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1.  Anal and dry sex in commercial sex work, and relation to risk for sexually transmitted infections and HIV in Meru, Kenya 
Sexually Transmitted Infections  2006;82(5):392-396.
Objective
To examine the practices of anal intercourse and dry sex within a cohort of female sex workers (FSWs) in Kenya, focusing on the prevalence and perceived risk of the practices, demographic and behavioural correlates, and association with sexually transmitted infections (STI).
Methods
A survey was conducted among FSWs in Meru, Kenya, with 147 participants randomly sampled from an existing cohort of self identified FSWs.
Results
40.8% of participants reported ever practising anal intercourse and 36.1% reported ever practising dry sex. Although the majority of women surveyed believed anal intercourse and dry sex to be high risk practices for HIV infection compared with vaginal sex, about one third of women reported never or rarely using condoms during anal intercourse, and about 20% never or rarely using condoms during dry sex. Reported consistent condom use was lower with both of these practices than with penile‐vaginal intercourse. Anal intercourse was associated with experience of recent forced sexual intercourse, while dry sex was not. Anal intercourse was almost always initiated by clients, whereas dry sex was likely to be initiated by the women themselves. Sex workers reported charging higher fees for both practices than for vaginal intercourse. Both practices were associated with reported symptoms and diagnoses of STI.
Conclusions
Both anal intercourse and dry sex were common in this sample, and although perceived as high risk practices, were not adequately protected with condom use. Education and other interventions regarding these high risk sexual behaviours need to be translated into safer practices, particularly consistent condom use, even in the face of financial vulnerability.
doi:10.1136/sti.2006.019794
PMCID: PMC2563859  PMID: 16790563
anal intercourse; dry sex; high risk practices; female sex workers; sexually transmitted infections; HIV; Kenya
2.  Injection Drug Use, Sexual Risk, Violence, and STI/HIV among Moscow FSWs 
Sexually transmitted infections  2012;88(4):278-283.
Background/objectives
The HIV prevalence in Eastern Europe and Central Asia continues to increase. While injection drug use (IDU) is leading factor, heterosexual transmission is on the rise. Little is known about female sex workers (FSWs) in the region despite the central role of commercial sex in heterosexual STI/HIV transmission globally. We evaluated the prevalence of STI/HIV among Moscow-based FSWs, and potential risk factors including IDU, sexual risks, and violence victimization.
Methods
Moscow-based FSWs (n=147) completed a clinic-based survey and STI/HIV testing over an eight month period in 2005.
Results
HIV prevalence was 4.8%, and 31.3% were infected with at least one STI including HIV. Sexual behaviors significantly associated with STI/HIV included anal sex (AOR 3.48), high client volume (three or more clients daily, AOR 2.71), recent subbotnik (sex demanded by police; AOR 2.50), and regularly being presented with more clients than initially agreed to (AOR 2.45). Past year experiences of physical violence from clients and threats of violence from pimps were associated with STI/HIV (AOR 3.14; AOR 3.65 respectively). IDU was not significantly associated with STI/HIV. Anal sex and high client volume partially mediated the associations of abuse with STI/HIV.
Conclusion
Findings illustrate substantial potential for heterosexual STI/HIV transmission in a setting better known for IDU-related risk. Many of the STI/HIV risks observed are not modifiable by FSWs alone. STI/HIV prevention efforts for this vulnerable population will benefit from reducing coercion and abuse perpetrated by pimps and clients.
doi:10.1136/sextrans-2011-050171
PMCID: PMC3628729  PMID: 22287530
3.  Exploring dynamics of anal sex among female sex workers in Andhra Pradesh 
Objective:
The anal sex among heterosexual couples is on the rise as reported in many scientific studies. Considering that unprotected anal sex has higher risk of human immunodeficiency virus (HIV) transmission than the vaginal sex, we undertook a study to understand the anal sex practices among Female Sex Workers (FSW).
Materials and Methods:
The study was conducted among FSW attending 11 randomly selected sexually transmitted infection (STI) clinics in Bill and Melinda Gates supported targeted interventions in Andhra Pradesh. A structured questionnaire was administered to the 555 FSW attending these clinics by project clinic counselors. Informed consent was obtained from all the study participants.
Results:
Engaging in anal sex was self reported by 22% of sex workers, though demand from clients was reported to be much higher (40%). The reasons for anal sex practices included more money (61%), clout/influence of the client (45%), risk of losing client (27%), and forced sex (1.2%). Factors associated with anal sex were higher number of clients, higher duration of sex work, higher income, and older age group. Associated risks perceived by FSW were bleeding and injury to anal canal (98%) while only 28% associated it with higher HIV transmission risk. Reported Condom and lubricant use was about 88% and 39% respectively.
