0.15). Other STI were not associated with cervicitis. Regular clinic attendance (aOR = 0.54 [0.34, 0.87], p = 0.01) and Ecuadorian nationality (aOR = 0.31 [0.13, 0.76], p = 0.01) were associated with reduced risk of cervicitis.
Conclusions
Cervicitis was common in FSW working Peru and was predominantly nongonococcal and non-chlamydial in etiology. Further study is warranted to clarify the role of BV and other emerging cervicitis pathogens in this population. The current Peruvian program of free health checks for FSW may be effective for reducing rates of cervicitis. The protective effect of Ecuadorian nationality prompts further study.
doi:10.1186/1471-2334-13-195
PMCID: PMC3664214  PMID: 23631602
Cervicitis; FSW; Peru; Bacterial vaginosis; Sexually transmitted infection
9.  Assessment of Respondent Driven Sampling for Recruiting Female Sex Workers in Two Vietnamese Cities: Reaching the Unseen Sex Worker 
Respondent driven sampling (RDS) is a relatively new method to sample hard-to-reach populations. Until this study, female sex workers (FSWs) in Vietnam were sampled using a variety of methods, including time location sampling (TLS), which may not access the more hidden types of FSWs. This paper presents an analysis from an HIV biological and behavioral surveillance survey to assess the feasibility and effectiveness of RDS to sample FSWs, to determine if RDS can reach otherwise inaccessible FSWs in Vietnam and to compare RDS findings of HIV risk factors with a theoretical TLS. Through face-to-face interviews with FSWs in Ho Chi Minh City (HCMC) and Hai Phong (HP), data were collected about the venues where they most often solicit their clients. These data were used to create three variables to assess whether FSWs solicit their clients in locations that are visible, semi-visible and non-visible. For this analysis, the visible group simulates a sample captured using TLS. Survey results in HIV prevalence and related risk factors and service utilization, adjusted for sampling methodology, were compared across each of the three FSW visibility groups to assess potential bias in TLS relative to RDS. The number of self-reported visible FSWs (HCMC: n=311; HP: n=162) was much larger than those of the semi-visible (HCMC: n=65; HP: n=43) and non-visible (HCMC: n=37; HP: n=10) FSWs in HCMC and HP. Non-visible FSWs in both cities were just as likely as visible and semi-visible FSWs to be HIV positive (HCMC: visible 14.5%, semi-visible 13.8%, non-visible 13.5%, p value = 0.982; HP: visible 35.2%, semi-visible 30.2%, non-visible 30.0%, p value = 0.801), to practice behaviors that put them at risk for contracting and transmitting HIV (injecting drug use—HCMC: visible 13.8%, semi-visible 12.3%, non-visible 5.4%, p value = 0.347; HP: visible 38.9%, semi-visible 23.3%, non-visible 30.0%, p value = 0.378, to have no condom use in the past month —HCMC only: visible 52.7%, semi-visible 63.1%, non-visible 48.6%, p value = 0.249) and to have symptoms of a sexually transmitted infection (STI) in the past year (HCMC: visible 16.1%, semi-visible 12.3%, non-visible 16.2%, p value = 0.742; HP: visible 13.6%, semi-visible 18.6%, non-visible 20.0%, p value = 0.640). There was a difference found among the visible, semi-visible and non-visible groups in HP for no past month condom use (visible 53.1%, semi-visible 79.1%, non-visible 60.0%, p value = 0.009). This study found that RDS was successful at recruiting hidden types of FSWs in Vietnam. Past reports of FSWs in Vietnam have assessed the more visible FSWs as being the most vulnerable and at risk for HIV. Although the number of visible FSWs is much higher than those of the semi and non-visible groups, this study found that the non-visible FSWs are very vulnerable to HIV infection. If prevention programs are targeting and responding to those who are most likely to be assessed (e.g., more visible types of FSWs) then this analysis indicates that a significant proportion of the FSW population at risk for HIV may not be receiving optimal HIV information and services.
