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This study elucidated the prevalence and correlates of four types of HIV stigma among women living with HIV (WLWH). Data were drawn from 2 years (September 1/15 to August 31/17) of follow-up from a longitudinal community-based open cohort of 215 cisgender or transgender WLWH who lived and/or accessed care in Metro Vancouver, Canada (2014-present). Bivariate and multivariable cumulative logistic regression using generalized estimating equations for repeated measures were used to examine correlates of HIV stigma, including: (1) anticipated; (2) enacted; (3) internalized; and (4) perceived stigma. In multivariable analysis, disclosure of HIV status without consent was significantly associated with heightened: anticipated; enacted; and perceived stigma. Verbal and/or physical violence related to HIV status was significantly associated with heightened enacted, internalized and perceived stigma. Negative physical effects/symptoms of HIV was significantly associated with all stigma outcomes. Results suggest a need to support safe disclosure of HIV status and address social and structural violence against WLWH. [ABSTRACT FROM AUTHOR]

While numerous ethical concerns have been voiced regarding HIV service scale-up strategies targeting key populations, few studies have examined these from the perspective of affected groups. This study therefore sought to understand transgender women's experiences and perspectives of targeted HIV services scale-up in the context of Argentina's Treatment as Prevention strategy. In 2016, 25 purposively selected transgender women living with HIV were interviewed by a peer research associate. Interviews were audio recorded, transcribed verbatim and analysed using participatory coding techniques. Findings suggest that procedures around informed consent, including the provision of full information in lay language and voluntariness, were lacking both pre- and post-HIV test. Further, many transgender women felt disrespected and disregarded by healthcare workers. While the majority of participants were unaware of Treatment as Prevention, once explained, most felt the approach was ethical overall, and helped improve equity in HIV service access. Study findings offer several community-driven suggestions to support patient rights and the ethical scale-up of HIV services for transgender women in Buenos Aires, including the need for training in and the provision of non-judgemental, gender-affirmative care and the inclusion of peer-navigators. [ABSTRACT FROM AUTHOR]

This study describes long-term viral load (VL) trajectories and their predictors among women living with HIV (WLWH), using data from Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment (SHAWNA), an open prospective cohort study with linkages to the HIV/AIDS Drug Treatment Program. Using Latent Class Growth Analysis (LCGA) on a sample of 153 WLWH (1088 observations), three distinct trajectories of detectable VL (≥50 copies/ml) were identified: 'sustained low probability of detectable VL', characterized by high probability of long-term VL undetectability (51% of participants); ' high probability of delayed viral undetectability', characterized by a high probability VL detectability at baseline that decreases over time (43% of participants); and ' high probability of detectable VL', characterized by a high probability of long-term VL detectability (7% of participants). In multivariable analysis, incarceration (adjusted odds ratio (AOR) = 3.24; 95%CI:1.34–7.82), younger age (AOR = 0.96; 95%CI:0.92–1.00), and lower CD4 count (AOR = 0.82; 95%CI:0.72–0.93) were associated with ' high probability of delayed viral undetectability' compared to 'sustained low probability of detectable VL.' This study reveals the dynamic and heterogeneous nature of WLWH's long-term VL patterns, and highlights the need for early engagement in HIV care among young WLWH and programs to mitigate the destabilizing impact of incarceration on WLWH's HIV treatment outcomes. [ABSTRACT FROM AUTHOR]

Given shifting sex work criminalization and enforcement in Canada, this study examined worrying about workplace inspections by authorities amongst indoor sex workers in Vancouver (2014–2017). Data were drawn from a community-based prospective cohort of sex workers (AESHA). Bivariate and multivariable logistic regression were used to investigate factors associated with worry about inspections. 23.9% of participants experienced workplace inspections; 51.6% worried about inspections. In multivariable analyses, worrying about inspections was associated with recent im/migration [adjusted odds ratio (AOR) 3.13; 95% confidence interval (CI) 1.77–5.53], police harassment (AOR 3.49; 95% CI 1.92–6.34), and workplace violence (AOR 1.66, 95% CI 1.09–2.51). In a multivariable confounder model, worry was independently associated with barriers to health access (AOR 1.45, 95% CI 1.06–1.98). Im/migrant indoor workers are disproportionately impacted by concerns about workplace inspections, which was independently linked to enhanced barriers to health access. Current criminalization measures may exacerbate health inequities among im/migrant sex workers. [ABSTRACT FROM AUTHOR]

Objectives: Involuntary child removal via the child protection system disproportionately affects marginalized women, yet the impacts on maternal health are under-investigated. This study prospectively examined the association of child removal with self-rated health of mothers who are sex workers. Given high levels of intergenerational family separation in this population, particularly among Indigenous sex workers, we also estimated joint effects of child removal spanning two generations. Methods: Analyses drew on 2010–2015 data from AESHA (An Evaluation of Sex Workers' Health Access), a prospective cohort of sex workers (n = 950) in Vancouver, Canada. Using logistic regression with generalized estimating equations, we modeled the association of past child removal and current self-rated health in a sample of 466 sex workers who ever had a live birth. Joint effects of child removal and history of removal from own parents were also investigated. Results: Of 466 sex workers, 180 (38.6%) reported child removal at baseline and 147 (31.6%) had a history of removal from own parents. In main effects model, child removal was associated with increased odds of poorer self-rated health [odds ratio (OR) 1.50, 95% confidence interval (CI) 1.04, 2.16]. Joint effects model showed higher odds of poorer self-rated health (OR 2.04, 95% CI 1.27, 3.27) among women with intergenerational family separation. Conclusion for Practice: Child removal was negatively associated with sex workers' health that was worsened when family separation spanned two generations. Findings underscore need to develop sex worker and Indigenous-led family support services, along with tailored interventions to address health needs of those separated from their children. [ABSTRACT FROM AUTHOR]

