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Universal Coverage without Universal Access : Institutional Barriers to Health Care among Women Sex Workers… Socías, María Eugenia; Shoveller, Jean; Bean, Chili; Nguyen, Paul; Shannon, Kate 2016

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RESEARCH ARTICLEUniversal Coverage without Universal Access:Institutional Barriers to Health Care amongWomen Sex Workers in Vancouver, CanadaM. Eugenia Socías1,2, Jean Shoveller3, Chili Bean4, Paul Nguyen1, Julio Montaner1,2,Kate Shannon1,2*1 British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, Canada,2 Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC, Canada,3 School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada, 4 SexWorkers United Against Violence Society, Vancouver, BC, Canada* gshi@cfenet.ubc.caAbstractBackgroundAccess to health care is a crucial determinant of health. Yet, even within settings that pur-port to provide universal health coverage (UHC), sex workers’ experiences reveal system-atic, institutionally ingrained barriers to appropriate quality health care. The aim of this studywas to assess prevalence and correlates of institutional barriers to care among sex workersin a setting with UHC.MethodsData was drawn from an ongoing community-based, prospective cohort of women sexworkers in Vancouver, Canada (An Evaluation of Sex Workers’ Health Access). Multivari-able logistic regression analyses, using generalized estimating equations (GEE), wereemployed to longitudinally investigate correlates of institutional barriers to care over a 44-month follow-up period (January 2010-August 2013).ResultsIn total, 723 sex workers were included, contributing to 2506 observations. Over the studyperiod, 509 (70.4%) women reported one or more institutional barriers to care. The mostcommonly reported institutional barriers to care were long wait times (54.6%), limited hoursof operation (36.5%), and perceived disrespect by health care providers (26.1%). In multi-variable GEE analyses, recent partner- (adjusted odds ratio [AOR] = 1.46, % 95% Confi-dence Interval [CI] 1.10–1.94), workplace- (AOR = 1.31, 95% CI 1.05–1.63), andcommunity-level violence (AOR = 1.41, 95% CI 1.04–1.92), as well as other markers of vul-nerability, such as self-identification as a gender/sexual minority (AOR = 1.32, 95% CI1.03–1.69), a mental illness diagnosis (AOR = 1.66, 95% CI 1.34–2.06), and lack ofPLOS ONE | DOI:10.1371/journal.pone.0155828 May 16, 2016 1 / 15a11111OPEN ACCESSCitation: Socías ME, Shoveller J, Bean C, Nguyen P,Montaner J, Shannon K (2016) Universal Coveragewithout Universal Access: Institutional Barriers toHealth Care among Women Sex Workers inVancouver, Canada. PLoS ONE 11(5): e0155828.doi:10.1371/journal.pone.0155828Editor: Eduard J Beck, UNAIDS, TRINIDAD ANDTOBAGOReceived: November 23, 2015Accepted: May 4, 2016Published: May 16, 2016Copyright: © 2016 Socías et al. This is an openaccess article distributed under the terms of theCreative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in anymedium, provided the original author and source arecredited.Data Availability Statement: Due to the highlycriminalized and stigmatized nature of this population,anonymized data may be made available on requestsubject to the UBC/ Providence Health EthicalReview Board, and consistent with our funding bodyguidelines (NIH and CIHR). Requests should bedirected to This research was supported by operatinggrants from the US National Institutes of Health(R01DA028648), the Canadian Institutes of HealthResearch (HHP-98835), the Canadian Institutes ofHealth Research/Public Health Agency of Canadaprovincial health insurance card (AOR = 3.47, 95% CI 1.59–7.57) emerged as independentcorrelates of institutional barriers to health services.DiscussionDespite Canada’s UHC, women sex workers in Vancouver face high prevalence of institu-tional barriers to care, with highest burden among most marginalized women. These find-ings underscore the need to explore new models of care, alongside broader policy changesto fulfill sex workers’ health and human rights.IntroductionAs a basic human right and a critical determinant of individual and population health out-comes [1], Universal Health Coverage (UHC) is the subject of a globally approved UnitedNations General Assembly resolution (A.67/81) [2], and has emerged as a key component ofthe 2030 Sustainable Development Goals [3]. Accumulating evidence suggest that access tohealth services is a multidimensional concept that results from the interaction between individ-ual