doi:10.1007/s11524-006-9099-5
PMCID: PMC1705478  PMID: 17031567
HIV; Respondent-driven sampling; Sex workers; Vietnam
10.  Assessment of Respondent Driven Sampling for Recruiting Female Sex Workers in Two Vietnamese Cities: Reaching the Unseen Sex Worker 
Respondent driven sampling (RDS) is a relatively new method to sample hard-to-reach populations. Until this study, female sex workers (FSWs) in Vietnam were sampled using a variety of methods, including time location sampling (TLS), which may not access the more hidden types of FSWs. This paper presents an analysis from an HIV biological and behavioral surveillance survey to assess the feasibility and effectiveness of RDS to sample FSWs, to determine if RDS can reach otherwise inaccessible FSWs in Vietnam and to compare RDS findings of HIV risk factors with a theoretical TLS. Through face-to-face interviews with FSWs in Ho Chi Minh City (HCMC) and Hai Phong (HP), data were collected about the venues where they most often solicit their clients. These data were used to create three variables to assess whether FSWs solicit their clients in locations that are visible, semi-visible and non-visible. For this analysis, the visible group simulates a sample captured using TLS. Survey results in HIV prevalence and related risk factors and service utilization, adjusted for sampling methodology, were compared across each of the three FSW visibility groups to assess potential bias in TLS relative to RDS. The number of self-reported visible FSWs (HCMC: n=311; HP: n=162) was much larger than those of the semi-visible (HCMC: n=65; HP: n=43) and non-visible (HCMC: n=37; HP: n=10) FSWs in HCMC and HP. Non-visible FSWs in both cities were just as likely as visible and semi-visible FSWs to be HIV positive (HCMC: visible 14.5%, semi-visible 13.8%, non-visible 13.5%, p value = 0.982; HP: visible 35.2%, semi-visible 30.2%, non-visible 30.0%, p value = 0.801), to practice behaviors that put them at risk for contracting and transmitting HIV (injecting drug use—HCMC: visible 13.8%, semi-visible 12.3%, non-visible 5.4%, p value = 0.347; HP: visible 38.9%, semi-visible 23.3%, non-visible 30.0%, p value = 0.378, to have no condom use in the past month —HCMC only: visible 52.7%, semi-visible 63.1%, non-visible 48.6%, p value = 0.249) and to have symptoms of a sexually transmitted infection (STI) in the past year (HCMC: visible 16.1%, semi-visible 12.3%, non-visible 16.2%, p value = 0.742; HP: visible 13.6%, semi-visible 18.6%, non-visible 20.0%, p value = 0.640). There was a difference found among the visible, semi-visible and non-visible groups in HP for no past month condom use (visible 53.1%, semi-visible 79.1%, non-visible 60.0%, p value = 0.009). This study found that RDS was successful at recruiting hidden types of FSWs in Vietnam. Past reports of FSWs in Vietnam have assessed the more visible FSWs as being the most vulnerable and at risk for HIV. Although the number of visible FSWs is much higher than those of the semi and non-visible groups, this study found that the non-visible FSWs are very vulnerable to HIV infection. If prevention programs are targeting and responding to those who are most likely to be assessed (e.g., more visible types of FSWs) then this analysis indicates that a significant proportion of the FSW population at risk for HIV may not be receiving optimal HIV information and services.
doi:10.1007/s11524-006-9099-5
PMCID: PMC1705478  PMID: 17031567
HIV; Respondent-driven sampling; Sex workers; Vietnam
11.  Condom use within non-commercial partnerships of female sex workers in southern India 
BMC Public Health  2011;11(Suppl 6):S11.
Background
Although female sex workers (FSWs) report high levels of condom use with commercial sex clients, particularly after targeted HIV preventive interventions have been implemented, condom use is often low with non-commercial partners. There is limited understanding regarding the factors that influence condom use with FSWs’ non-commercial partners, and of how programs can be designed to increase condom use with these partners. The main objectives of this study were therefore to describe FSWs’ self-reported non-commercial partners, along with interpersonal factors characterizing their non-commercial partnerships, and to examine the factors associated with consistent condom use (CCU) within non-commercial partnerships.
Methods
This study used data collected from cross-sectional questionnaires administered to 988 FSWs in four districts in Karnataka state in 2006-07. We used bivariate and multivariable logistic regression analysis to examine the relationship between CCU (i.e., ‘always’ compared to ‘never’, ‘sometimes’ or ‘frequently’) with non-commercial partners of FSWs (including the respondents’ husband or main cohabiting partner [if not married] and their most recent non-paying partner [who is neither a husband nor the main cohabiting partner, and with whom the FSW had sex within the previous year]) and interpersonal factors describing these partnerships, as well as social and environmental factors. Weighting and survey methods were used to account for the cluster sampling design.
Results
Overall, 511 (51.8%) FSWs reported having a husband or cohabiting partner and 247 (23.7%) reported having a non-paying partner. CCU with these partners was low (22.6% and 40.3% respectively). In multivariable analysis, the odds of CCU with FSWs’ husband or cohabiting partner were 1.8-fold higher for FSWs whose partner knew she was a sex worker (adjusted odds ratio [AOR]: 1.84, 95% confidence intervals[CI]: 1.02-3.32) and almost 6-fold higher if the FSW was unmarried (AOR: 5.73, 95%CI: 2.79-11.76]. CCU with FSWs’ non-paying partner decreased by 18% for each one-year increase in the duration of the relationship (AOR: 0.82, 95%CI: 0.68-0.97).