Conclusion:
The study shows that there is frequent anal sex, inconsistent condom and infrequent lubricant usage, economic and physical coercion, and low awareness of STI/HIV transmission risk among FSW, which have serious implications for HIV prevention programmes. There is a need to focus on anal sex education and use of lubricants along with condoms during anal sex in FSW-targeted interventions in AP.
doi:10.4103/0253-7184.93787
PMCID: PMC3326863  PMID: 22529447
Anal sex; female sex workers; human immunodeficiency virus; HIV transmission; sexually transmitted infection
4.  Factors Associated with Risky Sexual Practices among Female Sex Workers in Karnataka, India 
PLoS ONE  2013;8(4):e62167.
Introduction
The objectives of this study are to develop a summary measure of risky sexual practice and examine the factors associated with this among female sex workers (FSWs) in Karnataka, India.
Materials and Methods
Data were drawn from special behavioral surveys (SBS) conducted in 2007 among 577 FSWs in two districts of Karnataka, India: Belgaum and Bangalore. FSWs were recruited using the two-stage probability sampling design. FSWs' sexual practice was considered risky if they reported inconsistent condom use with any sexual partner and reported experience of one of the following vulnerabilities to HIV risk: anal sex, alcohol consumption prior to sex and concurrent sexual relationships.
Results
About 51% of FSWs had engaged in risky sexual practice. The odds of engaging in risky sex were higher among FSWs who were older (35+ years) than younger (18–25 years) (58% vs. 45%, Adjusted Odds Ratio (AOR): 2.0, 95% confidence interval (CI): 1.2–3.4), who were currently married than never married (61% vs. 51%, AOR: 4.8, 95% CI: 2.5–9.3), who were in sex work for 10+ years than those who were in sex work for less than five years (66% vs. 39%, AOR: 2.6, 95% CI: 1.6–4.2), and who had sex with 3+ clients/day than those who had sex with fewer clients (67% vs. 38%, AOR: 3.7, 95% CI:2.5–5.5).
Conclusion
FSWs who are older, currently married, practicing sex work for longer duration and with higher clientele were more likely to engage in risky sexual practices. HIV prevention programs should develop strategies to reach these most-at risk group of FSWs to optimize the effectiveness of such programs.
doi:10.1371/journal.pone.0062167
PMCID: PMC3630134  PMID: 23637991
5.  An Evaluation of Intravaginal Rings as a Potential HIV Prevention Device in Urban Kenya: Behaviors and Attitudes That Might Influence Uptake within a High-Risk Population 
Journal of Women's Health  2008;17(6):1025-1034.
Abstract
Purpose
We sought to assess the potential acceptability of intravaginal rings (IVRs) as an HIV prevention method among at-risk women and men.
Methods
We conducted a qualitative assessment of initial attitudes toward IVRs, current HIV prevention methods, and common behavioral practices among female sex workers (FSWs) and men who frequent FSWs in Mukuru, an urban slum community in Nairobi, Kenya. Nineteen women and 21 men took part in six focus group discussions.
Results
Most participants, both male and female, responded positively to the concept of an IVR as a device for delivering microbicides. Women particularly liked the convenience offered by its slow-release capacity. Some female respondents raised concerns about whether male customers would discover the ring and respond negatively, whereas others thought it unlikely that their clients would feel the ring. Focus groups conducted with male clients of FSWs suggested that many would be enthusiastic about women, and particularly sex workers, using a microbicide ring, but that women's fears about negative responses to covert use were well founded. Overall, this high-risk population of FSWs and male clients in Nairobi was very open to the IVR as a potential HIV prevention device.
Conclusion
Themes that emerged from the focus groups highlight the importance of understanding attitudes toward IVRs as well as cultural practices that may impact IVR use in high-risk populations when pursuing clinical development of this potential HIV prevention device.
doi:10.1089/jwh.2007.0529
PMCID: PMC2942749  PMID: 18681822
6.  Intravaginal and Menstrual Practices among Women Working in Food and Recreational Facilities in Mwanza, Tanzania: Implications for Microbicide Trials 
AIDS and Behavior  2010;14(5):1169-1181.