factors, social and physical living and working environments, the characteristics of thehealth system, and macro-structural-level factors (e.g., laws and policies) [4–6]. Among these,health system-related factors, including service accessibility (e.g., distance/transportation),availability (e.g., waiting times), and acceptability (e.g., language and cultural barriers, enactedand perceived stigma) have been acknowledged as particularly important from a health policyperspective as they concomitantly disenfranchise those most in need, while being most amena-ble to institutional-level interventions (e.g., funding formulae; hospital policies; legal frame-works) [7, 8].Although Canada is frequently described as a leader in the realization of UHC [9], in reality,many Canadians, including women, recent immigrants, Aboriginal people, and youth, facemultiple institutionally-generated barriers when trying to access good quality and appropriatehealth services [10–15]. As a result, many postpone or forgo seeking care, with potentially cata-strophic impacts on their health [16, 17].Research shows that in Canada, and in other contexts that criminalize sex work, sex workersbear an array of health and social harms, including violence, exposure to HIV and other STIs,and substance use that require attention within the health care system [18–21]. While access tohealth care has been identified as a key determinant of sex workers’ health [18, 22], research oninstitutional-level barriers that affect sex workers’ access to appropriate and high-quality healthcare remains limited, particularly in settings with UHC. To address this gap, the current studydocuments the prevalence and correlates of institutional-level barriers to health servicesamong a prospective cohort of street- and off-street sex workers in Vancouver, Canada.Materials and MethodsStudy design, population and proceduresAn Evaluation of Sex Workers’Health Access (AESHA) is an ongoing community-based, pro-spective cohort of sex workers beginning in 2010, that was developed based on community col-laborations with sex work agencies since 2005, and that has been described in detail previously[23]. In brief, using time-location sampling [24, 25], sex workers are recruited through out-reach during alternate working hours to outdoor/public (e.g., streets, alleys), indoor (e.g.,Institutional Barriers to Care among SexWorkersPLOS ONE | DOI:10.1371/journal.pone.0155828 May 16, 2016 2 / 15(HEB-330155), and MacAIDS. KS is partiallysupported by a Canada Research Chair in GlobalSexual Health and HIV/AIDS and Michael SmithFoundation for Health Research. MES is a MichaelSmith Foundation for Health Research Post-DoctoralFellow. JM is supported with grants paid to hisinstitution by the British Columbia Ministry of Healthand by the US National Institutes of Health(R01DA036307).Competing Interests: JM has received limitedunrestricted funding, paid to his institution, fromAbbvie, Bristol-Myers Squibb, Gilead Sciences,Janssen, Merck, and ViiV Healthcare. This does notalter the authors’ adherence to PLOS ONE policieson sharing data and materials.massage parlours, micro-brothels), and off-street (e.g., online and newspapers advertisements)sex work venues across Metro Vancouver. These venues are identified and regularly updatedthrough community mapping with current/former sex workers. Individuals aged 14 years andolder, who self-identify as women, have exchanged sex for money in the previous 30 days atbaseline, and provide written informed consent, are eligible for inclusion.After providing written informed consent, at baseline, and on a bi-annual basis thereafter,participants complete an interviewer-administered questionnaire, followed by voluntary HIV/HCV/STI testing. Basic treatment for STIs is also offered onsite, regardless of participation inthe study. Interview, outreach and nursing staff include both experiential (current/former sexworkers) and non-experiential staff with substantial community rapport. The questionnairecollects socio-demographic data, sex work and drug use patterns, and physical, social-struc-tural characteristics of the working and living environment, as well as information on overallhealth and wellness, and health services access and utilization. Participants receive an honorar-ium of $40CAD for their time and expertise at each study visit. The study has been approvedby the Providence Health Care/University of British Columbia Research Ethics Board, and ismonitored by a community advisory board of 15+ women, sex work and policy partner