Food security is both a basic human right and a public health necessity. Despite known gendered contexts of food insecurity, there is a dearth of research on prevalence and factors driving increased food insecurity for sex workers in a criminalized setting. The current study longitudinally examines the prevalence and structural and individual factors associated with increased odds of food insecurity among street and off-street sex workers in a Canadian urban setting. Prospective analyses drew on data from a community-based longitudinal cohort of cis and trans women in street and off-street sex work in An Evaluation of Sex Workers Health Access (2010-2014). The primary outcome was a time-updated measure of food insecurity, using the Radimer-Cornell scale. We used bivariable and multivariable logistic regression using generalized estimating equations to prospectively model correlates of food insecurity over a five-year period. Of 761 cis and trans women sex workers, 72.4% (n = 551) were food insecure over the study period. Over a third (35.2%, n = 268) identified as Indigenous and a quarter, 25.6% (n = 195) were of a gender/sexual minority. Within the 11.0% (n = 84) of women living with HIV, 96.4% (n = 81) were food insecure over the follow-up period. In multivariable analysis, Indigenous ancestry (AOR = 1.58 [95% CI 1.18, 2.10]), unstable housing (AOR = 1.27 [95% CI 1.03, 1.57]), stimulant use (AOR = 1.97 [95% CI 1.57, 2.45]), heroin use (AOR = 1.72 [95% CI 1.36, 2.19]), mental health diagnosis (AOR = 2.38 [95% CI 1.85, 3.05]), recent violence (AOR = 1.54 [95% CI 1.24, 1.91]), means of food access: reliant on food services only vs. self-sufficient (AOR = 1.78 [95% CI 1.38, 2.29]), and means of food access: both vs. self-sufficient (AOR = 2.29 [95% CI 1.84, 2.86]) were associated with food insecurity. In separate multivariable models, both recent and lifetime physical and/or sexual violence remained independently associated with food insecurity (AOR 1.54 [95% CI 1.24, 1.91]; AOR 4.62 [95% CI 2.99, 7.14], respectively). Almost all study participants living with HIV reported being food insecure. These intersecting risks demonstrate the negative impacts associated with living with HIV, experiencing food insecurity and/or physical or sexual violence. This study also highlights the potential for interventions that address structural inequities (e.g., decriminalizing sex work) to have crosscutting impacts to reduce barriers to accessing necessities (including food) or health and social services (e.g., methadone; primary care). [ABSTRACT FROM AUTHOR]

To better understand the structural drivers of women living with HIV’s (WLWH’s) reproductive rights and choices, this study examined the structural correlates, including non-consensual HIV disclosure, on WLWH’s pregnancy decisions and describes access to preconception care. Analyses drew on data (2014-present) from SHAWNA, a longitudinal community-based cohort with WLWH across Metro-Vancouver, Canada. Multivariable logistic regression was used to model the effect of non-consensual HIV disclosure on WLWH’s pregnancy decisions. Of the 218 WLWH included in our analysis, 24.8% had ever felt discouraged from becoming pregnant and 11.5% reported accessing preconception counseling. In multivariable analyses, non-consensual HIV disclosure was positively associated with feeling discouraged from wanting to become pregnant (AOR 3.76; 95% CI 1.82-7.80). Non-consensual HIV disclosure adversely affects WLWH’s pregnancy decisions. Supporting the reproductive rights of WLWH will require further training among general practitioners on the reproductive health of WLWH and improved access to women-centred, trauma-informed care, including non-judgmental preconception counseling. [ABSTRACT FROM AUTHOR]

While sex workers (SWs) bear the brunt of the epidemic in Uganda, there remains a dearth of empirical research on the structural drivers of HIV prevention among SWs. This study examined the drivers of inconsistent condom use by one-time and regular clients of young women SWs in Gulu, Northern Uganda. Data were drawn from the Gulu Sexual Health Study, a cross-sectional study of young SWs, aged 14 years and older (2011-2012). SWs were recruited using peer/SW-led outreach, in partnership with The AIDS Support Organization and other CBOs. Multivariable logistic regression was used to examine the correlates of inconsistent condom use by one-time and regular clients. In total, 84.5% of the 381 SWs servicing regular clients and 76.8% of the 393 SWs servicing one-time clients reported inconsistent client condom use. In multivariable analysis, physical/sexual violence by clients (AOR = 5.39; 95%CI 3.05-9.49), low sexual control by workers (measured by the validated Pulweritz scale) (AOR = 2.86; 95%CI 1.47-5.58), alcohol/drug use while working (AOR = 1.98; 95%CI 1.17-3.35) and migration to Gulu for sex work (AOR = 1.73; 95%CI 0.95-3.14) were positively correlated with inconsistent condom use by one-time clients. Correlates of inconsistent condom use by regular clients included: low sexual control by workers (AOR = 4.63; 95%CI 2.32-9.23); physical/sexual violence by clients (AOR = 3.48; 95%CI 1.85-6.53); police harassment (AOR = 2.57; 95%CI 1.17-5.65); and being a single mother (AOR = 2.07; 95%CI 1.09-3.93). Structural and interpersonal factors strongly influence inconsistent condom use by clients, with violence by clients and police, low sexual control by workers, migration and single-parenthood all linked to non-condom use. There is a need for peer-led structural interventions that improve access to occupational health and safety standards (e.g., violence prevention and alcohol/drug harm reduction policies/programming). Shifts away from the current punitive approaches towards SWs are integral to the success of such interventions, as they continue to undermine HIV prevention efforts. [ABSTRACT FROM AUTHOR]