Conclusions
This study revealed important patterns and interpersonal determinants of condom use within non-commercial partnerships of FSWs. Integrated structural and community-driven HIV/STI prevention programs that focus on gender and reduce sex work stigma should be investigated to increase condom use in non-commercial partnerships.
doi:10.1186/1471-2458-11-S6-S11
PMCID: PMC3287549  PMID: 22376171
12.  Sustained high prevalence of sexually transmitted infections among female sex workers in Cambodia: high turnover seriously challenges the 100% condom use programme 
Background
Cambodia's 100% Condom-Use Programme (CUP), implemented nationally in 2001, requires brothel-based female sex workers (FSWs) to use condoms with all clients. In 2005, we conducted a sexually transmitted infection (STI) survey among FSWs. This paper presents the STI prevalence and related risk factors, and discusses prevalence trends in the context of the 100% CUP in Cambodia.
Methods
From March-May, 1079 FSWs from eight provinces consented to participate, provided specimens for syphilis, chlamydia, and gonorrhoea testing, and were interviewed. Univariate and multivariate logistic regression analysis was used to determine factors associated with STIs. STI prevalence was compared with data from the 1996 and 2001 STI surveys.
Results
Most FSWs were young (55% aged 15–24) and new to sex work (60% had worked 12 ≤ months). Consistent condom use with clients was reported by 80% of FSWs, but only 38% of FSWs always used condoms with sweethearts or casual partners. Being new to sex work was the only factor significantly associated with "any STI" (OR = 2.1). Prevalence of syphiliwas 2.3%; chlamydia, 14.4%; gonorrhoea, 13.0%; and any STI, 24.4%. Prevalence of each STI in 2005 was significantly lower than in 1996, but essentially the same as prevalence observed in 2001.
Conclusion
New FSWs were found to have substantially higher prevalence than those with longer experience. The percent of FSWs who used condoms consistently was high with clients but remained low with non-paying sex partners. Because of the high turnover of FSWs, the prevention needs of new FSWs should be ascertained and addressed. Despite 100% CUP implementation, the prevalence of STIs among FSWs was the same in 2005 as it was in 2001. Limited coverage and weak implementation capacity of the programme along with questionable quality of the STI services are likely to have contributed to the sustained high prevalence. The programme should be carefully reviewed in terms of intensity, quality and coverage.
doi:10.1186/1471-2334-8-167
PMCID: PMC2640393  PMID: 19077261
13.  Sex trafficking, sexual risk, STI and reproductive health among a national sample of FSWs in Thailand 
Background
The trafficking of women and girls for sexual exploitation is an internationally recognized form of gender-based violence, and is thought to confer unique sexual and reproductive health vulnerabilities. To date, little research has compared sexual risk or health outcomes among female sex workers (FSWs) based on experiences of sex trafficking. The current study sought to compare experiences of sexual risk and sexual and reproductive health outcomes among FSWs based on experiences of trafficking as an entry mechanism to FSW.
Methods
Data from a national sample of FSWs in Thailand (n=815) to was used to assess a) the prevalence of sex trafficking as an entry mechanism into FSW, and b) associations of sex trafficking with sexual risk and health outcomes.
Results
Approximately 10% of FSWs met criteria for trafficking as an entry mechanism to sex work. Compared with their non-trafficked counterparts, sex trafficked FSWs were more likely to have experienced sexual violence at initiation to sex work (ARR 2.29, 95% CI 1.11, 4.72), recent workplace violence or mistreatment (ARR 1.38, 95% CI 1.13, 1.67), recent condom failure (ARR 1.80, 95% CI 1.15, 2.80), condom non-use (ARR 3.35, 95% CI 1.49, 7.52), and abortion (ARR 2.83, 95% CI 1.48, 5.39).
Discussion
Both the prevalence of sex trafficking as an entry mechanism to FSW, coupled with the threats to sexual and reproductive health observed based on trafficking status, demonstrate the need for comprehensive efforts to identify and support this vulnerable population. Moreover, existing STI/HIV prevention programming may be stymied by the limited condom use capacity, and high levels of violence observed among those trafficked into FSW.
doi:10.1136/jech.2009.096834
PMCID: PMC3521618  PMID: 20515895
Sex trafficking; sexual risk; condom; STI; reproductive health; sex work
14.  HIV Risk Behaviours Differ by Workplace Stability Among Mexican Female Sex Workers With Truck Driver Clientele 
Background
In a study of female sex workers (FSWs) servicing truck driver clients in Mexican border cities, we evaluated differences in HIV/STI risk behaviours determined by workplace.
Design and Methods
Our study was cross-sectional and its population comprised 100 FSWs from Nuevo Laredo (US border) and 100 FSWs from Ciudad Hidalgo (Guatemalan border). The main outcome was primary place of sex work defined as unstable (street, vehicle, gas station, etc.) vs stable (bar, brothel, and hotel). Logistic regression was used to identify correlates associated with trading sex at unstable workplaces in the last month.