agen-cies. For the current analysis, cohort participants who completed at least one study visitbetween January 1, 2010 and August 31, 2013 were eligible for inclusion. Thus, the cohort dataused in this analysis was collected during the same time frame.Study variablesThe primary outcome of interest for this study was a time-updated variable (using the prior 6months as a reference point) of having experienced one or more institutional-level barriers toaccessing health care. Institutional-level barriers were categorized in two broad ways: (1) Avail-ability of care (operationalized as having experienced no or poor access to care due to any or allof the following: limited hours of operation or limited number of physicians at clinical site(s),and long wait times); and (2) Acceptability of care (operationalized as having experienced poorquality care due to any or all of the following: was not served in preferred language, health careprovider of preferred sex/gender was not available, and felt disrespected by health careproviders).Based on prior literature examining access to health care we considered a number of inde-pendent variables that have been shown to influence access to health services, with a particularfocus on social-structural-level factors [4, 5, 22]. Time-fixed variables of interest at baselineincluded: socio-demographic characteristics, such as: age, Indigenous/Aboriginal ancestry; sex-ual/gender identity (lesbian, gay, bisexual, transgender or two-spirit,—LGBT2S—versus cis-gender and straight); and migration status (immigrant versus Canadian-born). All other vari-ables considered were time-updated variables at each semi-annual follow-up using the last 6months as a reference point, and were dichotomized (yes versus no) unless otherwise specified.These include: individual medical comorbidities (HIV and HCV sero-status, and self-reportedlifetime diagnosis of mental illness, including depression, post-traumatic stress disorder, anxi-ety, schizophrenia, and borderline personality); individual behaviours, such as non-injection orinjection drug use; and interpersonal-level risks, such as physical/sexual violence by partners orclients. We also accounted for other previous experiences of violence, including having beenthreatened/verbally assaulted by community residents or businesses, self-reported policeharassment, arrest, and incarceration. Furthermore, the analysis included other structural-levelfactors, such as unstable housing (i.e.,1 night in a single room occupancy hotel, shelter, treat-ment/recovery house, couch surfing, staying in a vehicle, on the street/alley/park), financiallysupporting dependents (e.g., child or partner), having a provincial health insurance card; asInstitutional Barriers to Care among SexWorkersPLOS ONE | DOI:10.1371/journal.pone.0155828 May 16, 2016 3 / 15well as physical and social features of the environments where sex workers provide primarilyservices (formal sex work establishment, such as massage/beauty parlours or micro-brothels;informal indoor venues, such as sauna, bar/clubs, hotel/hourly rental, or clients’ house; or out-door/public space, such as street, public washroom, or car).Statistical AnalysesAs a first step we examined individual-, interpersonal- and structural-level factors among par-ticipants at baseline, stratified by having experienced institutional-level barriers to care at somepoint during the study period. Since analyses of factors potentially associated with reportinginstitutional barriers to health care included serial measures for each participant, we then ranbivariate and multivariable logistic regression using generalized estimating equations (GEE)analyses with a logit link for the dichotomous outcome. The GEE method provides standarderrors adjusted for the repeated measurements from the same participant using an exchange-able correlation structure. Variables found to be associated with institutional-level barriers at p<0.10 level in bivariate analyses were considered for inclusion into the multivariable model. Asin previous research [26, 27], the multivariable model was built using a backward selectionapproach. Quasi-likelihood under the independence model criterion (QIC) was used to identifythe model with the best overall fit as indicated by the lowest QIC value [28]. A complete caseanalysis approach was employed, where cases with missing observations were excluded fromthe multivariable analyses. This reduced the data set available for the multivariable analysisfrom 2506 to 2457 observations. All statistical analyses were