The telling of birth stories (i.e. stories that describe women's experiences of giving birth) is a common and important social practice. Whereas most research on birth narratives reflects the stories of middle-class, 'adult' women, we examine how the birth stories told by early-age mothers interconnect with broader narratives regarding social stigma and childbearing at 'too early' an age. Drawing on narrative theory, we analyse in-depth interviews with 81 mothers (ages 15-24 years) conducted in Greater Vancouver and Prince George, Canada, in 2014-15. Their accounts of giving birth reveal the central importance of birth narratives in their identity formation as young mothers. Participants' narratives illuminated the complex interactions among identity formation, social expectations, and negotiations of social and physical spaces as they narrated their experiences of labour and birth. Through the use of narrative inquiry, we examine the ways in which re-telling the experience of giving birth serves to situate young mothers in relation to their past and future selves. These personal stories are also told in relation to a meta-narrative regarding social stigma faced by 'teenage' mothers, as well as the public's 'gaze' on motherhood in general - even within the labour and delivery room. [ABSTRACT FROM AUTHOR]

Objectives: Increased risk of herpes simplex virus 2 (HSV-2) has been proposed as a possible indirect pathway through which hormonal contraceptives (specifically depot medroxyprogesterone acetate (DMPA)) may increase the risk of HIV acquisition among women. We investigated the effects of DMPA on HSV-2 acquisition among female sex workers.Methods: Longitudinal data were drawn from a prospective cohort of sex workers in Vancouver, Canada. The primary outcome was HSV-2 seroconversion. Extended Cox regression analyses were used to model the independent effect of DMPA use on HSV-2 acquisition.Results: Between January 2010 and February 2014, 149 HSV-2 seronegative women were enrolled, contributing to 228 person-years (py) of follow-up. Of these, 19 (13.3%) reported DMPA use. There were 39 HSV-2 seroconversions (12 among DMPA users and 27 among non-users) over the study period (median follow-up of 18.6 months (IQR 8.4-29.9)), resulting in an overall incidence rate of 17.1 cases per 100 py (95% CI 12.4 to 23.6). Incidence rates were higher among DMPA users (57.4 cases per 100 py, 95% CI 31.4 to 105.0) compared with non-users (13.1 cases per 100 py, 95% CI 8.9 to 19.1). After adjusting for key confounders, use of DMPA remained an independent predictor of HSV-2 acquisition (adjusted HR 4.43, 95% CI 1.90 to 10.35).Conclusions: The high observed incidence rates of HSV-2, together with a strong association between DMPA exposure and HSV-2 acquisition, raise serious concerns about the provision of optimal reproductive and sexual healthcare to sex workers in this setting. Given the known links between HSV-2 and HIV, our findings underscore the need for further research to better understand the potential association between DMPA and increased risk of HSV-2 and other STIs to help inform the development of safer reproductive choices for women worldwide. [ABSTRACT FROM AUTHOR]

Despite universal health care in Canada, sex workers (SWs) and im/migrants experience suboptimal health care access. In this analysis, we examined the correlates of unmet health needs among SWs in Metro Vancouver over time. Data from a longitudinal cohort of women SWs (An Evaluation of Sex Workers Health Access [AESHA]) were used. Of 742 SWs, 25.5% reported unmet health needs at least once over the 4-year study period. In multivariable logistic regression using generalized estimating equations, recent im/migration had the strongest impact on unmet health needs; long-term im/migration, policing, and trauma were also important determinants. Legal and social supports to promote im/migrant SWs’ access to health care are recommended. [ABSTRACT FROM PUBLISHER]

This research aimed to determine the effect of food insecurity on sexual HIV risk with clients among youth sex workers (YSWs) <30 years in Metro Vancouver, Canada. Data were drawn from a prospective community cohort of sex workers (2010-2013). We examined the independent relationship between YSWs' food insecurity and being pressured into sex without a condom by clients ('client condom refusal'). Of 220 YSWs, 34.5 % (n = 76) reported client condom refusal over the 3.5-year study period and 76.4 % (n = 168) reported any food insecurity. Adjusting for other HIV risk pathways, food insecurity retained an independent effect on client condom refusal (AOR 2.08, 95 % CI 1.23-3.51), suggesting that food insecurity is significantly associated with HIV risk among YSWs. This study indicates a critical relationship between food insecurity and HIV risk, and demonstrates YSWs' particular vulnerability. Public policies for food assistance as a harm reduction measure may be key to addressing this disparity. [ABSTRACT FROM AUTHOR]

Community empowerment can be a powerful determinant of HIV risk among sex workers (SWs). This study modeled the impact of social cohesion on client condom refusal among SWs in Vancouver. Longitudinal data were drawn from a prospective cohort of SWs (2010-2013). Lippman and colleagues' Social Cohesion Scale measured SWs' connectedness (i.e., perception of mutual aid, trust, support). Multivariable logistic regression examined the independent effect of social cohesion on client condom refusal. Of 654 SWs, 22 % reported baseline client condom refusal and 34 % over 3 years. The baseline median social cohesion score was 24 (IQR 20-29, range 4-45). In the final confounding model, for every one-point increase in the social cohesion score, average odds of condom refusal decreased by 3 % (AOR 0.97; 95 % CI 0.95-0.99). Community empowerment can have a direct protective effect on HIV risk. These findings highlight the need for a legal framework that enables collectivization and SW-led efforts in the HIV response. [ABSTRACT FROM AUTHOR]

