Understanding the impact of multiple forms of violence on sexual and drug-related HIV risk in female sex workers
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Date
2017-09-13
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Johns Hopkins University
Abstract
Background: Female sex workers (FSW) are a key population in the HIV epidemic and in many settings face high levels of violence from intimate partners, clients, police, and pimps. FSW are therefore at risk of polyvictimization, or experiencing multiple types of violence.
Methods: Using respondent-driven sampling, 754 FSW from Russia were recruited. Participants self-reported lifetime exposure to client, police, intimate partner, and pimp violence, as well as recent injecting drug use, inconsistent condom use with intimate partners, and inconsistent condom use with clients.
Results: Lifetime violence was prevalent, with 44.8% experiencing any violence, including 31.7% from clients, 16.0% from police, 15.7% from intimate partners, and 11.4% from pimps. One-fifth (20.4%) experienced polyvictimization. Client violence was one of the strongest independent correlates of the other three types of violence.
Respondents reported prevalent recent injecting drug use (10.7%), inconsistent condom use with intimate partners (45.1%), and inconsistent condom use with clients (22.5%). Intimate partner violence was associated with all three risk behaviors, police violence was associated with both sexual risk outcomes, and client violence was associated with injecting drug use, while pimp violence was not associated with any of the three risk behaviors.
Linear dose-response analyses standard to syndemics research demonstrated that the risk of injecting drug use (ARR=1.37, 95% CI 1.04, 1.81), inconsistent condom use with intimate partners (ARR=1.04, 95% CI 1.01, 1.08), and inconsistent condom use with clients (ARR=1.27, 95% CI 1.07, 1.49) rises as the number of types of violence experienced increases. We propose three novel analyses to measure whether these four types of violence synergistically increase HIV risk; none demonstrated synergism.
Conclusions: The present study is unique for measuring four major types of violence against FSW and three major HIV risk pathways. All three pathways were associated with multiple types of violence; these results support the World Health Organization mandate that violence prevention needs to be integrated into HIV prevention programming for FSW, and demonstrates the importance of considering multiple forms of violence and of considering different types of violence for each specific HIV risk pathway. The novel synergism analyses proposed can be leveraged to advance syndemics research.
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Keywords
HIV, violence, sex workers