Results
Of the FSWs surveyed, 18% reported an unstable workplace. The majority of FSWs surveyed were young (<30 years), single, had <9th grade education, and had worked in the sex trade for a median of 4.9 years. After controlling for study site, FSWs with unstable vs stable workplaces were more likely to have a majority/all truck driver clientele, but were less likely to have visited a gynaecologist in the last year (OR 0.1, 95% CI 0.03-0.4) or ever had an HIV test (OR 0.1, 95% CI 0.06-0.3), and there was a trend towards lower condom use self-efficacy scores (OR 0.8 per unit increase, 95% CI 0.7-1.0). On multivariate regression, unstable workplace was associated with having majority/all truck driver clientele, being surveyed in Nuevo Laredo, and decreased odds of ever having an HIV test.
Conclusions
Among Mexican FSWs with truck driver clients, providing safe indoor spaces for sex work may help facilitate public health interventions that improve HIV/STI prevention and reproductive health outcomes.
doi:10.4081/jphr.2012.e32
PMCID: PMC3979342  PMID: 24724056
female sex workers; HIV; sexually transmitted infection; risk behaviour; work environment
15.  Prevalence of HIV and other sexually transmitted infections and factors associated with syphilis among female sex workers in Panama 
Sexually Transmitted Infections  2012;89(2):156-164.
Objectives
Biological and behavioural surveillance of HIV and sexually transmitted infections (STIs) among populations at highest risk have been used to monitor trends in prevalence and in risk behaviours. Sex work in Panama is regulated through registration with the Social Hygiene Programme, Ministry of Health. We estimated prevalence of HIV and STIs, and factors associated with active syphilis among female sex workers (FSWs).
Methods
A cross-sectional study using venue-based, time-space sampling was conducted among FSWs in Panama from 2009 to 2010. FSWs were interviewed about sociodemographic characteristics, sexual risk behaviour, health history and drug use using an anonymous structured questionnaire. Blood was collected for serological testing of HIV and other STIs. Factors associated with active syphilis were studied using logistic regression analysis.
Results
The overall HIV-1 prevalence of 0.7% varied by FSW category; 1.6% in 379 unregistered, and 0.2% in 620 registered FSWs. Overall prevalence (and 95% CI) of STIs were: syphilis antibody, 3.8% (2.7% to 5.2%); herpes simplex virus type 2 antibody (anti-HSV-2), 74.2% (71.4% to 76.9%); hepatitis B surface antigen, 0.6% (0.2% to 1.3%); hepatitis B core antibody, 8.7% (7.0% to 10.6%); and hepatitis C antibody, 0.2% (0.0% to 0.7%). In multivariate analysis, registration (adjusted OR (AOR)=0.35; 95% CI 0.16 to 0.74), having a history of STI (AOR=2.37; 95% CI 1.01 to 5.58), forced sex (AOR=2.47; 95% CI 1.11 to 5.48), and anti-HSV-2 (AOR=10.05; 95% CI 1.36 to 74.38) were associated with active syphilis.
Conclusions
Although HIV prevalence is low among FSWs in Panama, unregistered FSWs bear a higher burden of HIV and STIs than registered FSWs. Programmes aimed at overcoming obstacles to registration, and HIV, STI and harm reduction among unregistered FSWs is warranted to prevent HIV transmission, and to improve their sexual and reproductive health.
doi:10.1136/sextrans-2012-050557
PMCID: PMC3595153  PMID: 23002191
Surveillance; Commercial Sex; HIV; Seroprevalence; Syphilis
16.  Prevalences of sexually transmitted infections in young adults and female sex workers in Peru: a national population-based survey 
The Lancet Infectious Diseases  2012;12(10):765-773.
Summary
Background
We assessed prevalences of seven sexually transmitted infections (STIs) in Peru, stratified by risk behaviours, to help to define care and prevention priorities.
Methods
In a 2002 household-based survey of the general population, we enrolled randomly selected 18–29-year-old residents of 24 cities with populations greater than 50 000 people. We then surveyed female sex workers (FSWs) in these cities. We gathered data for sexual behaviour; vaginal specimens or urine for nucleic acid amplification tests for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; and blood for serological tests for syphilis, HIV, and (in subsamples) herpes simplex virus 2 (HSV2) and human T-lymphotropic virus. This study is a registered component of the PREVEN trial, number ISRCTN43722548.