In light of limited data on structural determinants of access and retention in antiretroviral therapy (ART) among sex workers, we examined structural correlates of ART use among sex workers living with HIV over time. Longitudinal data were drawn from a cohort of 646 female sex workers in Vancouver, Canada (2010-2012) and linked pharmacy records on ART dispensation. We used logistic regression with generalized estimating equations (GEE) to examine correlates of gaps in ART use (i.e., treatment interruptions or delayed ART initiation), among HIV seropositive participants ( n = 74). Over a 2.5-year period, 37.8 % of participants experienced gaps in ART use (i.e., no ART dispensed in a 6-month period). In a multivariable GEE model, younger age, migration/mobility, incarceration, and non-injection drug use independently correlated with gaps in ART use. In spite of successes scaling-up ART in British Columbia, younger, mobile, or incarcerated sex workers face persistent gaps in access and retention irrespective of drug use. Community-based, tailored interventions to scale-up entry and retention in ART for sex workers should be further explored in this setting. [ABSTRACT FROM AUTHOR]

Objectives. We longitudinally examined the social, structural, and geographic correlates of cervical screening among sex workers in Metropolitan Vancouver, British Columbia, to determine the roles that physical and social geography play in routine reproductive health care access. Methods. Analysis drew on (2010-2013) data from an open prospective cohort of sex workers (An Evaluation of Sex Workers' Health Access). We used multivariable logistic regression with generalized estimating equations (GEE) to model correlates of regular cervical screening. Results. At baseline, 236 (38.6%) of 611 sex workers in our sample had received cervical screening, and 63 (10.3%) were HIV-seropositive. In multivariable GEE analysis, HIV-seropositivity (adjusted odds ratio [AOR] = 1.65; 95% confidence interval [CI] = 1.06, 2.58) and accessing outreach services (AOR = 1.35; 95% CI = 1.09, 1.66) were correlated with regular cervical screening. Experiencing barriers to health care access (e.g., poor treatment by health care staff, limited hours of operation, and language barriers) reduced odds of regular Papanicolaou testing (AOR = 0.81; 95% CI = 0.65, 1.00). Conclusions. Sex workers in Metropolitan Vancouver had suboptimal levels of cervical screening. Innovative mobile outreach service delivery models offering cervical screening as one component of sex worker--targeted comprehensive sexual and reproductive health services mayhold promise. [ABSTRACT FROM AUTHOR]

Background: Sex workers (SWs) experience a disproportionately high burden of HIV, with evidence indicating that complex and dynamic factors within work environments play a critical role in mitigating or producing HIV risks in sex work. In light of sweeping policy efforts to further criminalize sex work globally, coupled with emerging calls for structural responses situated in labour and human-rights frameworks, this meta-synthesis of the qualitative and ethnographic literature sought to examine SWs' narratives to elucidate the ways in which physical, social and policy features of diverse work environments influence SWs' agency to engage in HIV prevention.Methods: We conducted a meta-synthesis of qualitative and ethnographic studies published from 2008 to 2014 to elucidate SWs' narratives and lived experiences of the complex and nuanced ways in which physical, social, and policy features of indoor and outdoor work environments shape HIV prevention in the sex industry.Results: Twenty-four qualitative and/or ethnographic studies were included in this meta-synthesis. SWs' narratives revealed the nuanced ways that physical, social, and policy features of work environments shaped HIV risk and interacted with macrostructural constraints (e.g., criminalization, stigma) and community determinants (e.g., sex worker empowerment initiatives) to shape SWs' agency in negotiating condom use. SWs' narratives revealed the ways in which the existence of occupational health and safety standards in indoor establishments, as well as protective practices of third parties (e.g., condom promotion) and other SWs/peers were critical ways of enhancing safety and sexual risk negotiation within indoor work environments. Additionally, working in settings where negative interactions with law enforcement were minimized (e.g., working in decriminalized contexts or environments in which peers/managers successfully deterred unjust policing practices) was critical for supporting SWs' agency to negotiate HIV prevention.Conclusions: Policy reforms to remove punitive approaches to sex work, ensure supportive workplace standards and policies, and foster SWs' ability to work collectively are recommended to foster the realization of SWs' health and human rights across diverse settings. Future qualitative and mixed-methods research is recommended to ensure that HIV policies and programmes are grounded in SWs' voices and realities, particularly in more under-represented regions such as Eastern Europe and Sub-Saharan Africa. [ABSTRACT FROM AUTHOR]

Our study documents the correlates of barriers to pregnancy and mothering among sex workers in Vancouver, Canada. We used baseline data from An Evaluation of Sex Workers’ Health Access (AESHA), a prospective cohort of sex workers. Among the 399 sex workers who had ever been pregnant or had a child, 35% reported having ever experienced a barrier, with lower education, homelessness, and history of injecting drugs significantly correlated with pregnancy and mothering barriers. Our findings highlight a critical need for tailored and nonjudgmental services and supports, including improved programs to address intersecting aspects of poverty, health literacy, stigma, and substance use. [ABSTRACT FROM PUBLISHER]

Background This study aims to report on a newly developed Safer Indoor Work Environmental Scale that characterises the social, policy and physical features of indoor venues and social cohesion; and using this scale, longitudinally evaluate the association between these features on sex workers' (SWs') condom use for pregnancy prevention. Methods Drawing on a prospective open cohort of female SWs working in indoor venues, a newly developed Safer Indoor Work Environment Scale was used to build six multivariable models with generalised estimating equations (GEE), to determine the independent effects of social, policy and physical venue-based features and social cohesion on condom use. Results Of 588 indoor SWs, 63.6% used condoms for pregnancy prevention in the last month. In multivariable GEE analysis, the following venue-based features were significantly correlated with barrier contraceptive use for pregnancy prevention: managerial practices and venue safety policies (adjusted OR (AOR)=1.09; 95% CI 1.01 to 1.17), access to sexual and reproductive health services/supplies (AOR=1.10; 95% CI 1.00 to 1.20), access to drug harm reduction (AOR=1.13; 95% CI 1.01 to 1.28) and social cohesion among workers (AOR=1.05; 95% CI 1.03 to 1.07). Access to security features was marginally associated with condom use (AOR=1.13; 95% CI 0.99 to 1.29). Conclusions The findings of the current study highlight how work environment and social cohesion among SWs are related to improved condom use. Given global calls for the decriminalisation of sex work, and potential legislative reforms in Canada, this study points to the critical need for new institutional arrangements (eg, legal and regulatory frameworks; labour standards) to support safer sex workplaces. [ABSTRACT FROM AUTHOR]

