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Objective: To estimate the prevalence of the curable sexually transmitted infections (STIs) Chlamydia trachomatis , Neisseria gonorrhoeae , Mycoplasma genitalium , Trichomonas vaginalis and Treponema pallidum , to identify associated risk factors and to assess ciprofloxacin resistance in N. gonorrhoeae -positive specimens among female sex workers (FSWs) in Guinea-Bissau., Methods: For this cross-sectional study, FSWs were recruited from October 2014 to May 2019. A questionnaire on STI risk factors was completed by the study participants, and the women were asked to provide a vaginal swab for nucleic acid amplification tests for C. trachomatis , N. gonorrhoeae , M. genitalium , T. vaginalis (Aptima, Hologica), as well as a blood sample for T. pallidum serological testing and discriminatory HIV-testing. The prevalence of STIs was determined, and multivariate logistic regression was used to identify STI risk factors., Results: The study included 467 women. The prevalence of current infection with any curable STI was 46.7%, and the most common pathogen was T. vaginalis (26.3%), followed by M. genitalium (21.9%), C. trachomatis (11.8%), N. gonorrhoeae (10.1%) and T. pallidum (2.8%). The proportion of asymptomatic infections among the diagnosed STIs was 61.8%, 61.5%, 55.3%, 55.3% and 52.2% for C. trachomatis, T. pallidum, N. gonorrhoeae, T. vaginalis and M. genitalium, respectively . The prevalence of the gyrA S91F mutation conferring ciprofloxacin resistance in N. gonorrhoeae -positive specimens was 84.0%. Significant risk factors for having a curable STI were age and HIV-1 infection, while use of female condoms was a protective factor., Conclusion: This study demonstrated that the prevalence of curable STIs was high among FSWs in Guinea-Bissau during the study period, indicating an unmet need for STI services. Moreover, the results indicated that symptomatic treatment might be insufficient, highlighting a need for periodic aetiological testing to facilitate detection of asymptomatic as well as symptomatic STIs to stop ongoing transmission., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Approximately half of Japanese men aged 20-49 years have purchased sexual services, but data concerning the use of commercial sex work (CSW) in Japan remain scarce., Methods: We used online survey data from the National Inventory of Japanese Sexual Behavior conducted in 2022 (N=4000 Japanese men aged 20-49 years). We calculated the median number of paid sexual partners over the lifetime. We performed logistic regression analysis to determine the sociodemographic, anthropometric and attitudinal factors associated with any lifetime CSW use among men in Japan., Results: The median number of paid sexual partners reported among men who had ever used CSW was 6 (IQR 3-17) across the lifetime; the corresponding value for those who had ever used CSW in the past year was 2 (IQR 1-4) over the last 12 months. In general, those reporting lifetime use of CSW were significantly more likely than their CSW-naïve counterparts to be older, be married, be heterosexual or bisexual, have higher income and have higher education. Those reporting higher self-rated attractiveness, high or low satisfaction with their sex lives, a desire to increase their frequency of sex and considering sex to be an important aspect of their lives were also found to have a higher likelihood of having used CSW., Conclusions: High rates of CSW use in Japan likely reflect ease of access, low stigma with respect to use of sexual services and the diversity in the type of services offered. High-income, employed older men have more financial resources at their disposal to purchase services, which can be cost-prohibitive for part-time or unemployed young men with low incomes. These findings will serve as a launchpad for public health efforts directed at promoting safe sexual practices and improved sexually transmitted infection screening rates among users of CSW in Japan., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The burden of HIV and other sexually transmitted infections (STIs) remains high in sex workers globally, calling for strengthening targeted prevention strategies, including HIV pre-exposure prophylaxis (PrEP). The study's objective was to assess HIV and STI burden among female, male and transgender sex workers in Flanders, Belgium, to guide targeting of PrEP strategies for sex workers., Methods: We conducted a retrospective analysis of routine data collected between January 2016 and December 2019 by community-based organisations providing sexual healthcare services for sex workers in Flanders. HIV prevalence stratified by gender was assessed and associations with sociodemographic characteristics were explored using bivariable and multivariable logistic regression. Positivity rates of chlamydia, gonorrhoea and syphilis tests were used as proxy indicators for STI burden., Results: The study included a total of 6028 sex workers, comprising 5617 (93.2%) female, 218 (3.6%) male and 193 (3.2%) transgender sex workers. The HIV prevalence was 0.3% among female, 8.9% among male and 12.3% among transgender sex workers. Engaging in escort sex work and originating from South America or Sub-Saharan Africa were associated with a higher likelihood of having acquired HIV. The positivity rate for gonorrhoea was higher among male sex workers (5.2% vs 2.2%) and syphilis was more frequently detected among male and transgender sex workers (3.0% and 6.1% vs 0.5%), all compared with female sex workers., Conclusions: HIV combination prevention, including improved access to PrEP, should be strengthened among sex workers in Flanders, with particular attention to male and transgender sex workers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Despite a growing HIV threat, there is no definition and characterisation of key populations (KPs), who could be the major drivers of the epidemic in Turkey. We used programmatic mapping to identify locations where KPs congregate, estimate their numbers and understand their operational dynamics to develop appropriate HIV programme implementation strategies., Methods: Female and transgender sex workers (FSWs and TGSWs), and men who have sex with men (MSM) were studied in İstanbul and Ankara. Within each district, hot spots were identified by interviewing key informants and a crude spot list in each district was developed. The spot validation process was led by KP members who facilitated spot access and interviews of KPs associated with that spot. Final estimates were derived by aggregating the estimated number of KPs at all spots, which was adjusted for the proportion of KPs who visit multiple spots, and for the proportion of KPs who do not visit spots., Results: FSWs were the largest KP identified in İstanbul with an estimate of 30 447 (5.8/1000 women), followed by 15 780 TGSWs (2.9/1000 men) and 11 656 MSM (2.1/1000). The corresponding numbers in Ankara were 9945 FSWs (5.2/1000 women), 1770 TGSWs (1/1000 men) and 5018 MSM (2.5/1000 men). Each KP had unique typologies based on the way they find and interact with sex partners. MSM were mostly hidden and a higher proportion operated through internet and phone-based applications. Night time was the peak time with Friday, Saturday and Sunday being the peak days of activity in both İstanbul and Ankara., Conclusions: This study has highlighted the presence of a substantial number of FSWs, TGSW and MSM in İstanbul and Ankara. The information obtained from this study can be used to set priorities for resource allocation and provide HIV prevention services where coverage could be the highest., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To characterise epidemiology of herpes simplex virus type 2 (HSV-2) in Latin America and the Caribbean., Methods: HSV-2 reports were systematically reviewed and synthesised, and findings were reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Meta-analyses and metaregressions were conducted., Finding: 102 relevant reports were identified including 13 overall incidence measures, 163 overall (and 402 stratified) seroprevalence measures, and 7 and 10 proportions of virus detection in genital ulcer disease and in genital herpes, respectively. Pooled mean seroprevalence was 20.6% (95% CI 18.7% to 22.5%) in general populations, 33.3% (95% CI 26.0% to 41.0%) in intermediate-risk populations, 74.8% (95% CI 70.6% to 78.8%) in female sex workers, and 54.6% (95% CI 47.4% to 61.7%) in male sex workers, men who have sex with men and transgender people. In general populations, seroprevalence increased from 9.6% (95% CI 7.1% to 12.4%) in those aged <20 years to 17.9% (95% CI 13.6% to 22.5%) in those aged 20-30, 27.6% (95% CI 21.4% to 34.2%) in those aged 30-40 and 38.4% (95% CI 32.8% to 44.2%) in those aged >40. Compared with women, men had lower seroprevalence with an adjusted risk ratio (ARR) of 0.68 (95% CI 0.60 to 0.76). Seroprevalence declined by 2% per year over the last three decades (ARR of 0.98, 95% CI 0.97 to 0.99). Pooled mean proportions of HSV-2 detection in GUD and genital herpes were 41.4% (95% CI 18.9% to 67.0%) and 91.1% (95% CI 82.7% to 97.2%), respectively., Conclusions: One in five adults is HSV-2 infected, a higher level than other world regions, but seroprevalence is declining. Despite this decline, HSV-2 persists as the aetiological cause of nearly half of GUD cases and almost all of genital herpes cases., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Female sex workers (FSWs) are vulnerable to human alphaherpesvirus 2 (HSV-2) infection due to their high numbers of sexual partners. The objective of this study was to evaluate the seroprevalence and risk behaviours associated with HSV-2., Methods: A cross-sectional study was conducted in Mato Grosso do Sul, Brazil. A total of 376 FSWs were recruited by respondent-driven sampling (RDS) methodology and answered an epidemiological questionnaire. Blood samples were collected to test for HSV-2 antibodies using commercial ELISA and for HSV-2 DNA using real-time PCR., Results: The seropositivity was 47.3% (178/376) for HSV-2 IgG and 10.1% (38/376) for HSV-2 IgM. HSV-2 viraemia was detected in two infected FSWs with primary infections. In bivariate and multivariate analyses, the OR for HSV-2 IgG increased with age (OR=2.53-7.90, OR=2.66-6.37) and the number of sexual partners (OR=2.30-3.25). On the other hand, daily alcohol consumption (OR=0.10) and the use of condoms during the last intercourse (OR=0.47) were protective factors against HSV-2 acquisition., Conclusion: Despite the impact of FSWs in public health policies with the dissemination of sexually transmitted infections, there have been few studies performed regarding the prevalence of HSV-2 in Brazil, making it difficult to implement any control or preventative measures. The results produced here using an RDS methodology demonstrated a high prevalence, risk behaviours and primary infection among the FSWs. These results reinforce the need to implement control and preventative measures for HSV-2 infection in this population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: We examined data collected as part of the fifth round of integrated biological and behavioural surveillance to determine the prevalence and factors associated with HIV infection among female sex workers (FSWs) in Pakistan., Methods: FSWs were defined as 'all females, age 13 years and above, who receive money or goods in exchange for sexual services, regardless of the site of operation'. Data were collected between October 2016 and January 2017 in 18 cities using multistage sampling techniques to randomly select FSWs from spots facilitated by peers. Behavioural data were collected by interviewers using structured questionnaires, which was followed by obtaining finger prick blood samples tested for HIV using two rapid tests. Multivariate logistic regression analysis was done to assess independent associations of potential correlates using HIV status as dependent variable., Results: We invited 5728 FSWs to participate, of which 68 refused to participate (refusal rate=1.2%). Of the 5660 FSWs who participated, 121 were HIV seropositive (weighted HIV prevalence 2.3%; 95% CI 1.9% to 2.7%) mostly concentrated within cities in Sindh. Multivariate analysis showed being uneducated/illiterate (adjusted OR (aOR) 2.1; 95% CI 1.4 to 3.4), directly dealing with clients without a pimp (aOR 1.8; 95% CI 1.1 to 2.8), non-use of condom with clients (aOR 1.8; 95% CI 1.1 to 2.8), having sexual contact with people who inject drugs (PWID) (aOR 2.2; 95% CI 1.3 to 3.7) and non-participation in HIV programmes (aOR 1.7; 95% CI 1.0 to 3.1) as factors independently associated with HIV seropositivity., Conclusions: We found a weighted national HIV prevalence of 2.3% and identified factors independently associated with HIV in FSWs. The country needs to scale up HIV prevention programmes to improve coverage, prioritising FSWs who are illiterate, work independently and have PWID as sex partners. Emphasis should be laid on strategies to improve condom use with both regular and non-regular partners., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Though highly vulnerable to HIV and STIs, transgender female sex workers (TFSWs) are understudied in the US HIV and STI response. This study examined the correlates of laboratory-confirmed STIs among a cohort of 62 TFSWs followed over the course of 1 year and explored associations between specimen site and self-reported engagement in insertive and receptive anal intercourse., Methods: Participants completed an interviewer-administered computer-assisted personal interview at baseline, 3-, 6-, 9- and 12-month visits where self-administered anal swabs and urine samples for gonorrhea, chlamydia and trichomoniasis were also collected. HIV testing was conducted at baseline, 6-month and 12-month visits., Results: Baseline HIV prevalence was 40.3% with no HIV seroconversions over follow-up. Baseline prevalence of gonorrhea, chlamydia and trichomoniasis was 9.7%, 17.7% and 14.5%, respectively. In the multivariable regression modelling, recent arrest was significantly associated with testing positive for any STI (adjusted risk ratio (RR) 1.77; 95% CI: 1.10 to 2.84). Insertive anal sex with clients was associated with increased risk of testing positive for an STI via urine specimen (RR 3.48; 95% CI: 1.14 to 10.62), while receptive anal sex was not significantly associated with specimen site., Conclusion: Our findings confirm a high prevalence of STIs among TFSWs and highlight the importance of addressing structural drivers such as criminal justice involvement as well as the need to ensure screening for STIs at all anatomical sites regardless of self-reported sites of potential exposure. More research is needed to better understand HIV and STI vulnerabilities and appropriate interventions for TFSWs in the USA., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Recommendations of 'social distancing' and home quarantines to combat the global COVID-19 pandemic have implications for sex and intimacy, including sex work. This study examined the effects of COVID-19 on male sex work globally and investigated how men who sold sex responded to and engaged with the virus in the context of work., Methods: This study made use of an existing database of deidentified data extracted from the online profiles maintained by male sex workers on a large, international website. Website engagement metrics were calculated for the periods before (September to December 2019) and during COVID-19 (January to May 2020); Poisson regression analyses were used to assess changes over time before and after, while a content analysis was undertaken to identify modes of engagement with the virus., Results: Data were collected from 78 399 profiles representing 19 388 individuals. In the 'before' period, the number of active profiles was stable (inter-rate ratio (IRR)=1.01, 95% CI 0.99 to 1.01, p=0.339) but during COVID-19 decreased by 26.3% (IRR=0.90, 95% CI 0.89 to 0.91, p<0.001). Newly created profiles also decreased during COVID-19 (59.4%; IRR=0.71, 95% CI 0.69 to 0.74, p<0.001) after a period of stability. In total, 211 unique profiles explicitly referenced COVID-19; 185 (85.8%) evoked risk reduction strategies, including discontinuation of in-person services (41.2%), pivoting to virtual services (38.9%), COVID-19 status disclosure (20.9%), enhanced sanitary and screening requirements (12.3%) and restricted travel (5.2%). Some profiles, however, seemed to downplay the seriousness of COVID-19 or resist protective measures (14.7%)., Conclusions: These findings support the contention that COVID-19 has dramatically impacted the sex industry; globally, male sex workers may be facing considerable economic strain. Targeted education and outreach are needed to support male sex workers grappling with COVID-19, including around the most effective risk reduction strategies. Those involved with the sex industry must have access to state-sponsored COVID-19 financial and other aid programmes to support individual and public health., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