Findings
15 261 individuals from the general population and 4485 FSWs agreed to participate in our survey. Overall prevalence of infection with HSV2, weighted for city size, was 13·5% in men, 13·6% in women, and 60·6% in FSWs (all values in FSWs standardised to age composition of women in the general population). The prevalence of C trachomatis infection was 4·2% in men, 6·5% in women, and 16·4% in FSWs; of T vaginalis infection was 0·3% in men, 4·9% in women, and 7·9% in FSWs; and of syphilis was 0·5% in men, 0·4% in women, and 0·8% in FSWs. N gonorrhoeae infection had a prevalence of 0·1% in men and women, and of 1·6% in FSWs. Prevalence of HIV infection was 0·5% in men and FSWs, and 0·1% in women. Four (0·3%) of 1535 specimens were positive for human T-lymphotropic virus 1. In men, 65·0% of infections with HIV, 71·5% of N gonorrhoeae, and 41·4% of HSV2 and 60·9% of cases of syphilis were in the 13·3% who had sex with men or unprotected sex with FSWs in the past year. In women from the general population, 66·7% of infections with HIV and 16·7% of cases of syphilis were accounted for by the 4·4% who had been paid for sex by any of their past three partners.
Interpretation
Defining of high-risk groups could guide targeting of interventions for communicable diseases—including STIs—in the general Peruvian population.
Funding
Wellcome Trust-Burroughs Wellcome Fund Infectious Disease Initiative and US National Institutes of Health.
doi:10.1016/S1473-3099(12)70144-5
PMCID: PMC3459082  PMID: 22878023
17.  Violence Victimization, Sexual Risk and STI Symptoms Among a National Sample of FSWs in Thailand 
Sexually transmitted infections  2010;86(3):236-240.
Background/objectives
Commercial sex work is widely recognized as a primary context for heterosexual transmission of HIV/AIDS in many regions, including Southeast Asia. While violence victimization is considered to compromise women’s ability to protect against HIV and other sexually transmitted infections (STIs), with female sex workers (FSWs) uniquely affected, little research has investigated the role of violence as it relates to sexual risk and STI outcomes among FSWs. The current study sought to compare experiences of sexual risk and STI symptoms among FSWs based on their recent exposure to violence.
Methods
Data from a national sample of FSWs in Thailand (n=815) was used to assess a) the prevalence of experiencing recent physical or sexual violence within the context of sex work, and b) associations of such victimization with sexual risk (i.e., anal sex, condom non-use, condom failure, client condom refusal) and self-reported STI symptoms.
Results
Approximately 1 in 7 FSWs (14.6%) had experienced physical or sexual violence in the week prior to the survey. As compared with their non-victimized counterparts, FSWs exposed to recent violence were at greater risk for recent condom failure (19.6% vs. 12.3%, ARR 1.92, 95% CI 1.24, 2.95) and client condom refusal (85.7% vs. 69.0%, ARR 1.24, 95% CI 1.14, 1.35). In analyses adjusted for sexual risk, violence related to both STI symptoms collectively (ARR 1.11, 95% CI 1.02, 1.21) and genital lesions as an individual STI symptom (ARR 1.78, 95% CI 1.20, 2.66).
Conclusion
Physical and sexual violence against FSWs in Thailand appears to be a common experience, with victims of such violence demonstrating diminished capacity for STI/HIV harm reduction and greater prevalence of STI symptoms. Comprehensive efforts to reduce violence towards this vulnerable population must be prioritized, as a means of protecting the human rights of FSWs, and as a key component of STI/HIV prevention and control.
doi:10.1136/sti.2009.037846
PMCID: PMC3578319  PMID: 20444745
Sex work; Violence; STI symptoms; Sexual Risk; Thailand
18.  Experience of violence and adverse reproductive health outcomes, HIV risks among mobile female sex workers in India 
BMC Public Health  2011;11:357.
Background
Female sex workers (FSWs) are a population sub-group most affected by the HIV epidemic in India and elsewhere. Despite research and programmatic attention to FSWs, little is known regarding sex workers' reproductive health and HIV risk in relation to their experiences of violence. This paper therefore aims to understand the linkages between violence and the reproductive health and HIV risks among a group of mobile FSWs in India.
Methods
Data are drawn from a cross-sectional behavioural survey conducted in 22 districts from four high HIV prevalence states (Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu) in India between September 2007 and July 2008. The survey sample included 5,498 FSWs who had moved to at least two different places for sex work in the past two years, and are classified as mobile FSWs in the current study. Analyses calculated the prevalence of past year experiences of violence; and adjusted logistic regression models examined the association between violence and reproductive health and HIV risks after controlling for background characteristics and program exposure.