performed using the SAS softwareversion 9.4 (SAS Institute, Cary, NC, USA).ResultsIn total, 723 sex workers were included, with a median age of 34.5 years (Interquartile range[IQR] 28.0–42.0). As shown in Table 1, over a third were of Indigenous ancestry (35.8%), andover a quarter were immigrants to Canada (27.4%). Overall, 11.2% participants were livingwith HIV and 41.8% with HCV. Recent use of non-injection and injection drugs at the time ofenrolment was relatively high, 68.6% and 39.4% respectively. These 723 sex workers contrib-uted to 2506 observations for this analysis. The median duration of follow-up per participantwas 18.2 months (IQR 0–30.8) months, which corresponds to a median number of study visitsof 3 (IQR 1–5). Over the study period, there were 1097 institutional-level barrier events(43.8%), with 509 participants (70.4%) reporting at least one time when they could not accesscare due to institutional-level barriers. As indicated in Fig 1, the most frequently reported insti-tutional-level barriers were those related to service availability including long wait times(54.6%) and limited hours of operation (36.5%). In addition, over one-quarter of study partici-pants reported having been unable to access acceptable health care due to feeling disrespectedby health care providers (26.1%).Table 2 presents results of the bivariate and multivariable GEE logistic regression analyses.In the bivariate analysis, factors positively associated with experiencing institutional barriersover the study period included self-identification as a gender/sexual minority, having ever beendiagnosed with a mental illness, recent use of injection drugs, having experienced violence byintimate partners and/or clients, not having a provincial health insurance card, having beenthreatened by community residents or businesses, and having been harassed or arrested by thepolice. On the contrary, women living with HIV and immigrant participants had reduced oddsof experiencing these barriers.In the multivariable GEE model, self-identification as a gender/sexual minority (adjustedodds ratio [AOR] = 1.32, 95% Confidence Interval [CI] 1.03–1.69), having ever been diagnosedInstitutional Barriers to Care among SexWorkersPLOS ONE | DOI:10.1371/journal.pone.0155828 May 16, 2016 4 / 15with a mental illness (AOR = 1.66, 95% CI 1.34–2.06), having experienced violence by intimatepartners (AOR = 1.46, 95% CI 1.10–1.94) or clients (AOR = 1.31, 95% CI 1.05–1.63), not hav-ing a provincial health insurance card (AOR = 3.47, 95% CI 1.59–7.57), and having beenthreatened by community residents or businesses (AOR = 1.41, 95% CI 1.04–1.92) remainedindependently associated with increased odds of experiencing institutional barriers to care;while women living with HIV remained associated with reduced odds (AOR = 0.54, 95% CI0.39–0.72).DiscussionDespite Canada’s universal health system, our results show that women sex workers in Van-couver face high prevalence of institutional barriers to health care. Over a 44-month follow-upperiod, seven of every ten participants reported institutional barriers to health services, approx-imately three-times higher than estimates of difficulty accessing care among the general Cana-dian population [11, 29]. Long wait times were the most frequently experienced institutional-Table 1. Baseline characteristics of sex workers, stratified by self-reported institutional-level barriers to health care at some point during thestudy period, Vancouver, Canada, 2010–2013.Characteristic Total, n (%)† (N = 723) Institutional barriers to healthcare*, n (%)Yes (n = 509) No (n = 214)Individual-level factorsAge <25 years old 96 (13.3) 63 (12.4) 33 (15.4)Indigenous ancestry 259 (35.8) 196 (38.5) 63 (29.4)Sexual/gender minority 184 (25.5) 146 (28.7) 38 (17.8)Immigrant to Canada 198 (27.4) 114 (22.4) 84 (39.3)HIV positive* 81 (11.2) 56 (11.0) 25 (11.7)HCV positive* 302 (41.8) 232 (45.6) 70 (32.7)Mental health illness* 347 (48.0) 282 (55.4) 65 (30.4)Non-injection drug use* 496 (68.6) 376 (73.9) 120 (56.1)Injection drug use* 285 (39.4) 227 (44.6) 58 (27.1)Interpersonal-level factorsPhysical/sexual violence by partners* 109 (15.1) 89 (17.5) 20 (9.4)Physical/sexual violence by clients* 168 (23.2) 131 (25.7) 37 (17.3)Structural-level factorsUnstable housing* 590 (81.6) 420 (82.5) 170 (79.4)Supports others financially* 209 (28.9) 133 (26.1) 76 (35.5)No provincial health insurance card* 12 (1.7) 7 (1.4) 5 (2.4)Primary place of servicing clients*Formal sex work/in-call establishment 222 (30.7) 127 (25.0) 95 (44.4)Informal indoor venue 