UBC Faculty Research and Publications

Early sex work initiation independently elevates odds of HIV infection and police arrest among adult… Goldenberg, Shira M.; Chettiar, Jill; Simo, Annick; Silverman, Jay G.; Strathdee, Steffanie A.; Montaner, Julio; Shannon, Kate Jan 1, 2015

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata


52383-Goldenberg_S_et_al_Early_sex_work.pdf [ 60.72kB ]
JSON: 52383-1.0320889.json
JSON-LD: 52383-1.0320889-ld.json
RDF/XML (Pretty): 52383-1.0320889-rdf.xml
RDF/JSON: 52383-1.0320889-rdf.json
Turtle: 52383-1.0320889-turtle.txt
N-Triples: 52383-1.0320889-rdf-ntriples.txt
Original Record: 52383-1.0320889-source.json
Full Text

Full Text

Early sex work initiation independently elevates odds of HIVinfection and police arrest among adult sex workers in aCanadian settingShira M. GOLDENBERG1,2, Jill CHETTIAR2, Annick SIMO2, Jay G. SILVERMAN1, SteffanieA. STRATHDEE1, Julio MONTANER2,3, and Kate SHANNON2,31Division of Global Public Health, University of California San Diego2Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St.Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y63Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 BurrardStreet, Vancouver, BC, CANADA, V6Z 1Y6AbstractObjectives—To explore factors associated with early sex work initiation, and model theindependent effect of early initiation on HIV infection and prostitution arrests among adult sexworkers (SWs).Design—Baseline data (2010–2011) were drawn from a cohort of SWs who exchanged sex formoney within the last month and were recruited through time-location sampling in Vancouver,Canada. Analyses were restricted to adults ≥18 years old.Methods—SWs completed a questionnaire and HIV/STI testing. Using multivariate logisticregression, we identified associations with early sex work initiation (<18 years old) andconstructed confounder models examining the independent effect of early initiation on HIV andprostitution arrests among adult SWs.Results—Of 508 SWs, 193 (38.0%) reported early sex work initiation, with 78.53% primarilystreet-involved SWs and 21.46% off-street SWs. HIV prevalence was 11.22%, which was 19.69%among early initiates. Early initiates were more likely to be Canadian-born (Adjusted Odds Ratio(AOR): 6.8, 95% Confidence Interval (CI): 2.42–19.02), inject drugs (AOR: 1.6, 95%CI: 1.0–2.5),and to have worked for a manager (AOR: 2.22, 95%CI: 1.3–3.6) or been coerced into sex work(AOR: 2.3, 95%CI: 1.14–4.44). Early initiation retained an independent effect on increased risk ofHIV infection (AOR: 2.5, 95% CI: 1.3–3.2) and prostitution arrests (AOR: 2.0, 95%CI: 1.3–3.2).Conclusions—Adolescent sex work initiation is concentrated among marginalized, drug andstreet-involved SWs. Early initiation holds an independent increased effect on HIV infection andCorresponding Author: Kate Shannon, PhD, MPH, Assistant Professor, Department of Medicine, University of British Columbia,Director, Gender and Sexual Health Initiative, B.C. Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard St.,Vancouver, BC, V6Z 1Y6, Canada, Tel: (604) 804-9459, Fax: (604) 806-9044, gshi@cfenet.ubc.ca.Conflicts of InterestThe authors declare no conflict of interest.NIH Public AccessAuthor ManuscriptJ Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.Published in final edited form as:J Acquir Immune Defic Syndr. 2014 January 1; 65(1): 122–128. doi:10.1097/QAI.0b013e3182a98ee6.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptcriminalization of adult SWs. Findings suggest the need for evidence-based approaches to reduceharm among adult and youth SWs.Keywordssex work; youth; adolescent; HIV; sexually transmitted infections; criminalization; policingINTRODUCTIONYouth who exchange sex are vulnerable to HIV infection, sexually transmitted infections(STIs), physical and sexual violence, substance use, and mental health disorders.[1–8] Theestimated prevalence of runaway and homeless youth who have been involved in sex workin North America ranges from 10–40%,[2] with up to 40% of individuals engaged in sexwork reported to be under age 18.[7, 8]Data from Canada, India, Nepal, and Thailand indicate that sex work entry prior to age 18may relate to an higher risk of HIV infection.[9–11] Sex workers’ (SWs) vulnerability toHIV and STIs is shaped by behavioral and interpersonal (e.g., sexual and drug use riskpractices), biological (e.g., the synergistic relationship between HIV and STI infection), andsocial-structural factors (e.g., sex work regulatory policies and their enforcement, violence,barriers to care).