To estimate the prevalence and factors associated with HIV and five other STIs among outdoor female sex workers (OSFW) and indoor FSW (IFSW)., Methods: Cross-sectional survey using respondent-driven sampling methodology. Participants answered a bio-behavioural questionnaire and were tested for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), Trichomonas vaginalis (TV), syphilis (lifetime contact) and Mycoplasma genitalium (MG). Weighted HIV and other STIs prevalence and 95% CIs were calculated. Weighted multivariate logistic regression was performed to identify factors associated with having at least one STI (including HIV)., Results: Between October 2017 and July 2018, 385 FSW participants were recruited, among whom 206 (53.5%) were IFSW and 179 (46.5%) were OFSW. The mean age was 31.4 years. Weighted HIV prevalence was 3.1% (95% CI 1.5 to 7.0). Weighted prevalence of other STIs was: 4.1% (95% CI 2.2 to 8.0) for NG, 8.8% (95% CI 5.9 to 13.0) for CT, 12.7% (95% CI 8.6 to 18.0) for TV, 13.9% (95% CI 9.9 to 19.0) for syphilis (lifetime contact) and 14.9% (95% CI 10.5 to 21.0) for MG. STI prevalence was significantly higher among OFSW for CT, TV and MG (p<0.001). In total, 43.2% of the participants had at least one HIV/STI. Factors associated with having HIV/STI were being an OFSW (OR 3.29; 95% CI 1.72 to 6.27); being registered in another Russian region (2.61 (95% CI 1.05 to 6.48)); having never been tested for HIV (2.51 (95% CI 0.98 to 6.41)) and having a low level of knowledge regarding HIV transmission (4.88 (95% CI 0.96 to 24.78))., Conclusion: Prevalence of HIV and STIs was high among FSW in Moscow. OFSW were more vulnerable to STIs. There is an urgent need to tailor programmes for sexual and reproductive health for FSW in Russia., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Transgender people are disproportionately affected by the HIV-1 epidemic. We evaluated the origin of HIV-1 variants carried by South American transgenders living in Milan by combining accurate phylogenetic methods and epidemiological data., Methods: We collected 156 HIV-1 pol sequences obtained from transgender patients engaged in sex work (TSWs) followed between 1999 and 2015 at L. Sacco Hospital, Milan, Italy. Phylogenetic analyses were conducted by HIV-TRACE, MrBayes, MacClade and Beast programs. Reference sequences were retrieved from Los Alamos and local databases. Last negative testing or proxy data from clinical records of infected individuals were used to investigate the country of infection., Results: Among South American TSWs, the most represented HIV-1 subtypes were B (70.5%), F1 (12.8%) and C (4.4%). Gene flow migrations of B subtype indicated significant fluxes from TSWs to Italians (21.3%) belonging to all risk groups (26.4% to heterosexuals (HEs), 18.9% to men who have sex with men (MSM), 15.1% to injecting drug users). The largest proportion of bidirectional fluxes were observed between Italians and TSWs (24.6%). For F1 subtype, bidirectional viral fluxes involved TSWs and Italians (7.1% and 14.3%), and a similar proportion of fluxes linked TSWs and Italian HEs or MSM (both 15.8%). Significant fluxes were detected from Italians to TSWs for subtype C involving both MSM (30%) and HEs (40%). Country of HIV-1 acquisition was identified for 72 subjects; overall, the largest proportion of patients with B subtype (73.5%) acquired HIV-1 infection in South America., Conclusions: Our results indicated that South American transgenders largely contribute to the heterogeneity of HIV-1 variants in our country. The high number of clusters based on all subtypes indicated numerous transmission chains in which TSWs were constantly intermixed with HEs and MSM. Our results strongly advocate interventions to facilitate prevention, diagnosis and HIV-1 care continuum among transgender people., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To characterise the Joint United Nations Programme on HIV/AIDS 90-90-90 cascade among female sex workers (FSW) and men who have sex with men (MSM)/transgender women (TGW) in Port Moresby, Papua New Guinea (PNG)., Methods: We conducted respondent-driven sampling surveys among FSW and MSM/TGW in Port Moresby, PNG from June to October 2016. All participants spoke English or Tok Pisin and were aged >12 years. FSW had to be born female and sell/exchange sex with a male in the past 6 months. MSM/TGW had to be born male and have oral/anal sex with another male-born person in the past 6 months. Participants were interviewed and offered rapid HIV diagnostic and viral load testing. HIV viral suppression (VS) was defined as <1000 copies/mL., Results: We recruited 674 FSW and 400 MSM/TGW; HIV prevalence was 15.2% (95% CI 11.7 to 18.8) and 8.5% (95% CI 5.0 to 11.9), respectively. Among FSW living with HIV, 39.0% (95% CI 26.6 to 51.4) self-reported having been diagnosed; of them 79.6% (95% CI 62.7 to 96.5) self-reported being on antiretroviral therapy (ART), and 54.1% (95% CI 31.8 to 76.4) achieved VS. Among MSM/TGW living with HIV, 24.4% (95% CI 4.7 to 44.1) self-reported having been diagnosed; of them 43.9% (95% CI 33.6 to 54.8) self-reported being on ART, and 86.1% (95% CI 71.1 to 93.9) achieved VS., Conclusions: ART use among those aware of their HIV status is encouraging. However, the generally low awareness of infection status among FSW and MSM/TGW with HIV and the low VS among FSW on ART indicate an urgent need for innovative strategies to increase testing uptake and ART adherence among these populations. Monitoring drug resistance may be warranted., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The HIV trend among female sex workers (FSWs) is understudied. We assessed the prevalence and trend of HIV and five other STIs among FSWs in Iran., Methods: We recruited FSWs (1337 in 2015, 1005 in 2010) from 21 sites in 13 cities in two cross-sectional biobehavioural surveys. Eligible FSWs were women aged ≥18 years who reported selling sex to more than one male client in the past 12 months. Consenting FSWs were interviewed using a behavioural questionnaire and tested for HIV and five other STIs. We considered study sites as clusters in the analysis and two-sided Fisher's exact test to compare the HIV prevalence between the two survey rounds., Results: HIV prevalence was 2.1% in 2015 (vs 4.0% in 2010, p=0.007). Lifetime drug injection was reported by 6.1% of participants in 2015 (vs 14.6% in 2010, p=0.003). In 2015, among FSWs with history of lifetime drug injection, HIV prevalence was 8.6% (vs 9.8% in 2010, p=0.425). The prevalence of other STIs in 2015 was 0.4% (95% CI 0.2 to 1.0) for syphilis, 1.3% (95% CI 0.8 to 2.1) for gonorrhoea, 6.0% (95% CI 4.8 to 7.4) for chlamydia, 11.9% (95% CI 8.5 to 16.5) for trichomoniasis and 41.8% (95% CI 39.2 to 44.5) for human papillomavirus., Conclusions: HIV prevalence among FSWs in Iran decreased, but remains considerably high. The decrease in HIV prevalence compared with 2010 might be explained by a decrease in drug injection. Other STIs are also high in this population. Harm reduction programmes need to be continued and scaled up among this underserved population in Iran., Competing Interests: Competing interests: PAK is affiliated with Ministry of Health, CDC, Tehran, Iran., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: We assessed the prevalence and risk factors associated with virological failure among female sex workers living with HIV on antiretroviral therapy (ART) in Kampala, Uganda., Methods: We conducted a cross-sectional study between January 2015 and December 2016 using routinely collected data at a research clinic providing services to women at high risk of STIs including HIV. Plasma samples were tested for viral load from HIV-seropositive women aged ≥18 years who had been on ART for at least 6 months and had received adherence counselling. Samples from women with virological failure (≥1000 copies/mL) were tested for HIV drug resistance by population-based sequencing. We used logistic regression to identify factors associated with virological failure., Results: Of 584 women, 432 (74%) with a mean age of 32 (SD 6.5) were assessed, and 38 (9%) were found to have virological failure. HIV resistance testing was available for 78% (28/38), of whom 82.1% (23/28) had at least one major drug resistance mutation (DRM), most frequently M184V (70%, 16/23) and K103N (65%, 15/23). In multivariable analysis, virological failure was associated with participant age 18-24 (adjusted OR (aOR)=5.3, 95% CI 1.6 to 17.9), self-reported ART non-adherence (aOR=2.6, 95% CI 1.2 to 5.8) and baseline CD4+ T-cell count ≤350 cells/mm 3 (aOR=3.1, 95% CI 1.4 to 7.0)., Conclusions: A relatively low prevalence of virological failure but high rate of DRM was found in this population at high risk of transmission. Younger age, self-reported ART non-adherence and low CD4+ T-cell count on ART initiation were associated with increased risk of virological failure., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The Victorian legislation requires sex workers to have quarterly screening for genital chlamydia and gonorrhoea, but screening for oropharyngeal infection is not mandatory in Victoria, Australia. In 2017, oropharyngeal screening for gonorrhoea and chlamydia was added as part of the routine quarterly screening for sex workers attending the Melbourne Sexual Health Centre (MSHC). The aim of this study was to examine the prevalence of oropharyngeal gonorrhoea and chlamydia among female sex workers (FSW)., Methods: We included females who (1) self-identified as sex workers or were attended MSHC for a sex work certificate and (2) had tested for any STI or HIV, between March 2015 and December 2017. The prevalence of HIV, syphilis, chlamydia and gonorrhoea was calculated., Results: There were 8538 FSW consultations among 2780 individuals during the study period. There was a twofold increase in genital gonorrhoea (from 0.5% (95% CI 0.3% to 0.9%) to 1.1% (95% CI 0.8% to 1.5%); p trend =0.047) and a 1.5-fold increase in genital chlamydia (from 2.2% (95% CI 1.6% to 2.8%) to 3.2% (95% CI 2.6% to 3.8%); p trend =0.031) during the period. Overall, the prevalence of HIV (0.2% (95% CI 0.1% to 0.3%)) and syphilis (0.1% (95% CI 0.0% to 0.2%)) remained low and did not change over time. In 2017, the prevalence of oropharyngeal gonorrhoea was 2.0% (95% CI 1.6% to 2.6%) and oropharyngeal chlamydia was 2.1% (95% CI 1.6% to 2.7%). Among FSW who were tested positive for gonorrhoea and chlamydia, 55% (n=41) and 34% (n=45) only tested positive in the oropharynx but not genital for gonorrhoea and chlamydia, respectively., Conclusion: The prevalence of oropharyngeal gonorrhoea and chlamydia is similar to the prevalence at genital sites and is often independent of genital infection. It is important to test the oropharynx and genital site for chlamydia and gonorrhoea among FSW., Competing Interests: Competing interests: None declared, (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: While men who have sex with men (MSM) are disproportionately affected by Peru's overlapping HIV and STI epidemics, there are few data on how partnership-level and network-level factors affect STI transmission in Peru. We explored partnership-level and network-level factors associated with gonorrhoea/chlamydia ( Neisseria gonorrhoeae and/or Chlamydia trachomatis (NG/CT)) and/or syphilis infection among MSM in Peru., Methods: We present the results of a cross-sectional secondary analysis of MSM (n=898) tested for syphilis and NG/CT infection as part of the screening process for two STI control trials in Lima, Peru. Participants completed questionnaires on demographics, sexual identity and role, characteristics of their three most recent sexual partners (partner sexual orientation, gender, role, partnership type, partner-specific sexual acts) and 30-day sexual network characteristics (number of sexual partners, partnership types, frequency of anal/vaginal intercourse). Participants were tested for syphilis and urethral, rectal and oropharyngeal NG/CT. Differences in network characteristics were analysed with χ 2 and Kruskal-Wallis tests., Results: Approximately 38.9% of participants had a new STI diagnosis (syphilis (rapid plasma reagin ≥16): 10.6%; NG/CT: 22.9%; syphilis-NG/CT coinfection: 5.4%). Condomless anal intercourse (CAI) was not significantly associated with an STI diagnosis. Gay-identified participants with exclusively homosexual networks had a higher prevalence of STIs (47.4%) than gay-identified MSM with only heterosexual/bisexual partners (34.6%, p=0.04), despite reporting fewer sexual partners (any partners: 2, 1-4 vs 3, 2-6; p=0.001; casual partners: 1, 0-3 vs 2, 1-4; p=0.001) and more stable partnerships (1, 0-1 vs 0, 0-1; p=0.003) in the last month., Conclusions: Network size and the number of casual sexual partners were associated with NG/CT infection among MSM in Peru. Despite reporting fewer sexual risk behaviours (smaller network size, more stable partnerships, less CAI), MSM with homosexual-only sexual networks had a higher prevalence of NG/CT and syphilis. These findings suggest network composition among MSM in Peru plays an important role in the risk for STI acquisition., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To determine prevalence of HIV and HIV-related behaviours in female seasonal farm workers (FSFWs) in two provinces of Souss Massa Draa (SMD) region in Morocco. SMD has a higher burden of HIV compared with other parts of Morocco and is characterised by a substantial aggregation of FSFW., Methods: We carried out a cross-sectional HIV biobehavioural survey using cluster-based sampling of farms in the provinces Chtouka Aït Baha and Taroudant Ouled Teïma in 2014. HIV testing was done using the Determine HIV-1/2 rapid test and reactive specimens were tested using ELISA and western blot. Collected data were post hoc weighted for region-based stratification and adjusted for clustering effects using complex survey functions of SPSS (V.21)., Results: Among those eligible to participate, the response rate was 92.8%. HIV prevalence was 0.9% (95% CI 0.4% to 2.4%) among 520 recruited participants. A high proportion of respondents (67.7%) had no education. Ever having sex was reported by 79.8% and among these, 12.7% ever exchanged sex for money or goods. Sixty-one per cent reported condom use at most recent commercial vaginal sex in the past 12 months. STI symptom recognition was found to be low because 62.4% and 46.8% of FSFW could not report any STI symptoms in men and women, respectively. Twenty-seven per cent of respondents had an HIV test in the past 12 months. In multivariable analysis, those with primary or higher education (adjusted OR (aOR)=2.38, 95% CI 1.33 to 4.27) and those who participated in an HIV educational session at their workplace (aOR=11.00, 95% CI 3.99 to 30.31) had higher odds of ever been tested for HIV., Conclusions: Although we found a relatively low HIV prevalence among FSFW in SMD, HIV interventions should be intensified, in particular, in a subgroup of women who are involved in sex work., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objectives: The existence of street and working children in Iran is undeniable. The precarious conditions of these children (including disrupted family, poverty, high prevalence of crime among relatives, family members and peers) cause social harm and high-risk behaviours, including drug addiction, selling sex or having sex with adolescents or peers. Here we explore the HIV, hepatitis B and hepatitis C status of street and working children in Tehran., Methods: One thousand street and labour children, aged 10-18 years, were recruited by using the time-location sampling method, and semistructured questionnaires were used to find demographic information and information on HIV/AIDS-related high-risk sexual behaviours. Blood samples were collected from children, with use of the dried blood sampling method., Results: 4.5% of children were HIV infected, 1.7% were infected with hepatitis B virus and 2.6% were infected with hepatitis C virus (HCV). Having parents who used drug, infected with HCV and having experience in trading sex significantly increased the likelihood of getting HIV among the street children of Tehran., Conclusion: HIV prevalence among street children is much higher than general population (<0.1%), and in fact ,the rate of positivity comes close to that among female sex workers in Iran. These findings must be an alarm for HIV policymakers to consider immediate and special interventions for this at-risk group., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objectives: Although sex work is frequently characterised as a practice with high risk for HIV and other STIs, little is known about the epidemiology of these infections among men who sell sex in Australia. This study reports the prevalence of chlamydia, gonorrhoea, infectious syphilis and HIV among men who have sex with men attending Australian publicly funded sexual health clinics and compares prevalence between sex workers and non-sex workers., Methods: From 2011 to 2014, de-identified patient data were extracted from 40 sexual health clinics in four Australian jurisdictions. The χ 2 and multiple logistic regression analyses were used to compare the prevalence of HIV and STIs among men attending these services who did and did not report sex work in the 12 months prior to consultation. All analyses were restricted to men who reported sex with other men and to each patient's first consultation at participating services., Results: In total, 27 469 gay, bisexual and other men who have sex with men attended participating clinics; 443 (1.6%) reported sex work. At