189 (26.1) 141 (27.7) 48 (22.4)Outdoor/public space 312 (43.2) 241 (47.4) 71 (33.2)Threatened/ verbally assaulted by community residents or businesses* 103 (14.3) 90 (17.7) 13 (6.1)Police harassment without arrest* 272 (37.6) 204 (40.1) 68 (31.8)Police arrest* 49 (6.8) 40 (7.9) 9 (4.2)Incarceration* 108 (14.9) 82 (16.1) 26 (12.2)* Time-updated variable using last 6 months as a reference point† Percentages may not necessarily sum to 100% due to missing observations or rounding error.doi:10.1371/journal.pone.0155828.t001Institutional Barriers to Care among SexWorkersPLOS ONE | DOI:10.1371/journal.pone.0155828 May 16, 2016 5 / 15level barrier, affecting more than half of the sex workers evaluated. Moreover, one quarter ofstudy participants reported that feeling disrespected by health care providers interfered withtheir ability to access care. Alarmingly, those who may have the greatest and most complexhealth care needs, including sex workers with mental illnesses and victims of gender-based vio-lence, were also more likely to report institutional barriers. Lack of training and sensitivity ofhealth care providers to marginalized populations is concerning, and warrants immediateaction at different levels, ranging from medical education and training to anti-discriminatoryhealth policies.A key and extremely relevant finding of the current study is that sex workers reporting hav-ing experienced violent events, either at the partner-, workplace- (i.e., client violence), or com-munity-level (i.e., threatened by community residents or businesses), were at 30% to 50%increased odds of experiencing institutional barriers to health care. This is in line with previousresearch demonstrating links between partner- and workplace-based violence and reducedaccess to health services [20, 30–32]. These findings reflect the pervasiveness of violence, aswell as ongoing stigma and discrimination against sex workers. Indeed, an emerging body ofevidence indicates that sex workers suffer a disproportionate burden of violence compared tothe general population of women, which is usually enhanced by the cultural taboos against thesell of sex and the criminalized or quasi-criminalized nature of sex work prevailing in manyparts of the world [31, 33–35]. Fear of arrest or police harassment forces sex workers to workin more isolated and hidden spaces, limiting their ability to work together, and placing them atincreased risk of violence [22]. Further, criminalization contributes to an environment, whereviolence against sex workers is seen as normal or justified [18]. Gender-based violence, in turn,is a well-known structural determinant of multiple adverse health outcomes, includingincreased risk for HIV infection, unintended pregnancies, mental health problems, and mortal-ity [31, 36]. Collectively, these findings point to the importance of a human rights approach tothe provision of health care, as well as other potential health-related benefits of decriminalizingsex work. Sex workers' safety and access to health services and other support resources is aFig 1. Frequency of institutional-level barriers to health care among sex workers in Vancouver, Canada, 2010–2013.doi:10.1371/journal.pone.0155828.g001Institutional Barriers to Care among SexWorkersPLOS ONE | DOI:10.1371/journal.pone.0155828 May 16, 2016 6 / 15public health imperative [19, 20, 37]. In addition, evidence from other settings suggests thatcommunity empowerment and other health-promoting institutional arrangements (e.g., sexwork collectives and unions) may also buttress other macro-level reforms (e.g., legal reformsregarding sex work), as well as other efforts to address violence reduction and promote moreaccessible and acceptable forms of health care for sex workers [38–42]. Alongside these effortsto reduce violence, systems should be put in place to rapidly respond when an episode of vio-lence occur, and facilitate access of victims of violence to non-judgemental health services,peer-based interventions, counselling and other relevant legal and social support [43].Unsurprisingly, not having a provincial health insurance card was a strong correlate ofreporting institutional-level barriers to health care. Despite Canada’s national publicly fundedhealth system, a substantial number of individuals lack health insurance, mainly homeless andmigrants with precarious status, all of whom might face multiple and intersecting health andsocial disparities [44–47]. Disrespectful treatment by health care providers, distance to avail-able health services or limited