Background: Using cross-sectional data from the Canadian Community Health Survey (2007-2008), this study aimed to examine the impact of community belonging on marijuana use among British Columbian youth aged 12-24. Methods: Bivariable and multivariable multinomial logistic regression was used to examine the association between self-perceived community belonging and youth marijuana use (i.e. never, tried once and more than once lifetime use), and stratified by high and low adult marijuana use regions to determine if the relationships varied by the extent of adult marijuana use in each region. Results: Of 2095 youth respondents, 21.8% had used marijuana at least once in the past year, with the majority (70.9%) reporting a strong sense of community belonging. Weak community belonging increased youth's odds of initiation [Adjusted odds ratio (AOR) = 1.74; 95% Confidence Interval (CI) 1.18-2.56] and odds of more-than-once lifetime use (AOR = 1.40; 95% CI 1.10-1.79), and these associations were increased in regions where adult marijuana use was high. Conclusion: These findings suggest an association between weak sense of community belonging and youth marijuana use, and that use in the general population may increase this relationship. There is a need to better understand how youth interpret 'community belonging', and further explore the relationship between marijuana availability and youth use. [ABSTRACT FROM AUTHOR]

Objective To better understand the prevalence and correlates of pregnancy intentions among female sex workers (FSWs). Design Cross-sectional analysis using data from an open prospective cohort of street and off-street FSWs in Vancouver, Canada, in partnership with local sex work and community agencies. Methods FSWs were recruited through outreach to street and off-street locations (e.g. massage parlours, micro-brothels) and completed interviewer-administered questionnaires and HIV/sexually transmitted infection testing. Bivariable and multivariable logistic regression was used to evaluate correlates of pregnancy intention, based on a 'yes' or 'no' response to the question "Are you planning on have any (any more) children in the future?". Results Of the 510 women, 394 (77.3%) reported prior pregnancy, with 140 (27.5%) of the entire sample reporting positive pregnancy intentions. Regarding ethnicity, 35.3% were Caucasian and 26.3% were Asian/visible minority, with no differences in pregnancy intention by ethnicity or HIV status; 38.4% reported Canadian Aboriginal ancestry. In our final multivariable model, servicing clients in formal indoor settings, inconsistent condom use by clients, younger age, and intimate partner violence (IPV) were associated with pregnancy intention. Conclusions FSWs may have pregnancy intention levels similar to that of women in other occupations. Policy changes are needed to improve FSWs' access to integrated HIV and reproductive health services and harm reduction services, particularly for FSWs experiencing IPV. [ABSTRACT FROM AUTHOR]

Background: There are an estimated 35 million unregistered children in Indonesia. To understand ways to best leverage existing health system-related resources and ensure greater protective measures for these vulnerable children, this study explores the predictive relationship between the utilization of perinatal health services and birth certificate ownership in two Indonesian provinces. Methods: This study employed a cross-sectional design with interviewer-administered household surveys to heads of households in West Nusa Tenggara and East Nusa Tenggara from May to July of 2013. The primary outcome of interest was birth certificate ownership among children under the age of 5 years old. Bivariate and multivariable regression analyses using Generalized Estimating Equations (GEE) considered a set of covariates that represented child and household socio-demographic characteristics along with health services utilization variables during pregnancy and post-pregnancy periods. Results: 389 heads of households were interviewed, yielding data on a sample of 451 children under the age of 5. Fewer than 28% of children in this sample possessed a birth certificate. Nearly 57% (n = 259) of children were delivered in a clinical facility, though only 36% (n = 93) of these were legally registered. Of children born in the home (n = 194), registration dropped to 16% (n = 31). Adjusted analyses accounting for socio-demographic factors suggest that children born in a clinic facility (AOR = 2.33, 95% CI: 1.27, 4.33), hospital (AOR = 2.38, 95% CI: 1.12, 5.09), or in the presence of a skilled birth attendant (AOR = 2.35, 95% CI: 1.31, 4.23) were significantly more likely to be registered. Children whose mothers sought post-natal care were 2.99 times more likely to possess a birth certificate (AOR = 2.99, 95% CI: 1.1, 7.57). Pre-natal care was not associated with birth registration. Conclusion: These findings suggest that use of perinatal health services increases the likelihood of registering a child's birth despite a lack of formal integration of vital registration with the health sector. Formally leveraging existing community-based health workers and perinatal services may serve to further increase registration rates in hard to reach areas of Indonesia. [ABSTRACT FROM AUTHOR]