first consultation, 18% of sex workers and 17% of non-sex workers were diagnosed with HIV or an STI (p=0.4): 13% of sex workers were newly diagnosed with chlamydia, 15% with gonorrhoea, 0.5% with infectious syphilis and 0.6% with HIV. After controlling for demographic and behavioural factors, sex work was not independently associated with an HIV or STI diagnosis., Conclusions: These findings provide estimates of HIV and STI prevalence among men who sell sex in Australia and they challenge assumptions of sex work as inherently risky to the sexual health of gay bisexual and other men who have sex with men., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background/objectives: Female sex workers (FSWs) are at risk for HIV and physical and sexual gender-based violence (GBV). We describe the prevalence of lifetime GBV and its associations with HIV risk behaviour, access to health services and barriers in accessing justice among FSWs in Cameroon., Methods: FSWs (n=1817) were recruited for a cross-sectional study through snowball sampling in seven cities in Cameroon. We examined associations of lifetime GBV with key outcomes via adjusted logistic regression models., Results: Overall, 60% (1098/1817) had experienced physical or sexual violence in their lifetime. GBV was associated with inconsistent condom use with clients (adjusted OR (AOR) 1.49, 95% CI 1.18 to 1.87), being offered more money for condomless sex (AOR 2.09, 95% CI 1.56 to 2.79), having had a condom slip or break (AOR 1.53, 95% CI 1.25 to 1.87) and difficulty suggesting condoms with non-paying partners (AOR 1.47, 95% CI 1.16 to 1.87). Violence was also associated with fear of health services (AOR 2.25, 95% CI 1.61 to 3.16) and mistreatment in a health centre (AOR 1.66, 95% CI 1.01 to 2.73). Access to justice was constrained for FSWs with a GBV history, specifically feeling that police did not protect them (AOR 1.41, 95% CI 1.12 to 1.78)., Discussion: Among FSWs in Cameroon, violence is prevalent and undermines HIV prevention and access to healthcare and justice. Violence is highly relevant to FSWs' ability to successfully negotiate condom use and engage in healthcare. In this setting of criminalised sex work, an integrated, multisectoral GBV-HIV strategy that attends to structural risk is needed to enhance safety, HIV prevention and access to care and justice., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objectives: This study examines violence experienced in work and personal contexts and relation to HIV risk factors in these contexts among female sex workers (FSW) in Andhra Pradesh, India., Methods: FSW at least 18 years of age (n=2335) were recruited through three rounds of respondent-driven sampling between 2006 and 2010 for a survey on HIV risk. Using crude and adjusted logistic regression models, any sexual/physical violence (last 6 months) perpetrated by clients and husbands were separately assessed in association with accepting more money for sex without a condom (last 30 days), consistent condom use with clients and husbands (last 30 days), and sexually transmitted infection (STI) symptoms (last 6 months)., Results: The mean age among participants was 32, 22% reported being currently married, and 22% and 21% reported physical/sexual violence by clients and husbands, respectively. In adjusted logistic regression models, FSW who experienced client violence were more likely to report accepting more money for unprotected sex trades (adjusted OR (AOR)=1.7; 95% CI 1.4 to 2.2), less likely to report consistent condom use with clients (AOR=0.6; 95% CI 0.5 to 0.7) and more likely to report STI symptoms (AOR=3.5; 95% CI 2.6 to 4.6). Women who reported husband violence were more likely to report accepting more money for unprotected sex trades (AOR=2.1; 95% CI 1.2 to 3.7), less likely to report consistent condom use with clients (AOR=0.5; 95% CI 0.3 to 0.8) and more likely to report STI symptoms (AOR=2.6; 95% CI 1.6 to 4.1)., Conclusions: Among FSW, experiences of violence in work and personal contexts are associated with sexual HIV risk behaviours with clients as well as STI symptoms., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: A review of historical trends in gonococcal diagnoses made at the Adelaide Sexual Health Clinic (ASHC), South Australia, identified a substantial rise in diagnoses among heterosexuals between 2006 and 2010. Sex work is illegal in South Australia, regulated in Victoria and legal in New South Wales. This and other factors that could have influenced the epidemic were explored in this analysis., Methods: Retrospective analyses of gonorrhoea diagnoses made by sexual health services between 1990 and 2012 in three Australian state capitals, Melbourne (Victoria) and Sydney (New South Wales) were undertaken., Results: At the ASHC the proportion of gonorrhoea diagnoses was higher between 2006 and 2010 among heterosexual men (5.34% vs 0.84%, p<0.001), non-sex worker women (0.64% vs 0.28%, p<0.001) and female sex workers (FSWs) (1.75% vs 0.24%, p<0.001) compared with other years. This relationship was not seen at the Melbourne Sexual Health Clinic and corresponding data from the Sydney Sexual Health Centre showed that FSWs were less likely to have gonorrhoea between 2006 and 2010 than the other groups (p=0.746, p=0.522, p=0.024, respectively). At ASHC FSWs were significantly more likely to be diagnosed between 2006 and 2010 (OR 2.8, 95% CI 1.48 to 5.27, p=0.002). Charges against sex workers peaked in 2007/2008., Conclusions: A substantial, self-limiting rise in diagnoses of heterosexual gonorrhoea was seen in Adelaide FSWs between 2006 and 2010. Removing barriers to condom use is vital to the prevention of HIV and STI transmission., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: To better understand risk behaviours and factors associated with low-fee female sex workers (FSW) and support HIV/sexually transmitted infections (STI) epidemic control among this key population in China., Methods: A cross-sectional study using convenience sampling to recruit 1487 eligible low-fee and medium-fee FSW was conducted in 2012 in three provinces. The participants were interviewed using a structured questionnaire and tested for HIV-1, herpes simplex virus (HSV)-2 and syphilis antibody. Log-binomial modelling was used to estimate prevalence ratios (PR) and examine factors associated with low-fee sex work., Results: Prevalence of HIV-1, syphilis and HSV-2 antibody positive were 0.5%, 4.8% and 27.8%, respectively. Low-fee FSW were more likely to have HSV-2 infection (adjusted prevalence ratio (APR)=1.3, 95% CI 1.1 to 1.7), but not more likely to have HIV-1 and syphilis infection compared with medium-fee FSW. Compared with medium-fee FSW, low-fee FSW were more likely to be ≥35 years of age (APR=2.1, 95% CI 1.3 to 3.6), engage in sex work ≥6 days/per week (APR=1.7, 95% CI 1.2 to 2.6), have ≥3 clients per day (APR=2.2, 95% CI 1.5 to 3.3), have clients decide condom use (APR=1.6, 95% CI 1.1 to 2.3), fail to persuade clients to use condoms (APR=1.6, 95% CI 1.1 to 2.6), express willingness to have unprotected sex in return for receipt of a higher fee (APR=1.8, 95% CI 1.2 to 2.8), have had genital symptoms in the past year (APR=1.4, 95% CI 1.1 to 1.8) and have migrated from another city., Conclusions: Low-fee FSW in China have unique risks for acquiring HIV/STI, in part due to greater economic pressures. Tailored interventions targeting low-fee FSW and incorporating their prevailing perception of HIV/STI risks and condom use negotiation challenges that they face are urgently needed., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: Sex workers (SW) are key populations at an increased risk of HIV infection. This study aimed to characterise risk-taking behaviours and assess HIV prevalence among SW in Portugal., Methods: A cross-sectional survey was conducted with 1040 SW using a participatory research approach. SW were recruited in sex-work locations and community-based organisation offices. Data were collected through a questionnaire with trained interviewers. An HIV rapid test was performed in 213 respondents., Results: Reported HIV prevalence was 8%: 17.6% of man-to-woman transgenders, 7.4% of women and 5% of men. Of SW reportedly living with HIV, 52.2% reported ever injecting drug use. Inconsistent condom use with clients in the last month was higher among male SW (26.5%) and with non-paying partners in the last year was higher among women (71.3%). Among reported HIV-positive SW, the proportions of inconsistent condom use were high. In multivariate regression analysis, reported HIV infection remained significantly higher among transgenders (OR 6.4; 95% CI 1.7 to 24.3), those older (OR 5.1; 95% CI 1.3 to 21.1), working outdoors (OR 5.4; 95% CI 1.9 to 15.6), having ever used psychoactive substances (OR 4.1; 95% CI 2.2 to 7.7) and earning ≤€1000 per month (OR 2.6; 95% CI 1.2 to 5.9). Of those who had an HIV rapid test, 8.9% were reactive; 73.7% were unaware of their seropositivity., Conclusions: The HIV infection burden in SW is high. Efforts to promote HIV testing must be sustained in order to reduce undiagnosed infection. The diverse risk profiles of SW must be addressed in targeted HIV interventions. Prevention interventions should be systematically implemented within most-at-risk subgroups of SW., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: Cross-sectional studies have shown a strong association between Mycoplasma genitalium and HIV infections. We previously reported that in a cohort of female sex workers in Uganda, M genitalium infection at baseline was associated with HIV seroconversion. Here we examine the temporal association between the M genitalium infection status shortly before HIV seroconversion and HIV acquisition., Methods: A nested case-control study was conducted within a cohort of women at high risk for HIV in Kampala. Cases were those of women acquiring HIV within 2 years of enrolment. For each of the 42 cases, 3 controls were selected from women HIV negative at the visit when the corresponding case first tested HIV seropositive. The association between HIV acquisition and M genitalium infection immediately prior to HIV testing was analysed using conditional logistic regression., Results: There was weak evidence of an association between M genitalium infection and HIV acquisition overall (crude OR=1.57; 95% CI 0.67 to 3.72, aOR=2.28: 95% CI 0.81 to 6.47). However, time of M genitalium testing affected the association (p value for effect-modification=0.004). For 29 case-control sets with endocervical samples tested 3 months prior to the first HIV-positive result, M genitalium infection increased the risk of HIV acquisition (crude OR=3.09; 95% CI 1.06 to 9.05, aOR=7.19; 95% CI 1.68 to 30.77), whereas there was little evidence of an association among the 13 case-control sets with samples tested at an earlier visit (crude OR=0.30: 95% CI 0.04 to 2.51; aOR=0.34; 95% CI 0.02 to 5.94)., Conclusions: Our study showed evidence of a temporal relationship between M genitalium infection and HIV acquisition that suggests that M genitalium infection may be a co-factor in the acquisition of HIV infection., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Surveillance studies among female sex workers (FSWs) in Mongolia have found no HIV but high rates of syphilis, ranging from 10.7% in 2002 to 20.8% in 2007., Objectives: To determine the current prevalence of HIV and syphilis among FSWs, and to identify syphilis risk factors., Methods: 761 FSWs were recruited by time-location sampling between 2 January and 29 March 2012 in Ulaanbaatar city, Darkhan-Uul, Orkhon, Khuvsgul and Dornod provinces in Mongolia. Participants were administered an anonymous structured survey. Blood samples were tested for HIV and syphilis. Bivariate and multivariate logistic regression analyses were performed to identify factors associated with syphilis., Results: The mean age of participants was 31 (median 30, interquartile range 24-38). HIV knowledge was modest: 41.3% correctly answered all questions. Consistent condom use with clients was reported by 49.1% of participants and exposure to HIV prevention programmes by 50.1%. Although no cases of HIV were found, syphilis prevalence was -27.8% (95% CI 24.3% to 31.7%). In multivariate analyses, variables associated with syphilis were younger age (age >30 years, OR=0.96, 95% CI 0.92 to 0.99) and occurrence of genital ulcer (OR=2.24, 95% CI 1.17 to 4.28)., Conclusions: A syphilis epidemic continues to grow among FSWs in Mongolia. These women are at high risk of HIV transmission if introduced into their sexual networks. With the increase in migration of mining workers in Mongolia, introduction of HIV may be imminent. Efforts to intensify treatment and prevention programmes among FSWs are needed., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Studies have demonstrated the central function of plasma HIV-1 RNA viral load (pVL) levels on determining the risk of HIV disease progression and transmission. However, there is limited empirical research on virologic outcomes among sex workers who use illicit drugs (SW-DU)., Methods: Data were derived from the AIDS Care Cohort to evaluate Exposure to Survival Services, a cohort of HIV-positive illicit drug users. Using generalised estimating equations, we studied the longitudinal relationship between sex work and pVL suppression. We also tested whether adherence to antiretroviral therapy (ART) mediated the relationship between sex work and pVL suppression., Results: Between May 1996 and May 2012, 587 ART-exposed participants (2224 person-years of observation) were included in the study, among whom 127 (21.6%) reported sex work. In a time-updated multivariate model adjusted for various demographic, socioeconomic and clinical confounders (eg, gender, incarceration, CD4 cell count), SW-DU had an independently reduced odds of pVL suppression compared to non-SW-DU (adjusted OR (AOR)=0.66; 95% CI 0.45 to 0.96). However, adding ART adherence to the multivariate model eliminated this association (p>0.05), suggesting adherence mediated the relationship between sex work and pVL suppression., Conclusions: Evidence-based interventions to improve adherence to ART among SW-DU are urgently needed to help produce the maximum HIV treatment and prevention benefit of ART among this highly vulnerable population., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: While female sex workers (FSWs) are assumed to be at increased risk of sexually transmitted infections (STIs), there are limited comparative data with other population groups available. Using routine STI surveillance data, we investigated differences in sexual health between FSWs and other female attendees at genitourinary medicine (GUM) clinics in England., Methods: Demographic characteristics, STI prevalence and service usage among FSWs and other attendees in 2011 were compared using logistic regression., Results: In 2011, 2704 FSWs made 8411 recorded visits to 131/208 GUM clinics, (primarily large, FSW-specialist centres in London). FSWs used a variety of services, however, 10% did not have an STI/HIV test at presentation. By comparison with other female attendees, FSWs travelled further for their care and had increased risk of certain STIs (e.g., gonorrhoea ORadj: 2.76, 95% CI 2.16 to 3.54, p<0.001). Migrant FSWs had better sexual health outcomes than UK-born FSWs (e.g., period prevalence of chlamydia among those tested: 8.5% vs 13.5%, p<0.001) but were more likely to experience non-STI outcomes (eg, pelvic inflammatory disease ORadj: 2.92, 95% CI 1.57 to 5.41, p<0.001)., Conclusions: FSWs in England have access to high-quality care through the GUM clinic network, but there is evidence of geographical inequality in access to these services. A minority do not appear to access STI/HIV testing through clinics, and some STIs are more prevalent among FSWs than other female attendees. Targeted interventions aimed at improving uptake of testing in FSWs should be developed, and need to be culturally sensitive to the needs of this predominantly migrant population., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: To assess the proportion of independent indoor female sex workers (FSW) in West Yorkshire, UK who advertise unprotected sex, and to investigate any association with cost, location and provision of anal sex., Methods: Data on whether independent indoor FSW (defined as those not advertising via an escort agency or through a parlour) advertised unprotected sexual services, along with demographic data, were collected from 462 advertisement profiles of FSW in West Yorkshire from the website http://www.adultwork.com. Independent t test and χ(2) statistics were used to test the association between advertised unprotected vaginal and oral sex, and FSW age, cost of services, location and whether they advertised anal sex., Results: Unprotected vaginal sex was advertised by 8% of FSW, and unprotected oral sex by 74% of FSW. FSW advertising unprotected vaginal sex were more likely to live in Wakefield and Bradford than in Leeds, had significantly lower hourly rates, and were more likely to advertise anal sex., Conclusions: Advertised condom use for vaginal and oral sex by independent indoor FSW in West Yorkshire was significantly lower than reported rates of protected sex found in previous studies based in London and the south of England. The advertisement of unprotected vaginal sex is associated with factors such as lower hourly rates and the advertisement of higher risk anal sex, which may signify greater economic need. FSW offering unprotected sex therefore represent an at-risk target group for health promotion.