knowledge on how to navigate them, as well as fear of beingdenounced to immigration among migrants with precarious status are obstacles frequentlyTable 2. Bivariate andmultivariable GEE logistic regression analyses of correlates of self-reporting institutional barriers to health care among aprospective community cohort of sex workers in Vancouver, Canada, 2010–2013.Characteristic Odds Ratio (95% CI)Unadjusted Adjusted‡Individual-level factorsAge <25 years old (yes vs. no) † 1.35 (0.96–1.88)Indigenous ancestry (yes vs. no) 0.96 (0.78–1.20)Sexual/gender minority (yes vs. no) † 1.49 (1.17–1.89) 1.32 (1.03–1.69)Immigrant to Canada (yes vs. no) † 0.78 (0.61–1.00)HIV-positive (yes vs. no) *† 0.57 (0.42–0.78) 0.54 (0.39–0.72)HCV-positive (yes vs. no) * 0.86 (0.69–1.06)Mental health illness (yes vs. no) *† 1.79 (1.45–2.20) 1.66 (1.34–2.06)Non-injection drug use (yes vs. no) * 1.07 (0.86–1.32)Injection drug use (yes vs. no) *† 1.22 (1.01–1.48)Interpersonal-level factorsPhysical/sexual violence by partners (yes vs. no) *† 1.70 (1.30–2.21) 1.46 (1.10–1.94)Physical/sexual violence by clients (yes vs. no) *† 1.53 (1.25–1.88) 1.31 (1.05–1.63)Structural-level factorsUnstable housing (yes vs. no) * 1.15 (0.95–1.40)Supports other financially (yes vs. no) * 1.13 (0.93–1.38)No provincial health insurance card (yes vs. no) *† 2.19 (1.02–4.72) 3.47 (1.59–7.57)Primary place of servicing clients (ref: formal sex work establishment/in-call venue) *informal indoor venue 1.07 (0.83–1.37)outdoor/public space 1.20 (0.93–1.57)Threatened/ verbally assaulted by community residents or businesses (yes vs. no) *† 1.73 (1.30–2.30) 1.41 (1.04–1.92)Police harassment without arrest (yes vs. no) *† 1.30 (1.09–1.54)Police arrest (yes vs. no) *† 1.89 (1.23–2.90) 1.52 (0.96–2.41)Incarceration (yes vs. no) * 1.17 (0.91–1.49)* Time-updated variable using last 6 months as a reference point† Significant at p <0.10 in the unadjusted analyses and considered as potential confounders in the multivariable model selection process.‡ Only the final list of variables included in the multivariable model after variable selection is included in this column.doi:10.1371/journal.pone.0155828.t002Institutional Barriers to Care among SexWorkersPLOS ONE | DOI:10.1371/journal.pone.0155828 May 16, 2016 7 / 15reported by these vulnerable groups [45, 46, 48, 49]. These barriers are often exacerbatedamong sex workers due to the criminalized and highly stigmatized nature of sex work in Can-ada [46, 47, 50]. In addition to being excluded from publicly funded coverage, uninsured indi-viduals usually cannot seek private health insurance due to high costs and/or lack ofcitizenship status [45, 46, 48, 49]. Indeed, previous research in Vancouver shows that recentmigrant women sex workers have 3-fold increased odds of unmet health care needs comparedto Canadian-born counterparts [51]. While community-based health centres offer no-costcare, their long waiting lists and enrolment requirements (e.g., to live within clinic’s catchmentarea, to have identification documents) often result in postponement or avoidance of care [46].Collectively, these data underscore the urgent need for structural-level interventions to removebarriers to care, particularly among medically uninsured sex workers. Models from a variety ofsettings, including the Mobile Access Project (MAP van) in Vancouver, Canada, the St. JamesInfirmary in San Francisco, CA, USA, and the Sonagachi Project in India, indicate that peer/sex worker-driven models are critical to facilitate access to health services for hidden, stigma-tized and highly mobile populations such as under housed and migrant sex workers [27, 52–55]. The elimination of waiting periods for provincial health insurance, alongside increases ofhuman and financial resources allocated to community health clinics and relaxation of theirenrolment criteria could go a long way to addressing the pressing health care needs of this vul-nerable population [46].In the current analysis, sexual/gender minority women were more likely to experience insti-tutional-level barriers to care, reinforcing the urgent need for gender-sensitive and culturallyappropriate care that is tailored to the special needs of sexual and gender minorities. Although,the LGBT community is not a homogenous group, they share a long history of pervasive mar-ginalization and systematic exclusion, which continues to shape the numerous health inequitiesthat affect this population [56–59]. LGBT populations face multiple challenges in accessingappropriate care, including refusal of