Results
Approximately one-third of the total mobile FSWs (30.5%, n = 1,676) reported experiencing violence at least once in the past year; 11% reported experiencing physical violence, and 19.5% reported experiencing sexual violence. Results indicate that FSWs who had experienced any violence (physical or sexual) were significantly more likely to be vulnerable to both reproductive health and HIV risks. For example, FSWs who experienced violence were more likely than those who did not experience violence to have experienced a higher number of pregnancies (adjusted odds ratio [OR] = 1.2, 95% confidence interval [CI] = 1.0-1.6), ever experienced pregnancy loss (adjusted OR = 1.4, 95% CI = 1.2-1.6), ever experienced forced termination of pregnancy (adjusted OR = 2.4, 95% CI = 2.0-2.7), experienced multiple forced termination of pregnancies (adjusted OR = 2.2, 95% CI = 1.7-2.8), and practice inconsistent condom use currently (adjusted OR = 1.97, 95% CI: 1.4-2.0). Among FSWs who experienced violence, those who experienced sexual violence were more likely than those who had experienced physical violence to report inconsistent condom use (adjusted OR = 1.8, 95% CI: 1.4-2.3), and experience STI symptoms (adjusted OR = 1.3, 95% CI: 1.1-1.7).
Conclusion
The pervasiveness of violence and its association with reproductive health and HIV risk highlights that the abuse in general is an important determinant for reproductive health risks; and sexual violence is significantly associated with HIV risks among those who experienced violence. Existing community mobilization programs that have primarily focused on empowering FSWs should broaden their efforts to promote reproductive health in addition to the prevention of HIV among all FSWs, with particular emphasis on FSWs who experienced violence.
doi:10.1186/1471-2458-11-357
PMCID: PMC3116498  PMID: 21599984
19.  Associations between Migrant status and sexually transmitted infections among female sex workers in Tijuana, Mexico 
Objective
To examine associations between migration and sexually transmitted infection (STI) prevalence among Mexican female sex workers (FSW).
Methods
FSW aged ≥18 years in Tijuana, Baja California (BC) underwent interviews and testing for HIV, syphilis, gonorrhea and Chlamydia. Multivariate logistic regressions identified correlates of STI.
Results
Of 471 FSW, 79% were migrants to BC. Among migrant FSW, prevalence of HIV, syphilis, gonorrhea, Chlamydia, and any STI was 6.6%, 13.2%, 7.8%, 16.3%, and 31.1% vs. 10.9%, 18.2%, 13.0%, 19.0%, and 42.4% among FSW born in BC. A greater proportion of migrant FSW were registered with local health services and were ever tested for HIV. Migrant status was protective for any STI in unadjusted models (Unadj. OR: 0.61, 95%CI: 0.39, 0.97). In multivariate models controlling for confounders, migrant status was not associated with an elevated odds of STI acquisition and trended towards a protective association.
Conclusions
Unexpectedly, migrant status (vs. native-born status) appeared protective for any STI acquisition. It is unclear which social or economic conditions may protect against STI and whether these erode over time in migrants. Additional research is needed to inform our understanding of whether or how geography, variations in health capital, or social network composition and information sharing attributes can contribute to health protective behaviors in migrant FSW. By capitalizing on such mechanisms, efforts to preserve protective health behaviors in migrant FSW will help control STI in the population and may lead to the identification of strategies that are generalizable to other FSW.
doi:10.1136/sti.2008.032979
PMCID: PMC2819150  PMID: 19188211
migration; female sex workers; sexually transmitted infections; HIV; Mexico
20.  HIV risk behaviors differ by workplace stability among Mexican female sex workers with truck driver clientele 
Background
In a study of female sex workers (FSW) servicing truck driver clients in Mexican border cities, we evaluated differences in HIV/STI risk behaviors by workplace.
Methods
Cross-sectional study of FSW servicing truck drivers in Mexico: 100 from Nuevo Laredo (U.S. border); 100 from Ciudad Hidalgo (Guatemalan border). Main outcome was unstable workplace, defined as primary place of sex work in a public place (street, vehicle, gas station, etc.) vs. stable workplace (bar, brothel, and hotel). Logistic regression was used to identify correlates associated with trading sex at unstable workplaces in the last month.
Results
Of the FSW surveyed, 18% reported an unstable workplace. The majority of FSW surveyed were young (<30), single, had <9th grade education, and had worked in the sex trade for a median of 4.9 years. After controlling for study site, FSW with unstable vs. stable workplaces were more likely to have a majority/all truck driver clientele, but were less likely to have visited a gynecologist in the last year (OR 0.1, 95%CI 0.03–0.4) or ever had an HIV test (OR 0.1, 95%CI 0.06–0.3), and there was a trend towards lower condom use self-efficacy scores (OR 0.8 per unit increase, 95%CI 0.7–1.0). On multivariate regression, unstable workplace was associated with having majority/all truck driver clientele, being surveyed in Nuevo Laredo, and decreased odds of ever having an HIV test.
Conclusions
Among Mexican FSW with truck driver clients, providing safe indoor spaces for sex work may help facilitate public health interventions that improve HIV/STI and reproductive health outcomes.