[12] Among younger SWs, individual biological factors increase the risk ofHIV/STI transmission, such as the larger areas of cervical ectopy and trauma to an immaturegenital tract experienced by younger women and girls during intercourse.[11, 13] Individualbehaviours such as drug use – particularly injection drug use – have also been associatedwith youth sex work involvement in Canada and Mexico.[3, 5, 8, 14–16] For example,among street youth in Montreal, predictors of sex work entry included using heroin, usingdrugs more than twice per week, and injection drug use.[15] Further, interpersonal factorssuch as challenges negotiating condom use with clients have been linked to earlier age ofsex work entry in South and South East Asia.[8, 11, 17]Sex workers’ health also depends on social-structural factors, such as laws and policiesgoverning sex work and their enforcement;[1, 14, 18–21] exposure to new risk environmentsas a consequence of migration [22–25]; and work environment factors, including third party(e.g., manager, pimp) roles [7, 26, 27] and features of sex work solicitation spaces, wherebystreet-based venues are often associated with HIV risk and youth sex work entry.[26, 28–30]Among adult SWs, the impacts of such social-structural factors include HIV/STI infection[1, 20, 31–35], inconsistent condom use [21, 36–39], and workplace violence [1, 18]. Forexample, criminalization of adult SWs through police arrest, harassment and violence hasbeen shown to exacerbate HIV risk by displacing women to isolated settings, posing barriersto health and support services, and increasing risk of HIV infection and client violence.[1,14, 18–21, 34, 35, 40, 41] Yet, data regarding the health and drug-related harms ofcriminalization for females who enter sex work during adolescence is notably lacking.Although interventions aimed at populations at greatest risk of HIV infection – such asadolescents in the sex industry – are globally recognized as critical to HIV preventionefforts, youth involved in sex work remain an under-recognized, poorly understoodpopulation.[7] Given the critical need for data regarding their experiences and health careGOLDENBERG et al. Page 2J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptneeds, we undertook this study to investigate the context and HIV-related health impacts ofyouth sex work, which are needed to inform public health interventions.[7]Objectives were to (1) explore individual, interpersonal, and social-structural factorsassociated with early sex work initiation (<18 years), and (2) model the independent effectof early sex work initiation on HIV infection and prostitution arrests among adult sexworkers (SWs) in Vancouver, Canada.METHODSSettingThis study took place in Vancouver, Canada, where SWs are highly criminalized andexperience multiple health-related harms, including HIV, STIs, and physical and sexualviolence.[1, 9, 14, 18] Substantial overlap exists between open street-based sex work anddrug use in Vancouver, which hosts the largest and most heavily concentrated open illicitdrug use scene in North America.[42] In Canada, the buying and selling of sex is only legalamong adults 18 years of age or older, and as such, many services and drop-in spaces for sexworkers do not serve SWs under 18 years of age. Moreover, laws and provisions prohibitingcommunication in public spaces for purposes of sex exchange, operation of a bawdy house,or living off the avails of prostitution create a criminalized sex work environment.Consequently, SWs are often displaced to work in more dangerous and deserted settings(e.g., alleys, side streets and industrial areas) where they lack protection from violence andexploitation, and experience reduced access to health and social services.