Elsevier

Drug and Alcohol Dependence

Volume 157, 1 December 2015, Pages 166-173
Drug and Alcohol Dependence

The role of dyad-level factors in shaping sexual and drug-related HIV/STI risks among sex workers with intimate partners

https://doi.org/10.1016/j.drugalcdep.2015.10.022Get rights and content

Highlights

  • The majority of sex workers reported inconsistent condom use with intimate partners.

  • Providing drugs or money were independently correlated with inconsistent condom use.

  • Intimate partner violence was independently correlated with inconsistent condom use.

  • Dyad-level factors shape sexual and drug-related HIV/STI risks for sex workers.

  • Couple and gender-focused interventions efforts are needed to reduce HIV/STI risks.

Abstract

Background

Despite high HIV burden among sex workers (SWs) globally, and relatively high prevalence of client condom use, research on potential HIV/STI risk pathways of intimate partnerships is limited. This study investigated partner/dyad-level factors associated with inconsistent condom use among SWs with intimate partners in Vancouver, Canada.

Methods

Baseline data (2010–2013) were drawn from a community-based prospective cohort of women SWs. Multivariable generalized estimating equations logistic regression examined dyad-level factors associated with inconsistent condom use (<100% in last six months) with up to three male intimate partners per SW. Adjusted odds ratios and 95% confidence intervals were reported (AOR[95%CI]).

Results

Overall, 369 SWs reported having at least one intimate partner, with 70.1% reporting inconsistent condom use. Median length of partnerships was 1.8 years, with longer duration linked to inconsistent condom use. In multivariable analysis, dyad factors significantly associated with increased odds of inconsistent condom use included: having a cohabiting (5.43[2.53–11.66]) or non-cohabiting intimate partner (2.15[1.11–4.19]) (versus casual partner), providing drugs (3.04[1.47–6.30]) or financial support to an intimate partner (2.46[1.05–5.74]), physical intimate partner violence (2.20[1.17–4.12]), and an intimate partner providing physical safety (2.08[1.11–3.91]); non-injection drug use was associated with a 68% reduced odds (0.32[0.17–0.60]).

Conclusions

Our study highlights the complex role of dyad-level factors in shaping sexual and drug-related HIV/STI risk pathways for SWs from intimate partners. Couple and gender-focused interventions efforts are needed to reduce HIV/STI risks to SWs through intimate partnerships. This research supports further calls for integrated violence and HIV prevention within broader sexual/reproductive health efforts for SWs.

Introduction

Intimate partner relationships are an important determinant of sex workers’ (SWs’) health and well being, including shaping HIV-related vulnerability and risk of other sexually transmitted infections (STIs). Globally, SWs face disproportionately high levels of HIV and related harms, with significant heterogeneity across settings (Kerrigan et al., 2013, Shannon et al., 2015). Overall, the prevalence of HIV among SWs has been estimated to be 11.8% in lower and middle-income countries (LMICs) and 1.8% in higher income settings (Baral et al., 2012, Beyrer et al., 2015a, Beyrer et al., 2015b). As in the general population, condom use with intimate or non-paying partners is consistently low among SWs, including being significantly lower than with clients (Argento et al., 2014, Deering et al., 2011, Johnson et al., 2001, Murray et al., 2007); this is a nearly universal trend, yet research and HIV prevention efforts that explore dyad-level factors within SWs’ intimate partnerships (with non-paying male partners) are limited. The complex roles of intimacy, gendered power, and pregnancy intentions are rarely considered at a partner/dyad-level. The majority of the literature focuses on SWs’ paying partners and increasing condom use with clients (Ang and Morisky, 2012, Blankenship et al., 2008, Krüsi et al., 2012, Urada et al., 2013).

Several studies have examined differences in prevalence of SWs’ condom use by clients versus with intimate partners; results from Benin and Cambodia indicate that close to 80% of SWs report using condoms with clients in the past week, compared to 20% with their intimate partners (Alary et al., 2002, Wong et al., 2003). Similarly, a study in India found that between 7 and 12% of SWs reported inconsistent condom use with occasional clients, while 58–97% reported inconsistent condom use with intimate partners (Travasso et al., 2014). Among SWs in a US study, 56% reported always using condoms with their clients, compared to 32% and 14% with occasional partners and regular partners, respectively (Johnson et al., 2001). With the advent of the HIV/AIDS epidemic and ensuing prevention programs, there has been a significant shift in SWs’ awareness of and insistence on using condoms with clients, however, this does not reflect in SWs’ intimate partner relationships.