Objectives: Male sex workers (MSW) are thought to be at increased risk of sexually transmitted infections (STI), however, limited comparative data with other groups are available. Disparities among MSWs by migrant status may also exist. Using newly available, cross-sectional surveillance data, the characteristics of MSWs and other male genitourinary medicine (GUM) clinic attendees can be investigated., Methods: Demographic characteristics, STI prevalence and service usage among MSWs and other male attendees between 1 January and 31 December 2011 were compared using logistic regression., Results: In 2011, 627 780 men attended GUM clinics; 488 (0.08%) were identified as MSWs. MSWs used a variety of services, however, one in seven had no HIV test at presentation. Adjusting for demographic factors and self-reported sexual orientation, MSWs had increased risk of some STIs and reinfection compared to other male attendees (eg, ORadj of gonorrhoea infection: 2.21, 95% CI 1.61 to 3.01, p<0.001, 14.1% vs 4.8% reinfected in 2011, p=0.005). Service usage did not vary between migrant and UK-born MSWs, but migrant MSWs were twice as likely to be diagnosed with chlamydia., Conclusions: Some STIs are more prevalent and some reinfections more common among MSWs than other male attendees. A minority of MSWs do not appear to access STI/HIV testing through GUM clinics, and targeted interventions to improve uptake of testing in MSWs should be developed. Service usage and sexual health of MSWs does not appear to vary greatly by migrant status, though the increased risk of chlamydia infection among migrant MSWs should be investigated further.