[21]Data collectionBaseline data was drawn from an open prospective cohort, An Evaluation of Sex WorkersHealth Access (AESHA) between January 2010 and October 2011. This study wasdeveloped based on community collaborations with sex work agencies since 2005[43] and ismonitored by a Community Advisory Board encompassing 15+ agencies. Eligibility criteriaincluded self-identified as female (including transgender (male-to-female)), exchanged sexfor money within the last 30 days and able to provide written informed consent. Given thatadults and youth (< 18 years old) are differentially treated by Canada’s criminal justicesystem and in order to evaluate the relationship between early sex work entry and futureprostitution arrests during adulthood, analyses were restricted to 508 adult SWs (18 years ofage or older) at baseline.Given the challenges of recruiting SWs in isolated and hidden locations [44], time-locationsampling was used to recruit SWs through outreach to outdoor/public (e.g., streets, alleys),off-street (e.g., online, newspaper advertisements) and indoor sex work locations (e.g.,massage parlours, micro-brothels, and in-call locations) across Metro Vancouver. Aspreviously described, indoor sex work venues and outdoor solicitation spaces (‘strolls’) wereidentified through community mapping [43] and updated by the outreach team on anongoing basis. SWs were given the option of completing questionnaires at study offices inMetro Vancouver or at their work or home location. Participants received $40CAD at eachvisit for their time, expertise and travel. All SWs provided informed consent prior toGOLDENBERG et al. Page 3J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptparticipating in the study. Study procedures were approved by the Providence Health Care/University of British Columbia Research Ethics Board, and were conducted in accordancewith the principles of the Declaration of Helsinki.Dependent Variable—Our primary dependent variable was early age of sex workinitiation, defined as the exchange of sex for money before 18 years of age (vs. 18+ years ofage).Covariates of Interest—SWs completed interviewer-administered questionnaires andreceived HIV/STI testing by a project nurse (as described below). The questionnaire coveredsocio-demographic characteristics (e.g., age, education, ethnicity), and sexual (e.g.,average number of clients per night/shift, week, and month and inconsistent condom useduring vaginal, oral, or anal sex with clients, in past 6 months) and drug (e.g., injection andnon-injection drug use, past 6 months and lifetime) risk patterns. Information was collectedon SWs’ work environment, including primary places of solicitation and servicing clientsin the past 6 months, physical conditions of street and indoor venues, establishment policies,interactions with managers (or pimps), police, security, city licensing, and occupationalviolence. Sex work solicitation spaces were measured based on primary place reported inresponse to “ways you solicited/hooked up with your clients?” in the last six months, andcoded as street/public space (e.g. street, park, alley); indoor (e.g. in-call/home, bar/club,massage parlour/health enhancement spa, home/micro-brothel or other managed indoorvenue); or off-street independent (e.g. escort agency, newspaper ads, online/newspaper self-advertizing, 1–800, phone/text). Worked for a manager/pimp was based on a “yes”response to “Have you ever paid someone like a manager, administrator, or pimp, or had toshare with someone a percentage of your income from clients?” Self-reported policeharassment without arrest were based on a “yes” response to any of ever told to move on,police raid (indoor venue), threatened with arrest/detainment/fine, searched without arrest,followed, picked up and driven elsewhere, verbally harassed, detained, drugs/drug useequipment taken, other property taken), and self-reported police abuse was based on a“yes” response to any of ever physically assaulted, propositioned to exchange sex, orcoerced into providing sexual favours. Self-reported police arrest on sex work-relatedcharges were based on lifetime arrest for any of the following criminal sanctions targetingadult sex workers: prohibitions on a) ‘communicating for purposes of prostitution publicspaces’; b) ‘working or operating a common bawdy house’; or c) ‘living off the avails ofprostitution’. Migration-related measures included birthplace, current place of residence,and recent migration, defined as having moved to Metro Vancouver from another country orcity ≤5 years ago (vs. moved to Metro Vancouver > 5 years ago or lived in Vancouver entirelife). Questions on past experiences of coercion/exploitation included being “turned out”/coerced at time of sex work entry, which was defined as a response of “Turned out (coercedinto work)” to the question, “How did you first get into sex work?”HIV/STI Outcomes of Interest—Following extensive pre-test counselling, BiolyticalINSTI [Biolytical Laboratories Inc, Richmond, BC] rapid tests were used for HIV screening,with reactive tests confirmed by blood draw for western blot at the BC Centre for DiseaseControl. Urine samples were collected for gonorrhea and chlamydia, and blood was drawnGOLDENBERG et al. Page 4J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptfor syphilis, HCV-2 antibody and HCV testing. Syphilis was tested using the rapid plasmareagin (RPR) (97.2% Se and 94.1% Sp) and the Treponema pallidum hemagglutinin assay(TPHA) for all samples with positive RPRs. RPR titers≥1:8 was considered indicative ofactive infection in the absence of treatment. All participants received post-test counselling.Treatment was provided by a project nurse onsite for symptomatic STIs, and free serologyand Papanicolaou testing were made available, regardless of study enrolment. STI/HIVinfection was defined as positive for any STI (syphilis, gonorrhea, or Chlamydia) or HIVinfection.Statistical AnalysesWe fit an explanatory model to identify associations with early sex work initiation (<18years vs. 18+). To evaluate differences in individual, interpersonal, and social-structuralfactors and HIV/STIs between SWs who reported early vs. later sex work entry, we used T-tests or Wilcoxon rank sum tests for continuous outcomes and Pearson’s Chi-squared orFisher’s exact test for binary outcomes. Univariate and multivariate logistic regressions wereperformed to identify individual, interpersonal, and social-structural correlates of early sexwork entry. Variables hypothesized a priori to be related to early sex work entry and with asignificance level of <10% in univariate regressions were considered for inclusion inmultivariate models. Model selection was constructed using a backward process. Akaike’sInformation Criteria (AIC) was used to determine the most parsimonious model.Next, we constructed confounder models to examine the independent effect of early sexwork entry on (1) HIV infection and (2) police arrests for prostitution charges (any of‘communicating in public spaces’, ‘working in a common bawdy house’, ‘living off theavails of prostitution’). Models were adjusted for key variables based on the results of ourexplanatory model. Sensitivity analyses were also conducted to explore the potentialconfounding effect of younger age of early sex work initiation (<16 years vs. 16+) on HIVinfection and police arrests for prostitution charges.RESULTSOf 508 adult SWs, 193 (38.0%) reported early sex work entry (< 18 years old) (Table 1); ofthese, 133 (68.91%) initiated sex work prior to age 16. The median age at sex work entrywas 20 years old (IQR: 15–30), which was 14 among those who began sex work asadolescents (vs. 27 among those who began as adults). Across the sample, median durationof sex work was 11 years (IQR: 4–19). Among early initiates, in the last 6 months, 78.53%solicited clients in primarily street-based settings, and 21.46% in off-street (i.e., indoor/independent) settings. HIV prevalence was 11.22%, which was 19.69% among earlyinitiates (Odds Ratio (OR): 3.82, 95% Confidence Interval (CI): 2.13–6.85). The combinedprevalence of any STI/HIV was 20.87% (n=106), which was 33.16% among SWs whoentered sex work during adolescence (OR: 3.32, 95% CI: 2.07–5.02).In comparison with participants who entered sex work as adults, those who reported earlyinitiation were more likely to report using injection (54.92% vs. 28.89%, p<0.001) and non-injection drugs (90.16% vs. 57.14%, p<0.001), and inconsistent condom use with clients(21.24% vs. 12.70%, p<0.011). Among participants with a history of injection drug useGOLDENBERG et al. Page 5J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript(n=257), 84 (32.68%) initiated injection drug use prior to age 18. Compared to later initiates,women who began sex work during adolescence were less likely to be foreign-born (2.59%vs. 62.22%, p<0.001) or recent migrants to Vancouver (16.06% vs. 32.38%, p<0.001).These women were more likely to report prior homelessness (89.64% vs. 54.60%, p<0.001)and to currently work on the street (78.53%), rather than in indoor (6.28%) venues(p<0.001). Early initiates also reported greater exposure to self-reported police harassment(74.61% vs. 49.21%, p<0.001), self-reported police abuse (27.98% vs. 12.06%, p<0.001),and self-reported arrest on prostitution charges (43.52% vs. 15.87%, p<0.001) than womenwho reported later