Research paperCurrent and recent drug use intensifies sexual and structural HIV risk outcomes among female sex workers in the Russian Federation
Introduction
Female sex workers (FSWs) and people who inject drugs (PWID) are vulnerable populations for HIV acquisition and transmission, with a 13-fold increased odds of HIV infection for FSWs compared to the adult female population (Baral et al., 2012). While HIV epidemics have declined globally, nine countries, including the Russian Federation, have witnessed increased HIV incidence within the last decade (UNAIDS, 2012). The majority of these infections are concentrated among key populations, including FSW and PWID. While HIV epidemiology is distinct among these two populations, they share both behavioral risk factors and sexual networks (El-Bassel et al., 2014, Mazhnaya et al., 2014, Platt et al., 2007, Platt et al., 2013). At the confluence of injection drug use (IDU) and heterosexual HIV risks, female sex workers who inject drugs (FSW-PWIDs) are a dually high-risk group exposed to both sexual and parenteral transmission pathways (Strathdee et al., 2010, Ulibarri et al., 2011).
The broader risk environment shapes harms related to both substance use and sex work (Maher et al., 2011, Rhodes, 2002). This framework posits a reciprocal interaction of physical, social, economic, and policy-related factors that act at the micro and macro-levels to “impact the production or reduction of drug harms” or harms related to sex work (Rhodes, 2009). The interplay of these environmental factors and their impact on HIV among FSW and PWID is increasingly evident (Blanchard and Aral, 2010, Shannon et al., 2014b, Strathdee et al., 2010). For example, for PWID, criminalization and heavy policing of drug use may lead to hidden injecting practices and rushed safety precautions that increase opportunities for HIV transmission and acquisition (Strathdee et al., 2010). Likewise, the use of condoms as evidence of sex work by law enforcement may reduce FSWs’ condom carriage and subsequent use with clients (Wurth, Schleifer, McLemore, Todrys, & Amon, 2013). Harms within the risk environment may be most pronounced for FSW-PWIDs who work and live in the nexus of these risk environments and who may be more hidden in their sex work and drug use so as to avoid encounters with police (Deering et al., 2013).
Sexual and structural harms are considered particularly high in the Russian Federation, where criminalization of illicit drug use and administrative penalties for engagement in sex work impart risk for police harassment and violence (Arps and Golichenko, 2014, Elovich and Drucker, 2008, Odinokova et al., 2014). Here, sex work generally takes place in a variety of forms including a range from (but not limited to) individual street-based sex work to employment with an agency or totcka in which sex workers may work collectively on the street or in bars, hotels and other venues (Aral, St Lawrence, Dyatlov, & Kozlov, 2005). Though working with agencies or totchkas carry their own risks related to the power dynamics of the organization, they offer some source of protection against violence from clients and police. Individual street-based sex workers may choose to work independently, but many FSW who engage in IDU are often expelled or prohibited from working with an agency or totchka and tend to take on individual street-based work (Decker et al., 2014). These women, given the visibility of where they work and lack of protection, are often more vulnerable to violence perpetrated by clients, police, and strangers, and may also be targeted as a result of drug use (Aral et al., 2005).
Much of the HIV-related research on FSWs in the Russian Federation draws from samples of PWIDs who also engage in sex work, with far less known about non-PWID FSWs and how their sexual and structural risks compare with FSW-PWIDs (Abdala et al., 2008, Abdala et al., 2010, Platt et al., 2005, Platt et al., 2007, Platt et al., 2009). There is also a need to understand the risks among FSW-PWID who bring drug use to cessation. While ending IDU may reduce risks inherent in injecting drug use, these FSW may still experience the impact of the drug use risk environment and remain at risk of relapse and re-entry into this environment (El-Bassel et al., 2014, Shannon et al., 2014a). In this vein, there is a need to consider the respective risk environments of sex work and IDU and the dynamic movement between them in order to comprehensively inform HIV prevention in the region. In other settings, epidemiologic studies of HIV among FSW, however, typically include measures of lifetime or recent IDU and, justifiably, include IDU as a confounder in associations with HIV infection due to associated parenteral transmission. However, we hypothesize that sex work and IDU may synergistically increase risk. As such, the role of IDU in the risk environment may be much more complex for FSW than simply parenteral transmission risks. Reducing IDU among FSW in the Russian Federation may lead to important improvements in HIV risks for FSW. In 2011, we conducted a study of HIV epidemiology among FSW as part of an evaluation of the Globus HIV prevention program for FSW in three cities of the Russian Federation. These cities included Tomsk, Kazan, and Krasnoyarsk, where little HIV epidemiologic research has been conducted with FSW. With this analysis, we evaluate the role of injection status (non-injection, active, and former injecting) with sexual and structural HIV risk outcomes as well as engagement in HIV services among FSWs.
Section snippets
Methods
Following an extensive formative and qualitative phase, a cross-sectional quantitative survey was conducted among FSW from July through September 2011. Data collection was conducted within an evaluation of the Globus HIV prevention program for female sex workers. The Globus program constituted the most significant source of funding and prevention efforts for key populations in The Russian Federation and came from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Further details are
Results
Among the 754 FSWs enrolled across three sites, 11% (n = 81) were actively injecting drugs (within the last 6 mo.) and 11% (n = 82) were former injectors (prior to the last 6mo.), totaling 163 (22%) with any history of injection use. Table 1 presents the sociodemographic characteristics of participants by injection status. Across injection status, there were significant differences in age; almost half of non-injectors were comprised of the youngest age group, while those with injecting histories
Discussion
Overall, this study identifies variations in HIV risk profile based on injection status among FSWs from three cities in the Russian Federation. FSWs who reported no history of injection were exposed to some levels of violence, with 6–8% reporting recent physical or sexual client violence and 23% reporting recent police extortion. Relative to this group and controlling for other factors, active injectors had markedly higher HIV risk outcomes. These outcomes included increased risk for
Authors’ contribution
ALW, MRD, CB, AP and VNM collaborated in the design and oversight of the study. MRD and ALW developed survey instruments; and ALW conducted statistical analysis in consultation with MRD, CB, AP and VNM. ALW wrote the initial drafts of this manuscript; MRD, CB, AP and VNM provided critical review. All authors had full access to the data, reviewed and edited the manuscript, and all take responsibility for its integrity as well as the accuracy of the analysis.
Acknowledgements
This work was supported by the Global Fund through the Open Health Institute, the Johns Hopkins University Center for AIDS Research (1P30AI094189), and the National Institute on Drug Abuse (R03DA03569102). We thank the female sex workers who participated in this study, Svetlana Sadretdinova and her team at the Simona Clinic (Kazan, Russia), Marina Malisheva and Julia Burdina and their team at the Krasnyi Yar program (Krasnoyarsk, Russia), Nadezhda Ziryanova and Anna Petrova and their team at
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