PMCID: PMC3979342  PMID: 24724056
female sex workers; HIV; sexually transmitted infection; risk behavior; work environment
21.  Vulnerabilities, health needs and predictors of high-risk sexual behaviour among female adolescent sex workers in Kunming, China 
Sexually Transmitted Infections  2012;89(3):237-244.
Objectives
This study assessed social and behavioural predictors for sexual risk taking and sexually transmitted infections (STIs) including HIV among adolescent female sex workers (FSWs) from Kunming, China. Additionally, health services needs and use were assessed.
Methods
A cross-sectional survey was conducted in 2010. Using snowball and convenience sampling, self-identified FSWs were recruited from four urban areas in Kunming. Women consenting to participate were administered a semi-structured questionnaire by trained interviewers identified from local peer-support organisations. Following interview, a gynaecological examination and biological sampling to identify potential STIs were undertaken. Descriptive and multivariable logistic regression analyses were performed.
Results
Adolescent FSWs had a mean age of 18.2 years and reported numerous non-paying sexual partners with very low rate of consistent condom use (22.2%). Half (50.3%) the respondents had sex while feeling drunk at least once in the past week, of whom 56.4% did not use condom protection. STI prevalence was high overall (30.4%) among this group. Younger age, early sexual debut, being isolated from schools and family, short duration in sex work, and use of illicit drugs were found to be strong predictors for unprotected sex and presence of an STI. Conversely, having access to condom promotion, free HIV counselling and testing, and peer education were associated with less unprotected sex. The majority reported a need for health knowledge, free condoms and low-cost STI diagnosis and treatment.
Conclusions
There is an urgent need to improve coverage, accessibility and efficiency of existing interventions targeting adolescent FSWs.
doi:10.1136/sextrans-2012-050690
PMCID: PMC3625825  PMID: 23220781
Adolescent; HIV; Prostitution; China; Sexual Behaviour
22.  Factors mediating HIV risk among female sex workers in Europe: a systematic review and ecological analysis 
BMJ Open  2013;3(7):e002836.
Objectives
We reviewed the epidemiology of HIV and selected sexually transmitted infections (STIs) among female sex workers (FSWs) in WHO-defined Europe. There were three objectives: (1) to assess the prevalence of HIV and STIs (chlamydia, syphilis and gonorrhoea); (2) to describe structural and individual-level risk factors associated with prevalence and (3) to examine the relationship between structural-level factors and national estimates of HIV prevalence among FSWs.
Design
A systematic search of published and unpublished literature measuring HIV/STIs and risk factors among FSWs, identified through electronic databases published since 2005. ‘Best’ estimates of HIV prevalence were calculated from the systematic review to provide national level estimates of HIV. Associations between HIV prevalence and selected structural-level indicators were assessed using linear regression models.
Studies reviewed
Of the 1993 papers identified in the search, 73 peer-reviewed and grey literature documents were identified as meeting our criteria of which 63 papers provided unique estimates of HIV and STI prevalence and nine reported multivariate risk factors for HIV/STI among FSWs.
Results
HIV in Europe remains low among FSWs who do not inject drugs (<1%), but STIs are high, particularly syphilis in the East and gonorrhoea. FSWs experience high levels of violence and structural risk factors associated with HIV, including lack of access to services and working on the street. Linear regression models showed HIV among FSWs to link with injecting drug use and imprisonment.
Conclusions
Findings show that HIV prevention interventions should be nested inside strategies that address the social welfare of sex workers, highlighting in turn the need to target the social determinants of health and inequality, including regarding access to services, experience of violence and migration. Future epidemiological and intervention studies of HIV among vulnerable populations need to better systematically delineate how microenvironmental and macroenvironmental factors combine to increase or reduce HIV/STI risk.
doi:10.1136/bmjopen-2013-002836
PMCID: PMC3731729  PMID: 23883879
23.  FSWs Typology and Condoms Use Among HIV High Risk Groups in Sindh, Pakistan: A Developing Country Perspective 
Objective
We aimed to determine the association of FSWs typology with condom use among HIV high risk groups in Sindh, Pakistan
Introduction
HIV is growing rapidly worldwide resulting in estimated 34 million population [1]. Recently, its epidemic has spread in Africa, Latin America, and the Caribbean, and most parts of Asia [2]. According to Antenatal sero surveillance study conducted in 2011 by Agriteam canada, it’s prevalence in Pakistan is <0.1 [3].Focusing narrowly, its prevalence in Sindh, (one of the provinces of Pakistan) is similar in general population, but it is in the phase of concentrated epidemic (having more than 5% of prevalence in high risk groups)in vulnerable groups like IDUs and Male sex workers and transgender [4].
