Amphetamine-type stimulant use and HIV/STI risk behaviour among young female sex workers in Phnom Penh, Cambodia

Abstract

Background

Use of amphetamine-type substances (ATS) has been linked to increased risk of HIV and other sexually transmitted infections (STI) worldwide. In Cambodia, recent ATS use is independently associated with incident STI infection among young female sex workers (FSWs).

Methods

We conducted 33 in-depth interviews with women (15–29 years old) engaged in sex work to explore ATS use and vulnerability to HIV/STI.

Results

Participants reported that ATS, primarily methamphetamine in pill and crystalline forms (yama), were cheap, widely available and commonly used. Yama was described as a “power drug” (thnam kamlang) which enabled women to work long hours and serve more customers. Use of ATS by clients was also common, with some providing drugs for women and/or encouraging their use, often resulting in prolonged sexual activity. Requests for unprotected sex were also more common among alternatives intoxicated clients and strategies typically employed to negotiate condom use were less effective.

Conclusion

ATS use was highly functional for young women engaged in sex work, facilitating a sense of power and agency and highlighting the occupational significance and normalization of ATS in this setting. This highly gendered dynamic supports the limited but emerging literature on women's use of ATS, which to date has been heavily focused on men. Results indicate an urgent need to increase awareness of the risks associated with ATS use, to provide women with sustainable alternatives for income generation, to better regulate the conditions of sex work, and to work with FSWs and their clients to develop and promote culturally appropriate harm reduction interventions.

Introduction

Worldwide, more than 30 million people aged 15 years and older are estimated to be infected with HIV, the majority (95%) in developing countries (UNAIDS, 2007). Asia, where the epidemic is expanding rapidly, accounts for an increasing proportion of global HIV infections (22%) (Cohen, 2004). In South and South East Asia, 29% of adults living with HIV in 2007 were women (up from 26% in 2001), and 40% of young people living with HIV are women and girls (UNAIDS, 2007). Asian women represent a large population in need of effective and culturally appropriate HIV prevention.

In 2007, an estimated 0.9% of the Cambodian population, or 65,000 people, were living with HIV (NCHADS, 2006, UNAIDS, 2007). Despite improvements in access to screening and antiretroviral therapy (ART) (Charles, 2006, NCHADS, 2006) increased condom use and reductions in commercial sex transactions (Saphonn et al., 2005), HIV and other STI prevalence among female sex workers (FSWs) remains high (Sopheab, Morineau, Neal, Saphonn, & Fylkesnes, 2008). HIV sentinel surveillance (HSS) indicates that FSWs have consistently had the highest HIV prevalence among all groups in Cambodia (NCHADS, 2006). HIV prevalence among direct FSWs was 14% in 2006. While data on indirect FSWs (women working in the sex industry indirectly in entertainment and drinking establishments) was not collected in the 2006 HSS, a recent study of ‘beer girls’ found that one in four women were HIV positive (Kim et al., 2005).

This is consistent with preliminary data from our recent study which found an HIV prevalence of 23% among young women engaged in sex work in Phnom Penh (Couture et al., 2011) Incidence of HIV in this study was 3.6 per 100 person-years observation and for STI (gonorrhoea and chlamydia), 21.2 per 100 person-years observation. Exposures independently associated with incident STI infection included duration (per year) of sex work (adjusted hazard ratio (AHR) 1.1; 95% CI: 1.1–1.2) and recent use of yama, a commonly used amphetamine-type substance (ATS) in Southeast Asia (AHR 4.3; 95% CI: 1.7–11.0) (Couture et al., 2011). Further analyses revealed independent associations between ATS use and increased numbers of sexual partners among women working in entertainment establishments (RR 2.51; 95% CI: 1.59–3.70) and brothels (RR 1.57; 95% CI: 1.09–2.28) and significant associations with inconsistent condom use among women working in multiple venues (OR 4.95; 95% CI: 1.23–29.8) (Couture et al., 2010).

ATS are synthetic psychostimulants such as methamphetamine, amphetamine and ecstasy which can be injected, smoked, or taken orally. Administration results in feelings of euphoria, alertness, arousal and increased libido and increases in heart rate, respiratory rate, blood pressure and perceived increases in confidence, energy and physical strength (Barr et al., 2006). With prolonged use and in high doses ATS can also produce anxiety, hyper-vigilance, paranoia, psychosis, severe panic and other serious adverse conditions (Barr et al., 2006, Hanson et al., 2004). Internationally, ATS use has been associated with increased HIV risk in young people (Moon, Binson, Page-Shafer, & Diaz, 2001), injecting drug users (Buavirat et al., 2003), non-injecting drug users (Molitor, Ruiz, Flynn, Mikanda, Sun, & Anderson, 1999) and HIV positive heterosexually identified men (Wohl et al., 2002).

In Cambodia, despite concerns that escalating ATS use may lead to a reversal of downward trends in HIV, ATS use and HIV risk among FSWs has received little attention. Recent epidemiological data (Couture et al., 2011) emphasize the need to understand how socio-cultural factors mediate the complex relationships between sex work, drug use and risk behaviour. We conducted qualitative research to further explore these relationships.