care, harassment, and lack of competent and sensitiveproviders with adequate knowledge of their unique needs, which may further exacerbate theseinequities [56, 57, 60–63]. Again, St. James Infirmary offers a best practices approach to sexworker-led occupational safety and health clinics for sex workers of all genders and sexual ori-entations [54]. Expanding and emphasizing LGBT-related topics in medical and nursingschools’ curricula, as well as recurrent training to health care workers could also contribute to amore knowledgeable and sensitive health care workforce. This, alongside the development ofstrong anti-discriminatory health policies will be critical for the achievement and sustainabilityof appropriate, safe and welcoming health service environments for all sex workers [64–66].It is well known that untreated mental health needs can have significant negative health andsocio-economic consequences, both for the individual and for the health system [67–71]. Thus,our findings that sex workers with mental disorders had increased odds of reporting institu-tional barriers to health services, including treatment for their mental health condition, ishighly concerning. Uptake of mental health services are known to be affected by several factors,including those at the intra- and inter-personal level (e.g., stigma, distrust about the effective-ness of treatments, low self-perceived need for services), as well as institutional-level barriers(e.g., availability and accessibility of services) [67, 72, 73]. Importantly, institutional barriersseem to be more prevalent among individuals with severe/moderate illnesses [67, 74, 75]. Inaddition, while services by psychiatrists are covered under the Canada’s UHC, other mentalhealth-related services, such as counselling or other psychosocial interventions, as well as out-patient prescription drugs are excluded, which might be contributing to a portion of unmetcare needs in this population [9]. Indeed, although to a lesser extent than the United States,financial barriers to mental health services are also reported in Canada [73, 76–78]. Further-more, and highly concerning, is that under the current Mental Health Act in British Columbia,Institutional Barriers to Care among SexWorkersPLOS ONE | DOI:10.1371/journal.pone.0155828 May 16, 2016 8 / 15individuals with presumptive mental illness can be involuntarily admitted to hospital basedsolely on police officers subjective diagnoses of potential harm to themselves or others (ratherthan on a professional medical evaluation) [79]. Altogether, these findings raise concern abouta potential hidden form of social control, and point to the need to revisit mental health servicesprovision and coverage by Canada’s publicly-funded health system, as well as to explore inter-ventions that take into account the specific needs of patients with mental illnesses in order toimprove their access to and quality of mental health services and other support resources, andultimately reduce health disparities.Finally, a somewhat unexpected finding of this analysis was that women living with HIVwere less likely to report institutional barriers to health care. Historically, women living withHIV have faced multiple barriers to appropriate and quality health care, including HIV relatedcare [80–82]. This is particularly true for key HIV-affected populations, such as women sexworkers. Pervasive stigma and discrimination within and outside the health sector, as well aspunitive laws targeting sex work, have been identified as important drivers of health care avoid-ance and sub-optimal HIV treatment outcomes among sex workers [22, 83–85]. However,within the current context in Vancouver, it could be the case that rapid scale up of an intensivegovernment-sponsored HIV prevention and care initiative [86], coupled with the roll-out ofwomen-centred care models [87] might have resulted in better access and engagement in HIVcare among women sex workers. This, in turn, might have contributed to improved generalcare among women living with HIV in our cohort. Yet, in a sub-analysis restricted to sex work-ers living with HIV, we found that marginalized sub-populations, including sexual/genderminorities, immigrants, and women without a provincial health insurance card were atincreased odds of reporting institutional barriers to health services (data not shown), highlight-ing the need for further research to examine access barriers as they specifically pertain towomen sex workers living with HIV. In addition, the evidence documenting the harms associ-ated