Background An estimated 230 million children remain unregistered and invisible worldwide. To understand ways to best leverage existing health system-related resources and ensure greater protective measures for Indonesia's vulnerable children, this study explores the predictive relationship between the utilization of perinatal health services and birth certificate ownership in two provinces, offering opportunities and suggestions for ways forward to increase registration coverage. Methods This study employed a cross-sectional design with interviewer-administered household surveys to heads of households in West Nusa Tenggara (NTB) and East Nusa Tenggara (NTT) from May to July of 2013. The primary outcome of interest was birth certificate ownership among children under the age of 5 years old. Bivariate and multivariable regression analyses using Generalize Estimating Equations (GEE) considered a set of covariates that represented child and household socio-demographic characteristics along with health services utilization variables during pregnancy and post-pregnancy periods. Results In total, 389 heads of households were interviewed, yielding data on a sample of 451 children under the age of 5. Fewer than than 28% of the children in this sample possessed a birth certificate. Nearly 57% (n = 259) of children were delivered in a clinical facility, though only 36% (n = 93) of these children were legally registered. Of those born in the home (n = 194), registration dropped to 16% (n = 31). Adjusted analyses accounting for socio-demographic factors suggest that children born in a clinic facility (AOR = 2.33, 95% CI: 1.27, 4.33), hospital (AOR = 2.38, 95% CI: 1.12, 5.09), or in the presence of a skilled birth attendant (AOR = 2.35, 95% CI: 1.31, 4.23) were significantly more likely to be registered. Children whose mothers sought post-natal care were 2.99 times more likely to possess a birth certificate (AOR = 2.99, 95% CI: 1.1, 7.57). Pre-natal care was not associated with birth registration. Conclusion These findings suggest that the use of perinatal health services can increase the likelihood of registering a child's birth despite a lack of formal integration of vital registration with the health sector. Opportunities to formally leverage existing community-based perinatal services and health workers already serving the community may serve to increase registration rates in hard to reach areas of Indonesia. [ABSTRACT FROM AUTHOR]

Despite increasing evidence of enhanced HIV risk among sexual minority populations, and sex workers (SWs) in particular, there remains a paucity of epidemiological data on the risk environments of SWs who identify as lesbian or bisexual. Therefore, this short report describes a study that examined the individual, interpersonal and structural associations with lesbian or bisexual identity among SWs in Vancouver, Canada. Analysis drew on data from an open prospective cohort of street and hidden off-street SWs in Vancouver. Bivariate and multivariable logistic regressions were used to examine the independent relationships between individual, interpersonal, work environment and structural factors and lesbian or bisexual identity. Of the 510 individuals in our sample, 95 (18.6%) identified as lesbian or bisexual. In multivariable analysis, reporting non-injection drug use in the last six months (adjusted odds ratio [AOR] = 2.89; 95% confidence intervals [CI] = 1.42, 5.75), youth ≤24 years of age (AOR = 2.43; 95% CI = 1.24, 4.73) and experiencing client-perpetrated verbal, physical and/or sexual violence in the last six months (AOR = 1.85; 95% CI = 1.15, 2.98) remained independently associated with lesbian/bisexual identity, after adjusting for potential confounders. The findings demonstrate an urgent need for evidence-based social and structural HIV prevention interventions. In particular, policies and programmes tailored to lesbian and bisexual youth and women working in sex work, including those that prevent violence and address issues of non-injection stimulant use are required. [ABSTRACT FROM PUBLISHER]

Objectives: We examined sexual decision making type among couples in HIV sero-discordant partnerships in Uganda, and investigated how sexual decision making type changed over time and its effect on condom use. Methods: Data were drawn from a longitudinal cohort of HIV sero-discordant couples, recruited through the AIDS Support Organisation in Jinja, Uganda. Sexual decision making was measured using the Sexual Relationship Power Scale, and couples' individual self-report answers were matched to assess agreement for decision making type and condom use. Generalised linear mixed effects modelling was used to assess statistically significant differences in time trend of sexual decision making type, and to investigate the independent association of decision making type on condom use status over time. Results: Of the 533 couples included in this analysis, 345 (65%) reported using condoms at last sex at study enrolment. In the time trend analysis of decision making, the proportion of couples who decided together increased over time while the proportions of couples who reported that one partner decided or no one decided/did not use condoms, decreased over time (overall p<0.001). Compared with couples who decided together, those who disagreed (adjusted OR=0.42, 95% CI 0.28 to 0.64) and those where one partner decided (adjusted OR=0.20, 95% CI 0.12 to 0.34) had significantly lower odds of condom use at last sex, even after controlling for confounders. Conclusions: Couples who disagreed on decision making, or agreed that one partner decides alone, had significantly lower odds of reporting condom use compared with couples who decided together. HIV counselling interventions that encourage joint sexual decision making may improve condom use within this population. [ABSTRACT FROM AUTHOR]

Objectives: Intimate partner violence (IPV) is associated with increased risk of HIV among women globally. There is limited evidence and understanding about IPV and potential HIV risk pathways among sex workers (SWs). This study aims to longitudinally evaluate prevalence and correlates of IPV among street and off-street SWs over two-years follow-up. Methods: Longitudinal data were drawn from an open prospective cohort, AESHA (An Evaluation of Sex Workers Health Access) in Metro Vancouver, Canada (2010–2012). Prevalence of physical and sexual IPV was measured using the WHO standardized IPV scale (version 9.9). Bivariate and multivariable logistic regression using Generalized Estimating Equations (GEE) were used to examine interpersonal and structural correlates of IPV over two years. Results: At baseline, 387 SWs had a male, intimate sexual partner and were eligible for this analysis. One-fifth (n = 83, 21.5%) experienced recent physical/sexual IPV at baseline and 26.2% over two-years follow-up. In multivariable GEE analysis, factors independently correlated with physical/sexual IPV in the last six months include: childhood (<18 years) sexual/physical abuse (adjusted odds ratio [AOR] = 2.05, 95% confidence interval [CI]: 1.14–3.69), inconsistent condom use for vaginal and/or anal sex with intimate partner (AOR = 1.84, 95% CI: 1.07–3.16),