sex work entry. Those who began sex work as youth were also morelikely to have worked for a manager or pimp (37.82% vs. 15.56%, p<0.001) or to reporthaving been “turned out” or coerced into sex work (20.73% vs. 5.40%, p<0.001).In unadjusted analysis, individual and interpersonal factors positively associated with earlysex work entry included recent injection and non-injection drug use and inconsistentcondom use with clients. Social-structural factors negatively associated with early initiationincluded recent migration to Vancouver and working indoors. Prior homelessness, beingCanadian-born, self-reported police harassment without arrest, police abuse, and arrest onprostitution charges, and having worked for a manager or been “turned out” or coerced intosex work were positively associated with early sex work entry. Early initiation was alsoassociated with increased risk of HIV infection and STIs.In a multivariate explanatory model, after adjusting for other factors, injection drug use(AOR: 1.59, 95%CI: 1.03–2.46), being Canadian-born (AOR: 6.79, 95%CI: 2.42–19.02),and having worked for a manager or pimp (AOR: 2.22, 95%CI: 1.35–3.63) or been “turnedout” or coerced into sex work (AOR: 2.25, 95%CI: 1.14–4.44) were positively associatedwith early sex work entry (Table 2). In separate confounder models (Table 3), early sexwork entry (<18 years) retained an increased independent effect on HIV infection (AOR:2.49, 95% CI: 1.35–4.64) and self-reported arrest on prostitution charges (AOR: 2.07,95%CI: 1.32–3.25). Sensitivity analysis using a younger age cut-off (<16 years) indicatedthat earlier age of adolescent sex work entry (defined as <16 years) retained an independentincreased effect on HIV infection (AOR: 1.88, 95%CI: 1.03–3.42) and arrest on prostitutioncharges (AOR: 2.75, 95%CI: 1.73–4.36).DISCUSSIONIn this study, 38% of sex workers reported early sex work entry before 18 years of age – aproportion that is consistent with estimates from diverse settings suggesting that between20–40% of sex workers initiate sex work as adolescents.[7, 8, 18, 45, 46] The vast majoritywere among street-based sex workers. In the current study, these participants were morelikely to be Canadian-born (vs. foreign-born), inject drugs, and to have worked for amanager during their lifetime. Initiation of sex work during adolescence was further shownto independently increase the odds of HIV infection and self-reported prostitution arrests.Contrary to public concerns around the exploitation and trafficking of young migrants,[47]adolescent sex workers were significantly less likely to be migrants from other countries orprovinces. Instead, these findings suggest that youth sex work is concentrated amongGOLDENBERG et al. Page 6J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptCanadian-born, marginalized, drug and street-involved sex workers. These participants weremore likely to have had a manager and to report prior coercion into the sex industry, whichis supported by prior studies indicating the potential for increased vulnerability toexploitation and trafficking among street-involved youth [7, 48, 49]. However, in this study,prior coercion was only reported by a minority of participants who began sex work asadolescents (20.73%), indicating the importance of distinguishing between youth sex workand coercion or trafficking into the sex industry [48].Whereas prior studies investigating the relationship between HIV and early sex work entryin Asia have postulated that sexual risks such as difficulties negotiating condom use withclients may explain increased HIV prevalence among this population,[11, 13, 17] ourmultivariate results emphasized the dominant role of injection drug use in potentiallyexplaining these differences. Our study adds to a growing body of North American evidenceregarding the key role of injection drug use in shaping youth sex work involvement.[5, 8,15] Among SWs along the Mexico-U.S. border, those who began sex work duringadolescence were more likely than their adult counterparts to begin drug use after sex work,and early sex work entry was associated with forced injection drug use initiation, inhalantuse (a common marker for homelessness and street entrenchment), and HIV risk behaviors,including receptive syringe sharing.