Intravaginal and menstrual practices may potentially influence results of trials of microbicides for HIV prevention through effects on the vaginal environment and on adherence to microbicide and placebo products. As part of the feasibility study for the Microbicides Development Programme Phase 3 trial of a vaginal microbicide in Mwanza, a variety of quantitative and qualitative methods were used to describe these practices, associations with behaviour and underlying social norms among women working in food and recreational facilities. Intravaginal cleansing by inserting fingers and either water alone or soap and water was thought necessary to remove “uchafu” (dirt), referring to vaginal secretions, including menstrual blood and post-coital discharge. Vaginal cleansing was carried out within 2 hours after 45% of sex acts. Sexual enhancement practices were less common. Intravaginal and menstrual practices and associated behaviours and demographic factors should be measured and monitored throughout microbicide trials to enable analyses of their impacts on microbicide effectiveness.
doi:10.1007/s10461-010-9750-8
PMCID: PMC2944961  PMID: 20665101
Africa; Vaginal practices; Women; HIV; Vaginal microbicides; Prevention of sexual transmission
7.  Microbicide Acceptability among Female Sex Workers in Beijing, China: Results from a Pilot Study 
Journal of Women's Health  2009;18(9):1377-1384.
Abstract
Objectives
To explore attitudes toward hypothetical vaginal microbicides and willingness to use them among female sex workers (FSWs) in a district of Beijing, China, and to identify factors likely to affect acceptability and use of microbicides for HIV prevention among this population.
Methods
An exploratory cross-sectional study using convenience sampling was conducted. A total of 54 FSWs were recruited from Shijingshan District in Beijing for a face-to-face interview. Main outcome variables were measured by a microbicide acceptability score, perception of HIV/STI risk and self-reported high-risk sexual behaviors, condom use, HIV/STI history, and self-reported experience of vaginal product use.
Results
Mean score of microbicide acceptability in FSWs was 2.73, with a standard deviation (SD) of 0.46 (ranging from 1 to 4). Acceptability score varied by partner types (p = 0.025), history of HIV testing (p = 0.037), and concern about contracting an STI (p = 0.042). Covert use of microbicides in FSWs with various sexual partners was statistically different (p = 0.001). FSWs preferred to pay for microbicides and to use them covertly.
Conclusions
In general, FSWs in Shijinghsan District might have a positive response to microbicides across all hypothetical characteristics. Further study is needed for comprehensive understanding of the contextual factors of microbicide use.
doi:10.1089/jwh.2008.1239
PMCID: PMC2825728  PMID: 19743909
8.  HIV transmission risk behaviours among HIV seropositive sexually transmitted infection clinic patients in Cape Town, South Africa 
Background: South Africa has one of the fastest growing HIV epidemics in the world and new infections may often result from people who have tested HIV positive. This study examined the sexual practices and risk behaviours of men and women living with HIV/AIDS being treated for a co-occurring sexually transmitted infection (STI). Methods: A sample of men and women receiving services at three South African STI clinics completed a computer administered behavioural assessment. Results: Among the 218 HIV positive STI clinic patients, 34 (16%) had engaged in unprotected vaginal or anal intercourse with uninfected or unknown HIV status sex partners in the previous month. A multivariate logistic regression indicated that unprotected sex with uninfected or unknown HIV status partners was independently associated with older age, female gender, alcohol use, and other drug use, and drug use in sexual contexts. Conclusions: People living with HIV/AIDS who contract co-occurring STI are at significant risk for transmitting HIV to uninfected partners. Positive prevention interventions are urgently needed for South Africa.
doi:10.1093/eurpub/ckp127
PMCID: PMC2860715  PMID: 19726591
HIV/AIDS; HIV infectiousness; positive prevention; sexually transmitted infections.
9.  Alcohol Use by Men Is a Risk Factor for the Acquisition of Sexually Transmitted Infections and Human Immunodeficiency Virus From Female Sex Workers in Mumbai, India 
Sexually transmitted diseases  2005;32(11):685-690.
Objective
We investigated whether men who were under the influence of alcohol when visiting female sex workers (FSW) were at greater risk for sexually transmitted infections (STI) and human immunodeficiency virus (HIV).
Study
A cross-sectional analysis using baseline data from a randomized controlled trial of an HIV prevention intervention for high-risk men in Mumbai, India.
Results
The overall HIV prevalence among 1741 men sampled was 14%; 64% had either a confirmed STI or HIV; 92% reported sex with an FSW, of whom 66% reported having sex while under the influence of alcohol (SUI). SUI was associated with unprotected sex (odds ratio [OR]: 3.1; 95% confidence interval [CI], 2.3–4.1), anal sex (OR: 1.5; 1.1–2.0), and more than10 FSW partners (OR: 2.2; 1.8–2.7). SUI was independently associated with having either an STI or HIV (OR: 1.5; 1.2–1.9).
Conclusion
Men who drink alcohol when visiting FSWs engage in riskier behavior and are more likely to have HIV and STIs. Prevention programs in India need to raise awareness of this relationship.
PMCID: PMC3709449  PMID: 16254543
10.  Sexual and Drug Use Behaviors Associated with HIV and Other Sexually Transmitted Infections among Female Sex Workers in the Mexico-U.S. Border Region 
Current opinion in psychiatry  2010;23(3):215-220.