The primary objectives of this study were to assess the changing demographic characteristics of female sex workers (FSWs) in the urban Bangalore district, India, and trends in programme coverage, HIV/sexually transmitted infection prevalence rates and condom use. Cross-sectional, integrated behavioural and biological assessments of FSWs were conducted in 2006, 2009 and 2011. Univariate and multivariate analyses were used to describe trends over time. The results indicate the mean age of initiation into sex work has increased (26.9 years in 2006 vs 27.6 years in 2011, p<0.01), a higher proportion of FSWs reported being in 'stable' relationships in 2011 (70.2% vs 43.2% in 2006, p<0.01) and having conducted sex work outside the district in the past 6 months (10.0% in 2011 vs 16.0% in 2006 p=0.01). There was an increase in the proportion of FSWs using cellphones to solicit clients (4.4% in 2006 vs 57.5% in 2011, p<0.01) and their homes for sex work (61.4% in 2006 vs 77.8% in 2011, p<0.01). Reactive syphilis prevalence declined (12.6% in 2006 to 4% in 2011, p=0.02), as did high-titre syphilis prevalence (9.5% in 2006 to 2.5% in 2011, p=0.01). HIV prevalence declined but not significantly (12.7% in 2006 and 9.3% in 2011, p=0.39). Condom use remained above 90% increasing significantly among repeat (paying) clients (66.6% in 2006 to 93.6% in 2011, p<0.01). However, condom use remained low with non-paying partners when compared with occasional paying partners (17.6% vs 97.2% in 2011, p<0.01). Given the changing dynamics in the FSW population at multiple levels, there is a need to develop and customise strategies to meet local needs.