Objectives: The number of children in care of the state continues to grow in BC, Canada with a historical legacy of child apprehension among criminalized and marginalized populations, particularly women of Aboriginal ancestry and sex workers. However, there is a paucity of research investigating child apprehension experiences among marginalized mothers. The objective of the current analysis is to examine the prevalence and correlates of child apprehensions among female sex workers in Vancouver, Canada. Methods: Analyses were drawn from the AESHA (An Evaluation of Sex Workers Health Access, 2010-present), a prospective cohort of street and off-street SWs, through outreach and semi-annual visits to the research office. Bivariate and multivariate logistic regression were used to examine correlates of child apprehension. Results: Of a total of 510 SWs, 350 women who had given birth to at least one child were included in the analyses (median age = 37 yrs: IQR: 31–44 yrs). The prevalence of child apprehension among mothers was 38.3%, with 37.4% reporting having been apprehended themselves by child welfare services. In multivariable analysis, servicing clients in outdoor public spaces (versus formal sex work establishments or informal indoor settings) (adjusted odds ratio, (aOR) = 2.73; 95%CI 1.27–5.90), history of injecting drugs (aOR = 2.53; 95%CI 1.42–4.49), Aboriginal ancestry (aOR = 1.66; 95%CI 1.01–2.74) were associated with increased odds of child apprehension. Discussion/Conclusions: Child apprehension rates are high, particularly among the most marginalized sex workers, including sex workers who use drugs and sex workers of Aboriginal ancestry. Structural reforms to child protection are urgently needed, that support family-based care address the historical legacy of colonization affecting Aboriginal peoples. [ABSTRACT FROM AUTHOR]

We conducted a systematic review in June 2012 (updated September 2013) to examine the prevalence and factors shaping sexual or physical violence against sex workers globally. We identified 1536 (update = 340) unique articles. We included 28 studies, with 14 more contributing to violence prevalence estimates. Lifetime prevalence of any or combined workplace violence ranged from 45% to 75% and over the past year, 32%to55%.Growing research links contextual factors with violence against sex workers, alongside known interpersonal and individual risks. This high burden of violence against sex workers globally and large gaps in epidemiological data support the need for research and structural interventions to better document and respond to the contextual factors shaping this violence. Measurement and methodological innovation, in partnership with sex work communities, are critical. [ABSTRACT FROM AUTHOR]

Background While crack cocaine has been associated with elevated sexual risks and transmission of HIV/STIs, particularly in the context of street-based sex work, few empirical studies have examined correlates of direct sex-for-crack exchanges. This study longitudinally examined the correlates of sex-for-crack exchanges and associated effects on sexual risk outcomes among street-based female sex workers (SW) who use drugs in Vancouver, Canada. Methods Data were drawn from a prospective cohort of street-based SWs (2006-2008), restricted to those who smoke crack cocaine. Multivariable generalized estimating equations (GEE) were employed to examine the correlates of exchanging sex for crack. A confounding model using GEE quasi-Poisson regression modeled the independent effect of exchanging sex for crack on number of clients/ week. Results Of 206 SWs, 101 (49%) reported sex-for-crack exchanges over 18 months of follow-up. In multivariable GEE analyses, sharing a crack pipe with a client (aOR = 1.98; 95%CI: 1.27- 3.08) and smoking crack in a group of strangers (e.g., in an alley or crackhouse) (aOR = 1.70; 95%CI: 1.13-2.58) were independently correlated with sex-for-crack exchanges. In our confounding model, exchanging sex for crack (aIRR = 1.34; 95%CI: 1.07-1.69) remained significantly associated with servicing a greater number (>10) of clients/week. Conclusions These findings reveal elevated sexual- and drug- risk patterns among those who exchange sex for crack. The physical and social environment featured prominently in our results as a driver of sex-for-crack exchanges, highlighting the need for gender-sensitive multilevel approaches to harm reduction, STI and HIV prevention that address SWs' environment, individual level factors, and the interplay between them. [ABSTRACT FROM AUTHOR]

Purpose: Studies suggest that people who are food insecure are more likely to experience mental illness. However, little is known about which aspects of food insecurity place individuals most at risk of mental illness. The purpose of this study was to establish the prevalence of mental illness among food insecure Canadians, and examine whether mental illness differs between those who are consuming insufficient amounts of food versus poor quality foods. Methods: This analysis utilized the publically available dataset from the Canadian Community Health Survey cycle 4.1. Bivariable and multivariable logistic regression were used to examine the associations between food insecurity and mental health disorder diagnosis, while adjusting for potential confounders. Stratified analyses were used to identify vulnerable sub-groups. Results: Among 5,588 Canadian adults (18-64 years) reporting food insecurity, 58 % reported poor food quality and 42 % reported food insufficiency. The prevalence of mental health diagnosis was 24 % among participants with poor food quality, and 35 % among individuals who were food insufficient (hunger). After adjusting for confounders, adults experiencing food insufficiency had 1.69 adjusted-odds [95 % confidence interval (CI): 1.49-1.91] of having a mental health diagnosis. Stratified analyses revealed increased odds among women (a-OR 1.89, 95 % CI 1.62-2.20), single parent households (a-OR 2.05, 95 % CI 1.51-2.78), and non-immigrants (a-OR 1.88, 95 % CI 1.64-2.16). Conclusion: The prevalence of mental illness is alarmingly high in this population-based sample of food insecure Canadians. These findings suggest that government and community-based programming aimed at strengthening food security should integrate supports for mental illness in this population. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to describe the perceptions of married men about barriers to accessing and accepting highly active antiretroviral therapy (HAART) by pregnant/ postnatal women positive for human immunodeficiency virus (HIV) and registered in Kabarole District's Program for the Prevention of HIV from Mother to Child (PMTCT-Plus). Materials and methods: Our study was a qualitative descriptive exploratory study using thematic analysis. Four focus group discussions were held with a convenience sample of 40 married men. Results: Lack of disclosure of a positive HIV diagnosis to the partner and stigmatization of persons with HIV were two major obstacles for women in accessing HAART. In addition, men felt that their low knowledge of HAART and their low HIV testing rate also constituted important barriers to these women taking treatment. Men complained that they were not sufficiently involved in the reproductive care of women and that couples' counseling could be a step towards addressing this problem. Conclusion: Barriers to HAART experienced by pregnant/postnatal women need to be addressed in order to improve their uptake of treatment, increase their low treatment coverage, improve their survival, and at the same time dramatically reduce HIV transmission from mother to child. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to describe barriers to accessing and accepting highly active antiretroviral therapy (HAART) by HIV-positive mothers in the Ugandan Kabarole District's Programme for the Prevention of Mother to Child Transmission-Plus (PMTCT-Plus). Methods: Our study was a qualitative descriptive exploratory study using thematic analysis. Individual in-depth interviews (n = 45) were conducted with randomly selected HIV-positive mothers who attended this programme, and who: (a) never enrolled in HAART (n = 17); (b) enrolled but did not come back to receive HAART (n = 2); (c) defaulted/interrupted HAART (n = 14); and (d) are currently adhering to HAART (n = 12). A focus group was also conducted to verify the results from the interviews. Results: Results indicated that economic concerns, particularly transport costs from residences to the clinics, represented the greatest barrier to accessing treatment. In addition, HIV-related stigma and non-disclosure of HIV status to clients' sexual partners, long waiting times at the clinic and suboptimal provider-patient interactions at the hospital emerged as significant barriers. Conclusions: These barriers to antiretroviral treatment of pregnant and post-natal women need to be addressed in order to improve HAART uptake and adherence for this group of the population. This would improve their survival and, at the same time, drastically reduce HIV transmission from mother to child. [ABSTRACT FROM AUTHOR]