Purpose of review
The purpose of this review is to summarize the latest research regarding HIV/STI risk among female sex workers (FSWs) along the Mexico-U.S. border. Although Mexico has a low prevalence of HIV overall, HIV prevalence among FSWs in Tijuana is quite high, and even higher among FSWs who inject drugs (FSW-IDUs). Efforts to better understand and curtail the HIV epidemic among FSWs in this region are greatly needed.
Recent findings
A brief HIV/STI risk reduction intervention for FSWs was successful in decreasing HIV/STI sexual risk behavior with clients among FSWs in Tijuana and Ciudad Juarez, Mexico. However, the intervention was less effective among FSW-IDUs, and had no effect on FSWs' condom use with their non-commercial partners. While the majority of research thus far has focused on FSWs' individual-level risk factors, comparatively less is known about their clients and non-commercial sexual partners who may heavily influence their behavior, and engage in high risk behaviors themselves.
Summary
Further studies including FSWs' intimate partners and clients are needed as well as interventions specific to FSW-IDUs. Targeting the most at risk populations and reducing both sexual and injection risk behaviors simultaneously may curb the growing HIV epidemic in the Mexico-U.S. border region.
doi:10.1097/YCO.0b013e32833864d5
PMCID: PMC3412621  PMID: 20308903
female sex workers; HIV/STIs; Mexico-U.S.; border
11.  Unsafe Sexual Behavior Among HIV-Infected Patients in Croatia, 2006: Prevalence and Associated Factors 
AIDS and behavior  2008;12(4 Suppl):S86-S92.
Information about risky sexual behavior among people living with HIV/AIDS is important to prevent the spread of the disease. Using an anonymous, self-administrated questionnaire, we surveyed 185 HIV-infected patients about risk behaviors at the University Hospital for Infectious Diseases in Croatia. Unprotected anal or vaginal sex in the preceding 6 months with partners of uninfected/unknown HIV status was reported by 20% of men who have sex with men (MSM), about half of whom reported multiple casual partners of unknown HIV status; 6% of heterosexual men; and 3% of women. Heterosexual patients were potentially more likely to expose regular partners to HIV but reported no risk behaviors with casual, non-concordant partners. MSM reported more risk behaviors, which were strongly associated with having ≥2 sexual partners in the last 6 months and both insertive and receptive anal sex. Educational interventions in Croatia should target MSM to prevent high rates of HIV transmission
doi:10.1007/s10461-008-9420-2
PMCID: PMC2715159  PMID: 18543093
Men who have sex with men; Risk factors; Condom use; Croatia; HIV
12.  Prevalence and Assessment of Clinical Management of Sexually Transmitted Infections among Female Sex Workers in Two Cities of India 
Objective. Control of sexually transmitted infections (STIs) among female sex workers (FSWs) is an important strategy to reduce HIV transmission. A study was conducted to determine the prevalence and assess the current clinical management of STIs in India. Methods. FSWs attending three clinics for regular checkups or symptoms were screened for study eligibility. A behavioral questionnaire was administered, clinical examination performed, and laboratory samples collected. Results. 417 study participants reported a mean number of 4.9 (SD 3.5) commercial clients in the last week. 14.6% reported anal sex in the last three months. Consistent condom use with commercial and regular partners was 70.1% and 17.5%, respectively. The prevalence of gonorrhea was 14.1%, chlamydia 16.1%, and trichomoniasis 31.1% with a third of all infections being asymptomatic. Syphilis seropositivity was 10.1%. Conclusions. At study sites, presumptive treatment for gonorrhea, chlamydia, and syphilis screening should continue. Presumptive treatment for trichomoniasis should be considered. Consistent condom use and partner treatment need to be reemphasized.
doi:10.1155/2011/494769
PMCID: PMC3124070  PMID: 21747642
13.  Vaginal Douching, Condom Use, and Sexually Transmitted Infections Among Chinese Female Sex Workers 
Sexually transmitted diseases  2005;32(11):696-702.
Background and Objective
Vaginal douching has been hypothesized to increase a woman’s risk for human immunodeficiency virus (HIV) infection. However, data on the prevalence of this practice and its association with condom use and sexually transmitted infections (STIs) are limited.
Study
A cross-sectional survey among 454 female sex workers (FSWs) in a Chinese county.
Results
Vaginal douching was reported by 64.7% of the women. The prevalence of self-reported history of STI and that of current STI was 19.4% and 41.5%, respectively. Fifteen percent of the women reported consistent use of condoms with their clients and 8.4% with their regular partners. Vaginal douching was significantly associated with decreased use of condoms (with clients: OR = 0.31; with regular partner(s): OR = 0.22) and increased rate of self-reported STI history (OR = 1.95). However, there was no direct relation between douching and current STI. Over one third of the women believed that douching can prevent STI/HIV.