with criminalization of sex work, including violence by clients and police, increased risk ofHIV, as well as food and housing insecurity, should not be overlooked [18, 20, 22, 31, 81]. Norshould we overlook the potential for criminalization of sex work and HIV to continue to pro-mote institutional level barriers to accessing health care through stigma, discrimination, andfear of legal reprisals, which creates serious impediments to a range of primary and secondaryprevention initiatives, in addition to HIV treatment efforts. As modelling studies indicate,decriminalization of sex work (as a single intervention) could avert approximately 40% of HIVinfections among sex workers and their clients in the next decade in Vancouver [22].A number of limitations should be considered in the interpretation of the current study.First, due to the criminalized and stigmatized nature of sex work in Canada, the study samplewas not randomly selected, and therefore our results might not be generalizable to all sex work-ers in Vancouver or to other settings with different health systems arrangements or sex worklaws. To mitigate this potential selection bias we employed time-location sampling [24, 25], awell-known strategy for achieving representative samples of hard-to-reach and hidden popula-tions. Second, this analysis relied on self-reported data that might have been affected by socialdesirability, underreporting or recall biases. However, all the interviews were conducted in safeand privacy-enhancing environments by interviewers with extensive experience and strongcommunity rapport (including experiential staff), and we have no reason to believe that therewould be differences in the reporting of sensitive data between participants who experiencedbarriers to health care and those who did not. Third, our primary outcome was based on a self-report measure over a 6-month recall period, which could have resulted in the underestimationof the real prevalence of institutional-level barriers to health care in this sample. Similarly, par-ticipants might have experienced other institutional-level barriers (e.g., costs, distance/trans-portation) that were not included in our questionnaire. Fourth, although this analysis relied onInstitutional Barriers to Care among SexWorkersPLOS ONE | DOI:10.1371/journal.pone.0155828 May 16, 2016 9 / 15prospective longitudinal data, the study design (e.g., 6-month reference point for both the timeupdated outcome and explanatory variables) does not permit the establishment of temporaland causal pathways.In summary, this study found that despite Canada’s universal health system, women sexworkers in Vancouver face alarmingly high prevalence of institutional-level barriers to healthservices, including long wait times, limited hours of operation, and perceived disrespect byhealth care providers. Further, consistent with the Inverse Care Law [88], some of the mostmarginalized women and with greatest health care needs in our sample were at increased riskof experiencing these barriers. First and foremost, our findings support global calls to theremoval of criminal sanctions against all aspects of sex work to fully fulfill women sex workershealth and human rights. In turn, results from this study highlight the need for safe andenabling environments that can promote sex workers’ access to appropriate health services.Globally, there are experiences of proportionate universalism approaches [89], where sex-worker-led, low-threshold service delivery models have been demonstrated to improve accessto care, and decrease the numerous health and social inequities faced by this population [27,52–55]. It is time to take similar action within the Canadian context in terms of our efforts toprovide universal access within a globally respected UHC system; too much is at stake to acceptthe status quo.AcknowledgmentsWe thank all those who contributed their time and expertise to this project, particularly partici-pants, AESHA community advisory board members and partner agencies. We wish toacknowledge Chrissy Taylor, Jennifer Morris, Tina Ok, Rachel Nicoletto, Julia Homer, EmilyLeake, Rachel Croy, Emily Groundwater, Meenakshi Mannoe, Silvia Machat, Jasmine McEa-chern, Brittany Udall, Chris Rzepa, Jungfei Zhang, Xin (Eleanor) Li, Melissa Braschel, KristaButler, Peter Vann, Sarah Allan and Jill Chettiar for their research and administrative support.Author ContributionsConceived and designed the experiments: MES KS. Analyzed the data: PN. Wrote the paper:MES. 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