Objectives: To assess HIV and syphilis prevalence, HIV-related behaviours and testing for HIV in female sex workers (FSW) in Sudan., Design: Bio-behavioural surveys using respondent-driven sampling were carried out among FSW in the capital cities of 14 states in Sudan in 2011-2012. HIV and syphilis testing was done by rapid tests., Results: 4220 FSW aged 15-49 years were recruited. The median age of recruited women varied from 21 to 28 years per site. The highest HIV prevalence was measured at two sites in the eastern zone (5.0% and 7.7%), while in the other zones it ranged from 0% to 1.5%. Syphilis prevalence ranged from 1.5% in the northern zone to 8.9% in the eastern zone. Ever having been tested for HIV was reported by 4.4%-23.9% of FSW across all sites. Condom use at last sex with a client varied from 4.7% to 55.1%, while consistent condom use with clients in the month preceding the surveys was reported by 0.7%-24.5% of FSW. The highest reporting of ever injecting drugs was measured at a site in the western zone (5.0%)., Conclusions: The surveys' findings indicate that the highest burden of HIV in FSW is in the eastern states of the country. Condom use and HIV testing data demonstrate the need for HIV interventions that should focus on HIV testing and risk reduction strategies that include stronger condom promotion programmes in FSW and their clients.

Objectives: In an effort to fully analyse and understand the HIV situation and its epidemiology in Pakistan, a bilateral collaboration between the National AIDS Control Program and the Canadian International Development Agency resulted in the establishment of an effective second-generation surveillance (SGS) system for HIV/AIDS between 2004 and 2012 in accordance with the published guidelines. This paper presents findings from the 4th round of SGS., Methods: A mapping exercise was initially conducted for size estimations of the key vulnerable populations: people who inject drugs (PWIDs), male sex workers (MSWs), hijra sex workers (HSWs), and female sex workers (FSWs), followed by an Integrated Behavioral and Biological Surveillance in 20 selected cities across Pakistan., Results: The estimated sizes of the four key populations mapped in the 20 cities were 89 178 FSWs, 46 351 PWIDs, 23 317 HSWs and 19 119 MSWs. The HIV sero-prevalence among PWIDs was the highest among all key populations surveyed at 37.8% (CI 37.3 to 38.3) nationally, followed by a prevalence of 7.2% (CI 6.8 to 7.5) among HSWs, 3.1% (CI 2.8 to 3.4) among MSWs and 0.8% (CI 0.4 to 1.0) for FSWs. Various key risk behaviours, that is, sharing of syringes by PWIDs and inconsistent use of condoms by sex workers, were documented., Conclusions: Pakistan's HIV epidemic that once was characterised primarily by transmission among PWIDs is now increasingly characterised by significant sexual transmission, and all types of sex workers (male, hijra and female) exhibit epidemiological proportions of infection. There is a need to develop concrete strategic plans for each vulnerable subpopulation, initially focusing prevention resources on those with a higher risk or vulnerability.