Conclusion
Vaginal douching exposes FSWs to a high risk of STI/HIV. Medical professional and public health workers should correct women’s misconception about the effectiveness of douching and discourage women from douching through educational activities.
doi:10.1097/01.olq.0000175403.68410.ec
PMCID: PMC1935451  PMID: 16254545
14.  Part time female sex workers in a suburban community in Kenya: a vulnerable hidden population 
Sexually Transmitted Infections  2002;78(4):271-273.
Background: In sub-Saharan Africa, female sex workers (FSWs) are a vulnerable high risk group for the acquisition and transmission of sexually transmitted infections (STI) and HIV.
Objectives: To study parameters of sexual behaviour and knowledge of STI and HIV, to describe health seeking behaviour related to STI, and to measure the prevalence of gonorrhoea, chlamydia, syphilis, and HIV-1, to provide baseline data for targeted STI and HIV prevention interventions.
Methods: In a cross sectional survey with snowballing recruitment, between February and March 2000, 503 self identified FSWs in a suburb in Mombasa, Kenya, were interviewed with a structured questionnaire and screened for gonorrhoea, chlamydia, syphilis, and HIV-1.
Results: The mean number of sexual partners in the previous week was 2.8 (SD 1.6). The mean number of non-regular clients and regular clients in the previous week was 1.5 (1.0) and 1.0 (0.9) respectively. The median weekly income from sex work was $US15. A total of 337 (67%) women had an alternative income in the informal sector. 146 (29%) and 145 (45%) never used a condom with a client and non-paying partner respectively. The prevalence of gonorrhoea, chlamydia, and syphilis was 1.8%, 4.2%, and 2.0% respectively. The overall HIV-1 seroprevalence was 30.6%.
Conclusions: There is a large need for intensive STI and HIV prevention interventions in part time FSW.
doi:10.1136/sti.78.4.271
PMCID: PMC1744494  PMID: 12181465
15.  Psychosexual and social-cognitive correlates of sexual risk behavior among male clients of female sex workers in Tijuana, Mexico 
AIDS care  2010;22(12):1473-1480.
Male clients of female sex workers (FSWs) may act as a bridge to the general population contributing to the spread of HIV and other sexually transmitted infections in the United States and Mexico. This study used cross-sectional data to identify psychosexual and social cognitive factors associated with sexual risk behavior in a bi-national sample of 300 male clients of FSWs recruited in Tijuana, Mexico from June to October, 2008. In a multiple regression analysis, the number of unprotected vaginal sex acts with FSWs was associated with higher sexual compulsivity scores, lower self-efficacy for condom use, greater use of illicit drugs, and more financial need. Behavioral interventions are urgently needed to assist clients of FSWs in reducing high-risk behaviors in an effort to prevent the spread of HIV/STIs in this high-risk population and their sexual partners.
doi:10.1080/09540121003758648
PMCID: PMC3082496  PMID: 21154035
male clients; female sex workers; sexual risk behavior; U.S.- Mexico border
16.  High risk of HIV in non-brothel based female sex workers in India 
BMC Public Health  2005;5:87.
Background
Heterosexual contact is the most common mode of HIV transmission in India that is largely linked to sex work. We assessed the non-use of condoms in sex work and with regular sex partners by female sex workers (FSWs), and identified its associations that could assist in planning HIV prevention programmes.
Methods
Detailed documentation of various aspects of sex work, and sexual behaviour with regular sex partners, was done through confidential interviews for 6648 FSWs in 13 districts in the Indian state of Andhra Pradesh. Multivariate analysis was done to understand condom non-use with clients.
Results
5010 (75.4%), 1499 (22.5%), and 139 (2.1%) FSWs were street-, home-, and brothel-based, respectively. Of the total 6648 FSWs, 6165 (92.7%) had penetrative vaginal/anal sex with at least one client in the last 15 days, and of these 2907 (47.2%; 95% CI 41.2–53.2%) reported non-use of condom with at least one of her last three clients. Lack of knowledge that HIV could be prevented (odds ratio 5.01; 95% CI 4.38–5.73), no access to free condoms (odds ratio 3.45; 95% CI 2.99–3.98), being street-based as compared with brothel-based (odds ratio 3.36; 95% CI 1.87–6.04), and no participation in FSW support groups (odds ratio 2.02; 95% CI 1.50–2.70) were the most significant predictors of condom non-use with clients. Other associations included lower social support, lower income, age >24 years, illiteracy, and living in medium-size urban or rural areas. Of the 2582 who had penetrative sex with regular sex partner within the last 7 days, 2428 (94%; 95% CI 92.1–95.9%) had not used condom at last sex, and 1032 (41.8%) had neither used condom consistently with clients nor with regular sex partner.