Several studies highlight the importance of socio-structural factors and community empowerment efforts in preventing the transmission of HIV among SWs by increasing prevalence of client condom use (Blankenship et al., 2008, Decker et al., 2014, Erausquin et al., 2012, Lippman et al., 2010, Pando et al., 2013, Shannon et al., 2009). While community/SW-led and structural interventions show promising results for reducing HIV/STI related risks, HIV prevention interventions that focus on behavior change may not be successful in increasing condom use by intimate partners (Foss et al., 2007). A recent brief behavioral intervention targeting SWs effectively increased client condom use, yet failed to increase condom use by intimate partners (Ulibarri et al., 2012).

Economic and emotional elements are often fused in intimate relationships, making the decision to use condoms or not a complex social and cultural phenomenon. Intimacy and gender roles within SWs’ non-paying partnerships may influence sexual decision-making power, including negotiating condom use (Bourgois et al., 2004, El-Bassel et al., 2005, Shannon et al., 2008). For example, in a study among Cambodian SWs, the main reason cited for why clients did not use condoms was because the SW could not persuade clients to; with intimate partners the main reason cited was love (Wong et al., 2003). Qualitative research conducted in India and Cambodia revealed that some SWs’ intimate partners refused to use condoms, suggesting that the male partner perceived condoms as symbolically preventing intimacy and that a woman's request to use condoms with her intimate partner violates traditional gender roles, potentially leading to experiences of physical violence (Argento et al., 2011, Maher et al., 2013). Emerging evidence highlights sexual relationship power and intimate partner violence (IPV) as key dyad-level factors associated with unprotected sex among SWs with their intimate partners (Ulibarri et al., 2015), and dual drug and sexual risk behaviors may significantly enhance risks for HIV transmission among drug-using couples (El-Bassel et al., 2011). Therefore, an understanding of the socio-structural determinants of HIV risk pathways for SWs, with special consideration of the ways in which dyad-level dynamics shape risks with intimate partners, is essential to inform evidence-based interventions for HIV.

To facilitate a better understanding of the sexual and drug-related HIV/STI risk pathways of intimate partnerships, this study aimed to investigate partner/dyad-level factors associated with inconsistent condom use among street- and off-street SWs with intimate partners in Metro Vancouver, Canada.

Section snippets

Study design and sample

This study is nested within a large, community-based open prospective cohort of women SWs, known as AESHA (An Evaluation of Sex Workers Health Access). AESHA was initiated in 2010 and consists of over 800 street and off-street SWs across Metro Vancouver. AESHA is based on substantial collaborations with community members and service providers since 2004 and is continuously monitored by a Community Advisory Board of over 15 sex work, women's health and HIV service agencies, as well as

Descriptive results

Overall, 369 SWs reported having at least one intimate partner in the last six months, with a mean of 2.2 intimate partners per SW (standard deviation = 7.5). Of the 448 total observations used in the analysis, the majority (n = 314, 70.1%) reported inconsistent condom use by their intimate partners. The median age of all participants was 33 (interquartile range [IQR] = 26–40) and three quarters (73.7%) were born in Canada, with 36.6% identifying as being of Aboriginal ancestry. Overall, one quarter

Discussion

Almost three-quarters of SWs reported inconsistent condom use with intimate partners in the last six months, similar to estimates in the general Canadian population (Black et al., 2009). Dyad-level factors independently correlated with inconsistent condom use with intimate partners among SWs in this setting included having a cohabiting or non-cohabiting intimate partner, providing drugs or financial support to an intimate partner, having an intimate partner provide physical safety, physical

Role of funding source

This work is supported by operating grants from the US National Institutes of Health (R01DA028648) and Canadian Institutes of Health Research (HHP-98835). KS is supported by a Canada Research Chair in Global Sexual Health and HIV/AIDS and Michael Smith Foundation for Health Research CI- 5CH -03018 (11-1). KD is supported by CIHR and MSFHR.

Contributors

Conceived and designed the experiments: EA KS KND. Performed the experiments: EA KS KND. Analyzed the data: PN SD. Wrote the paper: EA KS PN SD JC KND. Wrote the first draft and integrated suggestions from all authors: EA. Made significant contributions to the interpretation of the data, drafting of the manuscript: EA KS PN SD JC KND. Approved the final manuscript: EA KS PN SD JC KND.

Conflict of interest statement

No conflict declared.

Acknowledgments

We thank all those who contributed their time and expertise to this project, including participants, partner agencies and the AESHA Community Advisory Board. We wish to acknowledge Chrissy Taylor, Jennifer Morris, Sarah Allan, Peter Vann, Brittney Udall, Chantelle Fifton, Sandra Cortina, Sylvia Machat, Eva Breternitz, Julia Homer, Andrea Krusi, Emily Leake, Jane Li, Rachel Nicoletti, Tina Ok, Sabina Dobrer, Paul Nguyen, Ofer Amram, and Jill Chettiar for their research and administrative support.

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