Objectives: To provide an overview of the current level of development and results from the national HIV surveillance systems of the 23 countries of the Middle East and North Africa (MENA), and to assess the quality of HIV surveillance systems in the period 2007-2011., Methods: A questionnaire was used to collect the information about the structure, activities and the results of HIV surveillance systems from the National AIDS Programmes. Assessment of the quality was based on four indicators: timeliness of data collection, appropriateness of populations under surveillance, consistency of the surveillance sites and groups measured over time, and coverage of the surveillance system., Results: Only in four countries did surveillance systems enable assessment of epidemic trends in the same populations and locations over time, such as in pregnant women (Morocco, Iran), injecting drug users (Iran, Pakistan), female sex workers (Djibouti, Morocco) and male sex workers (Pakistan). There is increasing evidence of HIV infection being firmly established in at least one of the populations most at risk of HIV in nine MENA countries, while lower risk populations show elevated HIV prevalence in South Sudan, Djibouti and some parts of Somalia., Conclusions: The performance of HIV surveillance systems in several of the MENA countries has improved in recent years. The extent of HIV epidemics in the populations most at risk of HIV is still largely unknown in 10 countries. Multiple data sources that most of the countries still lack would enable indirectly estimation not only of the patterns of HIV epidemics but also the effectiveness of HIV responses.

Objectives: To determine the prevalence of HIV and related behavioural risks among Iranian female sex workers (FSW) via the first national biobehavioural surveillance survey., Methods: In 2010, 1005 FSW were approached and 872 recruited using facility-based sampling from 21 sites in 14 cities in Iran. We collected dried blood samples and conducted face-to-face interviews using a standardised questionnaire. Data were weighted based on the response rate and adjusted for the clustering effect of the sampling site. Adjustment was performed by weighting based on the sampling fraction of each site using a prior estimate of its total size of the FSW population., Results: The prevalence of HIV infection (95% CI) was 4.5% (2.4 to 8.3) overall, 4.8% (2.2 to 9.8) among those who had reported a history of drug use and 11.2% (5.4 to 21.5) among those who had a history of injection drug use. The frequencies of condom use in the last sexual act with paying clients and non-paying partners were 57.1% and 36.3%, respectively. Any drug use was reported by 73.8% of participants, and among this subgroup, 20.5% had a history of injection drug use., Conclusions: The prevalence of HIV was considerable among FSW particularly those who had a history of drug injection. A combination of prevention efforts addressing unsafe sex and injection are needed to prevent further transmission of HIV infection.

Background: We sought to describe differences in individual and structural vulnerabilities faced by female sex workers (FSWs) in Pakistan between 2006 and 2011, and to characterise risk factors for inconsistent condom use and HIV prevalence in this population., Methods: To describe differences in vulnerabilities, we analysed behavioural data from serial cross-sectional surveys conducted across nine cities in 2006 and 2011. Using data from 12 cities in 2011, we used logistic regression to characterise risk factors for (a) inconsistent condom use in the past month (N=6987), and (b) HIV (N=4301)., Results: Compared to FSWs in 2006, FSWs in 2011 were significantly more likely to solicit clients via cell phones, and to report a larger client volume and anal sex with clients, but also consistent condom use with clients (30.0% vs 23.6% in 2006). In 2011, independent risk factors for inconsistent condom use with clients included: recent sexual violence, recent sex with a person who injects drugs, and absence of programme exposure. HIV prevalence was 0.63% (95% CI 0.43% to 0.92%) in 2011, and was associated with a recent history of injection drug use and absence of programme exposure., Conclusions: While condom use with clients was higher in 2011, protective behaviours remained low and vulnerabilities related to sex work may have risen. HIV is emerging in this population and an adaptive HIV prevention programme that addresses different vulnerabilities and the intersection of sexual networks with injection drug use is needed.

Background: From 2004 to 2011, a collaborative project was undertaken to enhance the capacity of the Government of Pakistan to implement an effective second-generation surveillance system for HIV/AIDS, known as the HIV/AIDS Surveillance Project (HASP). In four separate rounds, behavioural questionnaires were administered among injection drug users, and female, male and hijra (transgender) sex workers. Dried blood spots were collected for HIV testing., Methods: Through interviews with project staff in Pakistan and Canada, we have undertaken a critical review of the role of HASP in generating, using and translating knowledge, with an emphasis on capacity building within both the donor and recipient countries. We also documented ongoing and future opportunities for the translation of knowledge produced through HASP., Results: Knowledge translation activities have included educational workshops and consultations held in places as diverse as Colombia and Cairo, and the implementation of HASP methodologies in Asia, the Middle East and sub-Saharan Africa. HASP methodologies have been incorporated in multiple WHO reports. Importantly, the donor country, Canada, has benefited in significant ways from this partnership. Operational and logistical lessons from HASP have, in turn, improved how surveillance is performed in Canada. Through this project, significant capacity was built among the staff of HASP, non-governmental organisations which were engaged as implementation partners, data coordination units which were established in each province, and in the laboratory. As is to be expected, different organisations have different agendas and priorities, requiring negotiation, at times, to ensure the success of collaborative activities. Overall, there has been considerable interest in and opportunities made for learning about the methodologies and approaches employed by HASP., Conclusions: Generally, the recognition of the strengths of the approaches and methodologies used by HASP has ensured an appetite for opportunities of mutual learning.

Background: We sought to describe the characteristics and operational dynamics of male sex workers (MSW) and hijra sex workers (HSWs) in 11 cities across Pakistan in 2011., Methods: We report descriptive statistics of self-reported sexual behaviour data from cross-sectional mapping and biological and behavioural surveys conducted among 1431 MSWs and 1415 HSWs in four cities across Pakistan in 2011., Results: While Karachi had the largest numbers of MSWs and HSWs, Quetta had the largest relative population sizes, with 3.6 MSWs per 1000 male adults and 3.3 HSWs per 1000 male adults. There was considerable variability in the proportion of HSWs who operate through deras, ranging from 2.2% in Peshawar to 62.7% in Karachi. The number of HSWs per guru varies by city, from 1.5 in Quetta to 16.5 HSWs per guru in Karachi. Among HSWs, the use of mobile phones for solicitation ranged from 37.6% in Quetta to 83% in Peshawar and among MSWs the use of mobile phones ranged from 27% in Karachi to 52% in Quetta. In Quetta, a large proportion of HSWs (41%) find clients through gurus. Client volume tended to be higher among HSWs and among both MSWs and HSWs in Quetta and Peshawar. Condom use with clients was most consistent in Quetta, with 31% of MSWs and 41% of HSWs reporting always using condoms with clients. Peshawar had the greatest proportion reporting never using condoms., Conclusions: There is considerable geographic heterogeneity in the characteristics and operational dynamics of MSWs and HSWs across Pakistan.

Background: Pakistan is known to have large populations of female sex workers (FSWs) with considerable geographic heterogeneity in their characteristics. In this paper, we describe the social organisation and structural patterns of female sex work in different geographic regions of Pakistan., Methods: We report geographic and network mapping data collected among FSWs in 15 cities across Pakistan in 2011 as part of the Canada-Pakistan HIV/AIDS Surveillance Project., Results: A total number of 89 178 FSWs were estimated in the target cities for an average of 7.2 FSWs per 1000 adult males. 55% of the estimated number of FSWs concentrated in Karachi and Lahore. Based on the operations of female sex work, two major typologies of FSWs were identified: establishment-based and non-establishment-based. FSWs were further subtyped into those operating through brothels, homes, kothikhanas, streets and by cell phone. Cities varied considerably in terms of predominance of different FSW typologies., Conclusions: There is considerable heterogeneity among FSWs in Pakistan, geographically and in terms of operational typology. Understanding the social organisation of sex work and the influence of social-cultural and legal factors in Pakistan is essential for the design of HIV prevention programmes and other services for FSWs.

Background: With competing interests, limited funding and a socially conservative context, there are many barriers to implementing evidence-informed HIV prevention programmes for sex workers and injection drug users in Pakistan. Meanwhile, the HIV prevalence is increasing among these populations across Pakistan. We sought to propose and describe an approach to resource allocation which would maximise the impact and allocative efficiency of HIV prevention programmes., Methods: Programme performance reports were used to assess current resource allocation. Population size estimates derived from mapping conducted in 2011 among injection drug users and hijra, male and female sex workers and programme costs per person documented from programmes in the province of Sindh and also in India were used to estimate the cost to deliver services to 80% of these key population members across Pakistan. Cities were prioritised according to key population size., Results: To achieve 80% population coverage, HIV prevention programmes should be implemented in 10 major cities across Pakistan for a total annual operating cost of approximately US$3.5 million, which is much less than current annual expenditures. The total cost varies according to the local needs and the purchasing power of the local currency., Conclusions: By prioritising key populations at greatest risk of HIV in cities with the largest populations and limited resources, may be most effectively harnessed to quell the spread of HIV in Pakistan.