Conclusion
About half the FSWs do not use condom consistently with their clients in this Indian state putting them at high risk of HIV infection. Non-brothel-based FSWs, who form the majority of sex workers in India, were at a significantly higher risk of HIV infection as compared with brothel-based FSWs. With their high vulnerability, the success of expansion of HIV prevention efforts will depend on achieving and sustaining an environment that enables HIV prevention with the non-brothel based FSWs.
doi:10.1186/1471-2458-5-87
PMCID: PMC1208909  PMID: 16111497
17.  Effect of Treatment Assignment on Intravaginal Cleansing in a Randomized Study of the Diaphragm with Candidate Microbicide 
Journal of Women's Health  2011;20(2):187-195.
Abstract
Background
Intravaginal cleansing may predispose women to adverse health outcomes and may interfere with the effectiveness and safety of female-initiated methods for preventing sexually transmitted infections (STIs). In a 4-week randomized study of 192 Malagasy sex workers, we evaluated associations between self-reported intravaginal cleansing and randomization assignment: diaphragm with viscous candidate microbicide gel (Acidform™, TOPCAD, Chicago, IL, licensed to Instead, Coppell, TX), diaphragm with placebo hydroxyethylcellulose gel (HEC, ReProtect LLC, Baltimore, MD), Acidform alone, or HEC alone.
Methods
Women were counseled to avoid intravaginal cleansing and were blinded to gel assignment. We evaluated changes in self-reported intravaginal cleansing across the study and assessed the effects of treatment assignment and covariates on frequent (more than once daily) intravaginal cleansing. Significant predictors in domain-specific models were evaluated in an all-domain multiple regression model.
Results
The proportion of women reporting intravaginal cleansing decreased from baseline (97%) to week 1 (82%) (p < 0.001). Self-reported frequent intravaginal cleansing decreased from baseline (87% to 56%) during the same time period (p < 0.001). In adjusted analyses, the Acidform-diaphragm group had 60% lower odds of frequent intravaginal cleansing during the study (odds ratio [OR] 0.4, 95% confidence interval [CI] 0.2-0.8) compared to the control group (HEC only). HEC-diaphragm and Acidform only users did not differ from controls. Living on the coast of Madagascar, not cohabiting, frequent intravaginal cleansing at enrollment, and high coital frequency predicted frequent intravaginal cleansing during follow-up.
Conclusions
Gel characteristics and the diaphragm's presence likely influenced women's cleansing. Viscous gel delivered by a cervical barrier (such as a diaphragm) may minimize the likelihood of frequent intravaginal cleansing.
doi:10.1089/jwh.2010.2143
PMCID: PMC3391708  PMID: 21314445
18.  Heterosexual Anal Sex among Female Sex Workers in High HIV Prevalence States of India: Need for Comprehensive Intervention 
PLoS ONE  2014;9(2):e88858.
Introduction
Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. This paper examines practice of HAS among Female Sex Workers (FSWs) and its correlates in India where the HIV epidemic is being primarily driven by core groups like FSWs.
Methods
Data for this paper are drawn from Round I survey of 9667 FSWs in the Integrated Biological and Behavioral Assessment (IBBA) from 23 districts of 4 high HIV prevalent states of India. Bivariate and multivariate analysis identified factors associated with HAS.
Results
Ever having anal sex was reported by 11.9% FSWs (95% CI: 11.3%–12.6%). Typology (AOR 2.20, 95% CI 1.64–2.95) and literacy (AOR 1.28, 95% CI 1.10–1.49) were positively associated with practice of HAS. Longer duration in sex trade (AOR 1.69, 95% CI 1.44–1.99), entertaining larger number of clients the previous week (AOR 1.78, 95% CI 1.47–2.15), alcohol consumption (AOR 1.21, 95% CI 1.03–1.42) and inability to negotiate condom use (AOR 1.53, 95% CI 1.28–1.83) were also correlated with HAS. Self-risk perception for HIV (AOR 1.46, 95% CI 1.25–1.71) did not impede HAS. Although symptoms of sexually transmitted infections (STIs) in the last 12 months were associated with anal sex (AOR 1.39, 95% CI 1.13–1.72) there was no significant association between laboratory confirmed HIV and other STIs with HAS.