Background: While HIV and unintended pregnancies are both occupational risks faced by female sex workers, the epidemiology of pregnancy and its drivers in this population remains understudied. This includes Cambodia, where the drivers of pregnancy among female entertainment and sex workers (FESW) remain unknown. The current study aimed to examine factors associated with incident pregnancy, as well as describe contraceptive use among FESW in Phnom Penh, Cambodia.Methods: This analysis drew from the Young Women's Health Study (YWHS)-2, a 12-month observational cohort of 220 FESW aged 15-29 years, conducted between August 2009 and August 2010. Interviewer-administered questionnaires were conducted at baseline and quarterly thereafter, alongside HIV and pregnancy testing. Bivariate and multivariable extended Cox regression analysis was used to examine correlates of incident pregnancy.Results: At baseline, 6.8% of participants were pregnant, and only 10.8% reported using hormonal contraceptives, with 11.3% reporting an abortion in the past 3 months. Pregnancy incidence was high, at 22/100 person-years (95% CI: 16.3-30.1). In multivariable analysis, younger age (19-24 years versus 25-29 years) (Adjusted Hazards Ratio (AHR): 2.28; 95% Confidence Interval (CI) 1.22-4.27), lower income (400,000-600,000 Riel (≤150$USD) versus > 600,000 Riel (> 150$USD)) (AHR 2.63; 95% CI 1.02-6.77) positively predicted pregnancy, while higher self-reported condom self-efficacy were associated with reduced pregnancy incidence (AHR 0.89; 95% CI 0.81-0.98).Conclusions: Results document high incidence of pregnancy and unmet reproductive health needs among FESWs in Cambodia. Findings point to an urgent need for multi-level interventions, including venue-based HIV/STI and violence prevention interventions, in the context of legal and policy reform. High pregnancy incidence in this population may also undermine recruitment and retention into HIV prevention intervention trials. The exploration of innovative and comprehensive sex worker-tailored sexual and reproductive health service models, also as part of HIV prevention intervention trials, is warranted. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to describe levels of pregnancy and contraceptive usage among a cohort of street-based female sex workers (FSWs) in Vancouver.Methods: The study sample was obtained from a community-based prospective cohort study (2006-2008) of 211 women in street-based sex work who use drugs, 176 of whom had reported at least one prior pregnancy. Descriptive statistics were used to estimate lifetime pregnancy prevalence, pregnancy outcomes (miscarriage, abortion, adoption, child apprehension, child custody), and contraceptive usage. In secondary analyses, associations between contraceptive usage, individual and interpersonal risk factors and high number of lifetime pregnancies (defined as greater than the sample mean of 4) were examined.Results: Among our sample, 84% reported a prior pregnancy, with a mean of 4 lifetime pregnancies (median = 3; IQR: 2-5). The median age of women reporting 5+ pregnancies was 38 years old [interquartile range (IQR): 25.0-39.0] compared to 34 years [IQR: 25.0-39.0] among women reporting 4 or fewer prior pregnancies. 45% were Caucasian and 47% were of Aboriginal ancestry. We observed high rates of previous abortion (median = 1;IQR:1-3), apprehension (median = 2; IQR:1-4) and adoption (median = 1; IQR:1-2) among FSWs who reported prior pregnancy. The use of hormonal and insertive contraceptives was limited. In bivariate analysis, tubal ligation (OR = 2.49; [95%CI = 1.14-5.45]), and permanent contraceptives (e.g., tubal ligation and hysterectomy) (OR = 2.76; [95%CI = 1.36-5.59]) were both significantly associated with having five or more pregnancies.Conclusion: These findings demonstrate high levels of unwanted pregnancy in the context of low utilization of effective contraceptives and suggest a need to improve the accessibility and utilization of reproductive health services, including family planning, which are appropriately targeted and tailored for FSWs in Vancouver. [ABSTRACT FROM AUTHOR]