Background: Considerable HIV transmission occurs among injection drug users (IDUs) in Pakistan and recently the HIV prevalence has been increasing among male (MSW), hijra (transgender; HSW) and female (FSW) sex workers. We describe past and estimate future patterns of HIV emergence among these populations in several cities in Pakistan., Methods: The density of these key populations per 1000 adult men was calculated using 2011 mapping data from Karachi, Lahore, Faisalabad, Larkana, Peshawar and Quetta, and surveillance data were used to assess bridging between these key populations. We used the UNAIDS Estimation and Projection Package model to estimate and project HIV epidemics among these key populations in Karachi, Lahore, Faisalabad and Larkana., Results: The density and bridging of key populations varied across cities. Lahore had the largest FSW population (11.5/1000 adult men) and the smallest IDU population (1.7/1000 adult men). Quetta had the most sexual and drug injection bridging between sex workers and IDUs (6.7%, 7.0% and 3.8% of FSW, MSW and HSW, respectively, reported injecting drugs). Model evidence suggests that by 2015 HIV prevalence is likely to reach 17-22% among MSWs/HSWs in Karachi, 44-49% among IDUs in Lahore and 46-66% among IDUs in Karachi. Projection suggests the prevalence may reach as high as 65-75% among IDUs in Faisalabad by 2025. HIV prevalence is also estimated to increase among FSWs, particularly in Karachi and Larkana., Conclusions: There is a need to closely monitor regional and subpopulation epidemic patterns and implement prevention programmes customised to local epidemics.

Objectives: Size estimates of populations at higher risk for HIV infection are needed to help policy makers understand the scope of the epidemic and allocate appropriate resources. Population size estimates of men who have sex with men (MSM), female sex workers(FSW) and intravenous drug users (IDU) are few or non-existent in Nairobi, Kenya., Methods: We integrated three population size estimation methods into a behavioural surveillance survey among MSM, FSW and IDU in Nairobi during 2010–2011. These methods included the multiplier method, ‘Wisdom of the Crowds’ and an approach that drew on published literature. The median of the three estimates was hypothesised to be the most plausible size estimate with the other results forming the upper and lower plausible bounds. Data were shared with community representatives and stakeholders to finalise ‘best’ point estimates and plausible bounds based on the data collected in Nairobi, a priori expectations from the global literature and stakeholder input., Results: We estimate there are approximately 11 042 MSM with a plausible range of 10 000–22 222, 29 494 FSW with a plausible range of 10 000–54 467 FSW and approximately 6107 IDU and plausibly 5031–10 937 IDU living in Nairobi., Conclusions: We employed multiple methods and used a wide range of data sources to estimate the size of three hidden populations in Nairobi, Kenya. These estimates may be useful to advocate for and to plan, implement and evaluate HIV prevention and care programmes for MSM, FSW and IDU. Surveillance activities should consider integrating population size estimation in their protocols.

Objectives: To investigate the prevalence and correlates of concurrent (overlapping) sexual partnerships among female sex workers (FSWs) and their non-commercial male partners in two Mexico-US border cities., Methods: A cross-sectional survey of FSWs and their non-commercial male partners was conducted in Tijuana and Ciudad Juárez, Mexico (2010-2011). Eligible FSWs and verified non-commercial partners were aged ≥18 years; FSWs had ever used hard drugs (lifetime) and recently exchanged sex for money, drugs or other goods (past month). Participants underwent baseline questionnaires obtaining dates of sex and condom use with ≤5 other recurring partners, including FSWs' regular clients. These dates were compared with dates of sex with enrolled study partners to determine overlap (ie, 'recurring' concurrency). Bivariate probit regression identified recurring concurrency correlates., Results: Among 428 individuals (214 couples), past-year recurring concurrency prevalence was 16% and was higher among women than their non-commercial male partners (26% vs 6%). In 10 couples (5%), both partners reported recurring concurrency. The majority of couples (64%) always had unprotected sex, and most of the individuals (70%) with recurring concurrency 'sometimes' or 'never' used condoms with their concurrent partners. Recurring concurrency was positively associated with FSWs' income, men's caballerismo (a form of traditional masculinity) and men's belief that their FSW partners had sexually transmitted infections (STIs)., Conclusions: Recurring concurrency, representing sustained periods of overlapping partnerships in which unprotected sex was common, should be addressed by couple-based STI prevention interventions.

Objectives: Sexually transmitted infections (STIs) are an important cause of morbidity among incarcerated women and female sex workers (FSW). Little is known about FSW incarcerated in New York City (NYC) jails. We reviewed jail health records to identify the STI and HIV prevalence among newly incarcerated FSW in NYC jails. We also examined the relationship of demographics and self-reported clinical and risk behaviour history with FSW status and compared FSW with non-FSW incarcerated women to identify FSW predictors and, guide NYC jail programme planning and policy., Methods: We retrospectively reviewed routinely collected jail health record data to identify the prevalence of chlamydia (Ct), gonorrhoea (Ng) and HIV infection among women newly incarcerated in NYC jails in 2009-2010 (study period) and studied the relationship of STIs, demographics and self-reported clinical and risk behaviour history with FSW status., Results: During the study period, 10 828 women were newly incarcerated in NYC jails. Of these, 10 115 (93%) women were tested for Ct and Ng; positivity was 6.2% (95% CI 5.7% to 6.7%) and 1.7% (95% CI 1.4% to 1.9%), respectively. Nine percent had HIV infection. Seven hundred (6.5%) were defined as FSW. FSW were more likely to have Ct (adjusted OR (AOR): 1.55; 95% CI 1.17 to 2.05; p<0.0001) but not Ng or HIV. FSW were more likely to report age 20-24 years, reside in boroughs other than Manhattan, ≥6 prior incarcerations, ≥2 incarcerations during the study period, condom use with current sex partners, multiple sex partners and current drug use., Conclusions: Women incarcerated in NYC jails had high rates of Ct, Ng, and HIV infection. FSW were at higher risk for Ct than non-FSW incarcerated women. These findings are being used to design targeted interventions to identify FSW, provide clinical and preventive services in jail and coordinate care with community partners.

Objectives: To assess the evidence of differences in the risk of HIV, sexually transmitted infections (STI) and health-related behaviours between migrant and non-migrant female sex workers (FSWs)., Methods: Systematic review of published peer-reviewed articles that reported data on HIV, STIs or health-related harms among migrant compared with non-migrant FSWs. Studies were mapped to describe their methods and focus, with a narrative synthesis undertaken to describe the differences in outcomes by migration status overall and stratified by country of origin. Unadjusted ORs are presented graphically to describe differences in HIV and acute STIs among FSWs by migration and income of destination country., Results: In general, migrant FSWs working in lower-income countries are more at risk of HIV than non-migrants, but migrants working in higher-income countries are at less risk. HIV prevalence was higher among migrant FSWs from Africa in high-income countries. Migrant FSWs in all countries are at an increased risk of acute STIs. Study designs, definitions of FSWs and recruitment methods are diverse. Behavioural data focussed on sexual risks., Discussion: The lack of consistent differences in risk between migrants and non-migrants highlights the importance of the local context in mediating risk among migrant FSWs. The higher prevalence of HIV among some FSWs originating from African countries is likely to be due to infection at home where HIV prevalence is high. There is a need for ongoing monitoring and research to understand the nature of risk among migrants, how it differs from that of local FSWs and changes over time to inform the delivery of services.

Objectives: To assess condom use and prevalence of sexually transmitted infections (STI) and HIV among male sex workers (MSW) in Abidjan, Côte d'Ivoire., Methods: A cross-sectional survey was conducted between October 2007 and January 2008 among MSW attending a sex worker clinic in Abidjan. A short questionnaire was administered in a face-to-face interview, and the participants were asked to provide a urine sample for STI testing and to self-collect transudate of the gingival mucosa for anonymous HIV testing, using a rapid test. A rectal swab for STI testing was taken by a physician. Molecular amplification assays were performed for the detection of Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis., Results: 96 MSW participated in the survey, their median age was 27 years and the median duration of sex work was 5 years. Consistent condom use with clients during the last working day was 86.0%, and consistent condom use with the regular partner during the last week was 81.6%. HIV infection was detected in 50.0% of the participants. The prevalence of N gonorrhoeae was 12.8%, chlamydia infection was present in 3.2% and T vaginalis in 2.1% of the study participants., Conclusions: HIV and STI rates found in this study confirm the high risk and vulnerability status of MSW in Côte d'Ivoire. There is a definite need for studies exploring risk and risk perceptions among MSW in more depth and for services tailored to their needs, including developing and validating simple algorithms for the diagnosis of STI in MSW and men who have sex with men.