[8] Although drug dependent individuals may enter sexwork to support drug and subsistence needs,[3, 15, 16, 30, 50] sex work may also lead todrug use, especially during adolescence [8].In this study, early sex work entry was shown to increase the likelihood of HIV infectionamong sex workers. Alarmingly high HIV prevalence (19.69%) was found amongparticipants who reported entry prior to age 18, a figure that is approximately three timesgreater than those who entered sex work as adults. This observation is supported by researchfrom South and South East Asia demonstrating that early sex work entry confers a two tofour-fold increase in the odds of HIV infection.[11, 13] However, these prior studies havelargely linked increased HIV risk among this population to reduced condom negotiationabilities or coercion into sex work,[11] whereas our findings uniquely situate drug use andcriminalization as potential pathways to HIV infection among younger sex workers.Early sex work initiation was also independently associated with greater criminalizationduring adulthood. These results suggest that adolescent sex workers are highly criminalized,and that current prohibitive sex work laws may exacerbate the long-term health and socialimpacts of adolescent sex work. In Mexico, early initiates also reported greater exposure topolice violence, including sexual abuse to avoid arrest and syringe confiscation by police.[8]Globally, police arrest, harassment and violence have been shown to increase risk of HIVinfection and client violence, and to pose barriers to health and social services.[1, 14, 18–21,35, 40] In addition to the fact that criminalization of adult sex work has been linked to thesenegative outcomes, this evidence suggests that the current law enforcement approach mayalso be inadvertently criminalizing and further marginalizing younger populations in the sexindustry.GOLDENBERG et al. Page 7J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptStrengths and limitationsGiven our limited ability to infer causality due to the cross-sectional nature of our analysis,longitudinal and mixed methods studies are recommended to strengthen our understandingof the health impacts of adolescent sex work. To develop evidence-based interventions,future observational and intervention studies engaging adolescents currently within the sexindustry are needed. Given the self-reported nature of our policing variables, studiestriangulating epidemiologic and law enforcement data would further strengthen ourunderstanding of how criminalization shapes young sex workers’ health. Given that thebuying and selling of sex is only legal among adults 18 years of age or older in Canada, andas such many services and drop-in spaces for sex workers do not serve SWs under 18 yearsof age, our analysis employed a cut-off of age 18 to define early sex work initiation, whichalso allowed us to compare our findings with other studies conducted internationally, whichhave typically employed this cut-off. However, our sensitivity analyses suggested a strongerrelationship between an even earlier age of initiation (<16 years) and police arrest,indicating the inadvertent negative impact of criminalization on younger ages of youth andthe need to consider this in public health and social interventions.ConclusionThe strikingly high prevalence of HIV and its associations with adolescent sex workinitiation suggest an urgent need to reduce exploitation and improve the HIV preventioncapacities of younger sex workers, especially those who inject drugs. Although multi-levelinterventions incorporating interpersonal (e.g., increasing condom use) and social-structural(e.g., policy change, sex work collectivization) factors among adult SWs have proven to besuccessful in reducing risk of HIV/STI infection [51–55], interventions tailored to the needsof adolescent SWs have yet to be developed.[7] The development and scale-up of suchinterventions are urgently needed given that youth in the sex industry may be less likely tohave access to conventional HIV prevention services; in many settings, HIV-related servicesfor this population are absent, which also poses an ethical barrier to their recruitment andretention in epidemiological studies.These data contribute to a growing evidence base suggesting that the health impacts of sexwork strongly depend on its social-structural context.[26, 28–30, 56] In Canada and othersettings where sex work overlaps with drug markets (e.g., Mexico, United Kingdom),criminalization by police and drug use may disproportionately shape the risks experiencedby younger women in sex work.