Conclusion
Practice of HAS by FSWs might significantly contribute to HIV transmission in India. This study also shows that despite self-risk perception for HIV, even literate FSWs with longer duration in sex work report HAS. General messages on condom use may not influence safe HAS. FSWs need to be targeted with specific messages on HIV transmission during anal sex. Women controlled prevention methods, such as rectal microbicides and vaginal microbicides are needed.
doi:10.1371/journal.pone.0088858
PMCID: PMC3930672  PMID: 24586416
19.  A nested case-control study of sexual practices and risk factors for prevalent HIV-1 infection among young men in Kisumu, Kenya 
Sexually transmitted diseases  2007;34(10):731-736.
Objectives
To investigate sexual practices and risk factors for prevalent HIV infection among young men in Kisumu, Kenya.
Goal
The goal of this study was to identify behaviors associated with HIV in Kisumu to maximize the effectiveness of future prevention programs.
Study Design
Lifetime sexual histories were collected from a nested sample of 1337 uncircumcised participants within the context of a randomized controlled trial of male circumcision to reduce HIV incidence.
Results
Sixty-five men (5%) tested positive for HIV. Multiple logistic regression revealed the following independent predictors of HIV: older age, less education being married, being Catholic, >4 lifetime sex partners, prior treatment for an STI, sex during partner’s menstruation, ever practicing bloodletting, and receipt of a medical injection in the last 6 months. Prior HIV testing and post coital cleansing were protective.
Conclusions
This analysis confirms the importance of established risk factors for HIV and identifies practices that warrant further investigation.
doi:10.1097/01.olq.0000261335.42480.89
PMCID: PMC2562680  PMID: 17495591
HIV; risk factors; sexual behavior; Africa
20.  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
21.  There’s No Pamphlet for the Kind of Sex I Have: HIV-Related Risk Factors and Protective Behaviors Among Transgender Men Who Have Sex with Non-Transgender Men 
Preliminary evidence has suggested that some transgender men who have sex with non-transgender men (“trans MSM”) may be at risk for HIV and STIs and that their prevention needs are not being met. Quantitative (n = 45) and qualitative (n =15) interviews explored risk behaviors, protective strategies, and perceptions of the impact of transgender identity on sexual decision-making among trans MSM. A majority of the participants reported inconsistent condom use during receptive vaginal and anal sex with non-trans male partners; HIV prevalence was 2.2%. Risk factors included barriers to sexual negotiation including unequal power dynamics, low self-esteem, and need for gender identity affirmation. Protective strategies included meeting and negotiating with potential partners online. Results of this study provide initial evidence that current risk behaviors could lead to rising HIV prevalence rates among trans MSM. Prevention programs must tailor services to include issues unique to trans MSM and their non-trans male partners.
doi:10.1016/j.jana.2009.06.001
PMCID: PMC2785444  PMID: 19732698
gender identity; HIV/STI prevention; MSM; sexual risk; transgender men
22.  Clients of Female Sex Workers as a Bridging Population in Vietnam 
AIDS and Behavior  2008;13(5):881-891.
Understanding bridging behaviors of clients of female sex workers (FSWs) is important for projecting and intervening in the spread of sexually transmitted infections in Vietnam. The goals of the study were to determine HIV/STI prevalence amongst different bridging groups, identify factors associated with being potential and active bridgers, and assess the association of drug use and unsafe sex with HIV and/or STI prevalence. In April, 2007, 292 clients were anonymously interviewed at sex venues in a two-stage time-location cluster sampling survey, followed by HIV, syphilis, and HSV-2 testing. Based on condom use with both high-risk (FSWs) and low-risk (wives/girlfriends) sexual partners, clients were classified as unlikely, potential, or active bridgers. The majority of clients were potential or active bridgers (55.8%) who had a significantly higher prevalence of herpes simplex type 2 (HSV-2) (21% and 33%, respectively) than unlikely bridgers (8.7%). HIV seropositivity was 4.4-fold (95% CI 1.1–17.1) higher among those who were HSV-2-positive. Clients of FSWs may be playing a major bridging role in transmitting HIV and sexually transmitted infections (STIs) in Vietnam. An observed synergistic interaction between drug use and condom slippage/breakage emphasizes the importance of proper condom use, particularly among drug users.
doi:10.1007/s10461-008-9463-4
PMCID: PMC2903541  PMID: 18830814
Sexual behaviors; Condoms; Bridging; Drug use; Male clients; Female sex workers (FSWs); Risk factors; Sexually transmitted infections (STIs); HIV
23.  Intravaginal insertion in KwaZulu-Natal: sexual practices and preferences in the context of microbicide gel use 
Culture, Health & Sexuality  2010;12(8):929-942.
