Assessing and Addressing Social Determinants of HIV among Female Sex Workers in the Dominican Republic and Tanzania through Community Empowerment-Based Responses

BACKGROUND Cisgender female sex workers (FSW) experience high rates of HIV and sexually transmitted infections (STIs) including chlamydia and gonorrhea. Community empowerment-based responses to the risk environment of female sex workers have been associated with significant reductions in HIV/STI risk and associated risk behaviors, yet evaluations of U.S. based interventions targeting FSW are limited. OBJECTIVE We describe the design, implementation, and evaluation of an ongoing comprehensive community-level intervention targeting FSW in Baltimore City, Maryland. METHODS The two intervention components are the SPARC drop-in center and the accompanying comprehensive mobile outreach program (in the west Baltimore area). The mission of SPARC is to provide low-barrier harm reduction services to at-risk non-men, with a special focus on women who sell sex and use drugs. SPARC addresses clients’ needs through nonjudgmental, convenient, safe, and non-stigmatizing interactions. Services are provided through a harm reduction framework and include: reproductive health and sexual health screenings; medication assisted treatment; legal aid, counseling; showers, lockers, laundry; and the distribution of harm reduction tools including naloxone and sterile drug use supplies (e.g., cookers, cotton, syringes, pipes). The SPARC intervention is being evaluated through the EMERALD study, which consists of: a prospective two-group comparative non-randomized trial (n=385); a cross sectional survey (n=100); and in-depth interviews assessing SPARC implementation (n=45). Participants enrolled in the non-randomized trial complete a survey and HIV/STI testing at four intervals (baseline, 6-, 12-, 18-months). Participants recruited from pre-defined areas closest to SPARC comprised the intervention group, and participants from all other areas of Baltimore were in the control. RESULTS We hypothesize that addressing structural drivers and more immediate medical needs, in combination with peer outreach, will lead to community empowerment and reduce FSWs’ HIV/STI cumulative incidence and behavioral risks. CONCLUSIONS In the United States, structural interventions aimed to reduce HIV and STIs among FSW are scarce, and to our knowledge this is the first intervention of its kind in the United States. The results of the EMERALD study can be used to inform the development of future interventions targeting FSW and other at-risk populations. CLINICALTRIAL NCT04413591

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Exploring peer navigation and support in the quality of HIV care experiences of female sex workers in the Dominican Republic

BMC Health Services Research ◽

10.1186/s12913-021-07439-4 ◽

2022 ◽

Vol 22 (1) ◽

Author(s):

Tahilin Sanchez Karver ◽

Clare Barrington ◽

Yeycy Donastorg ◽

Martha Perez ◽

Hoisex Gomez ◽

...

Keyword(s):

Dominican Republic ◽

Sex Workers ◽

Female Sex Workers ◽

Hiv Treatment ◽

Hiv Care ◽

Care Providers ◽

Female Sex ◽

Care Services ◽

Peer Navigation

Abstract Background Despite evidence on peer navigation’s association with positive HIV outcomes, such as engagement in HIV care and antiretroviral therapy (ART) initiation, the mechanisms through which peer navigation may influence these outcomes have been less explored. The purpose of this study is to describe the role of peer navigation and support on enhancing the quality of HIV treatment and care services experienced by female sex workers (FSWs). Methods Survey data was derived from a quantitative cohort (n = 211) of FSWs living with HIV in the Dominican Republic and complemented with data from two rounds of in-depth interviews (IDIs) from a qualitative subsample (n = 20 per round). Descriptive statistics and multivariable logistic regressions were used to explore the association between peer navigation and relational aspects of care and overall satisfaction of the quality of HIV treatment and care. Thematic analysis was employed to code and synthesize textual data from IDIs. Results 41.2% of the participants reported having had contact with a peer navigator in the last 6 months. Qualitative data revealed that peer navigation and support was instrumental in assisting FSWs linkage to HIV care after diagnosis, elevating FSWs’ ability to access more comprehensive clinical care facilities, and promoting agency by improving FSWs’ skills to more strategically and effectively engage with the clinic environment and health care providers. Peer navigation was positively associated with experiencing more respectful treatment by clinic staff (AOR: 6.65, 95% CI: 2.32–19.02), and greater satisfaction with overall HIV care services (AOR: 2.57, 95% CI: 1.77–3.74). Conclusion Promoting the full integration of peer navigation into healthcare structures is a strategic approach to enhance the quality of HIV care experienced by FSWs and improve their HIV-related outcomes.

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Co-occurring Threats to Agency Among Female Sex Workers in Baltimore, Maryland

Journal of Interpersonal Violence ◽

10.1177/0886260520978188 ◽

2020 ◽

pp. 088626052097818

Author(s):

Danielle F. Nestadt ◽

Catherine Tomko ◽

Kristin E. Schneider ◽

Deanna Kerrigan ◽

Michele R. Decker ◽

...

Keyword(s):

Drug Use ◽

Sex Work ◽

Sex Workers ◽

Female Sex Workers ◽

Latent Class ◽

Community Empowerment ◽

Sense Of Agency ◽

Structural Factors ◽

Unequal Distribution ◽

Female Sex

Driven largely by the unequal distribution of power, female sex workers (FSW) globally bear a disproportionately high burden of HIV, sexually transmitted infections, and interpersonal violence. Prior literature has identified a number of multi-level factors that may serve to constrain FSWs’ agency, or their ability to define and take action to realize goals. Among these are work-based violence and substance use, which are potentiated by the criminalization of sex work and structural vulnerability. Quantitative research related to U.S.-based FSWs’ own sense of agency, as well as the barriers that may impede it, is sparse. We sought to identify patterns of various threats to agency and explore to what extent they were associated with perceived agency among a cohort of 381 FSW in Baltimore, Maryland, United States, using latent class analysis. Latent class indictors were past-six-month experience of client-perpetrated sexual violence, client-perpetrated physical violence, homelessness, food insecurity, arrest, daily crack-cocaine use, and daily heroin use. Perceived agency was measured using the short form of the Pearlin Mastery Scale. We identified three typologies of threatened agency among women in our sample: a “threatened by structural factors, drug use, and violence” class, a “threatened by structural factors and drug use” class, and a “less threatened” class. Mean perceived agency score was significantly lower for the class characterized by client-perpetrated violence than for either of the other classes. This suggests violence, in the context of deeper, structural power imbalances embedded in hunger, homelessness, and drug use, may dramatically reduce one’s sense of agency and operate as a critical barrier to empowerment. Our study adds important insights to the broader FSW community empowerment literature and supports the need for interventions to bolster both individual and collective agency among U.S.-based FSW, including interventions to prevent sex work-related violence.

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