Sexual intercourse has been identified as major route especially in HIV high risk groups including male sex workers, female sex workers (FSWs), transgender (hijras) and IV drug users. Among them, FSWs are at high risk because of unprotected sex and illicit drug use. Their prevalence is found to be 30.7% in low and middle income countries [5]. South Asia contributed with 12.63 lakh FSW in India only [6]. On the basis of their station of work, they are categorized into facility based (kothikhana, brothel or home) and mobile (street, mobile or beggars). They use different preventive measures including condom for their protection from HIV [7]. It varies with availability and access [8] . FSWs typology have different cliental and mode of action, therefore, it important to explore the preventive methods.
Methods
Data was extracted from Second Generation Surveillance, Integrated behavioral and biological survey, Round IV for HIV infection conducted by Agriteam Canada in partnership with National AIDS Control Program, Pakistan in 2011. It was a cross sectional survey for high risk groups including FSWs from Pakistan. It was ethically approved by Review Board of the Public Health Agency of Canada and HOPE International’s Ethical Review Board, Pakistan. From Sindh province, FSWs based in Karachi, Sukkur and Larkana were recruited. Considering typology, they were categorized as mobile or facility based. After informed consent, socio-demographic and risk behavior were inquired. HIV was tested by ELISA/EIA and confirmed by Western Blot. Data was analyzed on SPSS 19. Continuous variables were expressed as mean±SD while categorical as frequency(%). Logistic regression assessed the association of FSWs typology with condoms use among HIV high risk groups.
Results
Out of 4567 high risk population, 1127 were identified as FSWs. Mean age was 26.9 years. Most of them were facility based (72.8%) and 81.3% used condoms. Typology, age, education, duration of involvement, number of client per day, number of paid oral sex per month, knowledge about STI and knowledge about drop in center were significantly associated with condom use among HIV high risk groups.
Conclusions
Majority of facility based FSWs use condoms to prevent HIV infection. Awareness and access to home based FSWs should be increased. It may help in targeting and designing preventive strategies for them at government and mass level.
PMCID: PMC3692789
FSW; typology; condoms; HIV high risk groups; Pakistan
24.  Reasons for non- use of condoms and self- efficacy among female sex workers: a qualitative study in Nepal 
BMC Women's Health  2011;11:42.
Background
Heterosexual contact is the most common mode of transmission of sexually transmitted infections (STIs) including Human Immunodeficiency Virus (HIV) in Nepal and it is largely linked to sex work. We assessed the non-use of condoms in sex work with intimate sex partners by female sex workers (FSWs) and the associated self-efficacy to inform the planning of STI/HIV prevention programmes in the general population.
Methods
This paper is based on a qualitative study of Female Sex Workers (FSWs) in Nepal. In-depth interviews and extended field observation were conducted with 15 FSWs in order to explore issues of safe sex and risk management in relation to their work place, health and individual behaviours.
Results
The main risk factor identified for the non-use of condoms with intimate partners and regular clients was low self efficacy. Non-use of condoms with husband and boyfriends placed them at risk of STIs including HIV. In addition to intimidation and violence from the police, clients and intimate partners, clients' resistance and lack of negotiation capacity were identified as barriers in using condoms by the FSWs.
Conclusion
This study sheds light on the live and work of FSWs in Nepal. This information is relevant for both the Government of Nepal and Non Governmental Organisations (NGO) to help improve the position of FSWs in the community, their general well-being and to reduce their risks at work.
doi:10.1186/1472-6874-11-42
PMCID: PMC3206429  PMID: 21943102
25.  Age Differences among Female Sex Workers in the Philippines: Sexual Risk Negotiations and Perceived Manager Advice 
AIDS Research and Treatment  2012;2012:812635.
Consistent condom use among high risk groups such as female sex workers (FSWs) remains low. Adolescent female sex workers are especially at higher risk for HIV/STI infections. However, few published studies have compared the sexual risk negotiations among adolescent, emerging adult, and older age groups or the extent a manager's advice about condom use is associated with an FSW's age. Of 1,388 female bar/spa workers surveyed in the southern Philippines, 791 FSW who traded sex in the past 6 months were included in multivariable logistic regression models. The oldest FSWs (aged 36–48) compared to adolescent FSWs (aged 14–17) were 3.3 times more likely to negotiate condoms when clients refused condom use. However, adolescent FSWs received more advice from their managers to convince clients to use condoms or else to refuse sex, compared to older FSWs. Both adolescent and the oldest FSWs had elevated sexually transmitted infections (STIs) and inconsistent condom use compared to other groups. Having a condom rule at the establishment was positively associated with condom negotiation. Factors such as age, the advice managers give to their workers, and the influence of a condom use rule at the establishment need to be considered when delivering HIV/STI prevention interventions.
doi:10.1155/2012/812635
PMCID: PMC3405561  PMID: 22848800

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