Intravaginal insertion is often associated with the concept of ‘dry’ sex. All HIV-prevention microbicides tested to date have been vaginally applied lubricant-based gels. In this paper, we examine whether the use of intravaginal insertions could be in conflict with the introduction of vaginal microbicide gels. The Africa Centre site was part of the Microbicides Development Programme evaluating PRO2000/5 microbicide gel. We conducted in-depth-interviews and focus-group discussions with women enrolled in the trial as well as women and men from the community. The analysis focused on people's knowledge of intravaginal insertion in the community and trial participants’ experience of using trial gels. Intravaginal use of a variety of products was widely acknowledged. We found that the experience of using trial gels - which made sex ‘hot’, ‘tight’ and ‘dry’ - matched the desired outcomes of intravaginal insertion. We found that vaginal ‘dryness’ described the removal of excessive amounts of unusual discharge, rather than the removal of normal vaginal secretions and that intravaginal insertion is not exclusively associated with a desire for ‘dry’ sex. Study findings provide evidence that vaginal microbicide gels may be more acceptable in communities where intravaginal insertion is practiced than was previously thought.
doi:10.1080/13691058.2010.507876
PMCID: PMC3024849  PMID: 20737330
intravaginal insertion; microbicides; KwaZulu-Natal; South Africa
24.  Male Sex Workers Who Sell Sex to Men Also Engage in Anal Intercourse with Women: Evidence from Mombasa, Kenya 
PLoS ONE  2013;8(1):e52547.
Objective
To investigate self-report of heterosexual anal intercourse among male sex workers who sell sex to men, and to identify the socio-demographic characteristics associated with practice of the behavior.
Design
Two cross-sectional surveys of male sex workers who sell sex to men in Mombasa, Kenya.
Methods
Male sex workers selling sex to men were invited to participate in surveys undertaken in 2006 and 2008. A structured questionnaire administered by trained interviewers was used to collect information on socio-demographic characteristics, sexual behaviors, HIV and STI knowledge, and health service usage. Data were analyzed through descriptive and inferential statistics. Bivariate logistic regression, after controlling for year of survey, was used to identify socio-demographic characteristics associated with heterosexual anal intercourse.
Results
From a sample of 867 male sex workers, 297 men had sex with a woman during the previous 30 days – of whom 45% did so with a female client and 86% with a non-paying female partner. Within these groups, 66% and 43% of male sex workers had anal intercourse with a female client and non-paying partner respectively. Factors associated with reporting recent heterosexual anal intercourse in bivariate logistic regression after controlling for year of survey participation were being Muslim, ever or currently married, living with wife only, living with a female partner only, living with more than one sexual partner, self-identifying as basha/king/bisexual, having one’s own children, and lower education.
Conclusions
We found unexpectedly high levels of self-reported anal sex with women by male sex workers, including selling sex to female clients as well as with their own partners. Further investigation among women in Mombasa is needed to understand heterosexual anal sex practices, and how HIV programming may respond.
doi:10.1371/journal.pone.0052547
PMCID: PMC3534678  PMID: 23300978
25.  Sexually transmitted infections and vaginal douching in a population of female sex workers in Nairobi, Kenya 
Sexually Transmitted Infections  2001;77(4):271-275.
Objective: To assess the association between vaginal douching and sexually transmitted infections (STI) among a group of female sex workers (FSWs) in Nairobi, Kenya.
Methods: This study was part of a randomised, placebo controlled trial of monthly prophylaxis with 1 g of azithromycin to prevent STIs and HIV infection in a cohort of Nairobi FSWs. Consenting women were administered a questionnaire and screened for STIs.
Results: The seroprevalence of HIV-1 among 543 FSWs screened was 30%. HIV infection was significantly associated with bacterial vaginosis (BV), trichomoniasis, gonorrhoea, and the presence of a genital ulcer. Regular douching was reported by 72% of the women, of whom the majority inserted fluids in the vagina, generally after each sexual intercourse. Water with soap was the fluid most often used (81%), followed by salty water (18%), water alone (9%), and a commercial antiseptic (5%). Douching in general and douching with soap and water were significantly associated with bacterial vaginosis (p = 0.05 and p = 0.04 respectively). There was a significant trend for increased frequency of douching and higher prevalence of BV. There was no direct relation observed between douching and risk for HIV infection or other STIs.
Conclusion: The widespread habit of douching among African female sex workers was confirmed. The association between vaginal douching and BV is of concern, given the increased risk of HIV infection with BV, which has now been shown in several studies. It is unclear why we could not demonstrate a direct association between douching and HIV infection. Further research is required to better understand the complex relation between douching, risk for bacterial vaginosis, and risk for HIV and other STIs.
Key Words: vaginal douching; sexually transmitted infections; female sex workers
doi:10.1136/sti.77.4.271
PMCID: PMC1744330  PMID: 11463927

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