[30] These data underscore the importance of legal reformsand social supports to strengthen adolescent and adult sex workers’ rights. Findings suggestthe need to move away from a law enforcement approach to an evidence-based public healthapproach to reducing harm among younger sex workers.AcknowledgmentsWe thank all those who contributed their time and expertise to this project, including participants, partner agenciesand the AESHA Community Advisory Board. We wish to acknowledge Gina Willis, Peter Vann, Cindy Feng,Sabina Dorber, Paul Nguyen, Ofer Amram, Jill Chettiar, Jennifer Morris, Alex Scot and Kathleen Deering for theirresearch and administrative support. This research was supported by operating grants from the US NationalInstitutes of Health (R01DA028648) and Canadian Institutes of Health Research (HHP-98835). SG is supported bya Canadian Institutes of Health Research fellowship. JM is supported by an Avante Garde award from US NIHGOLDENBERG et al. Page 8J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript(DP1DA026182). KS is supported by US National Institutes of Health (R01DA028648), the Michael SmithFoundation for Health Research, and the Canadian Institutes of Health Research. SS is supported through USNational Institutes of Health (R01 DA023877). JC is supported through a Canadian Institutes of Health ResearchFrederick Banting and Charles Best Canada Graduate Scholarships Master’s Award.SG and KS conceptualized the study. SG led the analyses and drafted the manuscript. KS had full access to all ofthe data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis.JC coordinated field data collection. AS conducted the statistical analyses and all authors interpreted the results.AS, JC, JS, SS, JM, and KS critically revised and edited the manuscript and participated in interpretation of thefindings.References1. Shannon K, Kerr T, Allinott S, Chettiar J, Shoveller J, Tyndall MW. Social and structural violenceand power relations in mitigating HIV risk of drug-using women in survival sex work. SocialScience & Medicine. 2008; 66:911–921. [PubMed: 18155336]2. Haley N, Leclerc P, Lemire N, Boivin J, Frappier J, Claessens C. Prevalence of HIV infection andrisk behaviours among Montreal street youth. International Journal of STD & AIDS. 2000; 11:241–247. [PubMed: 10772087]3. Chettiar J, Shannon K, Wood E, Zhang R, Kerr T. Survival sex work involvement among street-involved youth who use drugs in a Canadian setting. Journal of Public Health. 2010; 32:322–327.[PubMed: 20061578]4. Stoltz JAM, Shannon K, Kerr T, Zhang R, Montaner JS, Wood E. Associations between childhoodmaltreatment and sex work in a cohort of drug-using youth. Social Science & Medicine. 2007;65:1214–1221. [PubMed: 17576029]5. Weber AE, Boivin JF, Blais L, Haley N, Roy É. HIV risk profile and prostitution among femalestreet youths. Journal of Urban Health. 2002; 79:525–535. [PubMed: 12468672]6. Miller CL, Spittal PM, LaLiberte N, Li K, Tyndall MW, O’Shaughnessy MV, et al. Femalesexperiencing sexual and drug vulnerabilities are at elevated risk for HIV infection among youth whouse injection drugs. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2002; 30:335–341.7. Silverman J. Adolescent female sex workers: invisibility, violence and HIV. Archives of Disease inChildhood. 2011; 96:478–481. [PubMed: 21357241]8. Goldenberg SM, Rangel G, Vera A, Patterson TL, Abramovitz D, Silverman JG, et al. Exploring theimpact of underage sex work among female sex workers in two Mexico-US border cities. AIDSBehav. 2012; 16:969–981. [PubMed: 22012147]9. Shannon K, Bright V, Gibson K, Tyndall MW. Sexual and drug-related vulnerabilities for HIVinfection among women engaged in survival sex work in Vancouver, Canada. Canadian Journal ofPublic Health. 2007; 98:465–469. [PubMed: 19039884]10. Silverman; JG, Decker M, Gupta J, Maheshwari A, Patel V, Raj A. HIV prevalence and predictorsamong rescued sex-trafficked women and girls in Mumbai, India. Journal of Acquired ImmuneDeficiency Syndromes. 2006; 43:588–593. [PubMed: 17019369]11. Silverman; JG, Decker M, Gupta J, Maheshwari A, Willis B, Raj A. HIV Prevalence andPredictors of Infection in Sex-Trafficked Nepalese Girls and Women. Journal of the AmericanMedical Association. 2007; 298:536–542. [PubMed: 17666674]12. Baral S, Beyrer C, Muessig K, Poteat T, Wirtz AL, Decker MR, et al. Burden of HIV amongfemale sex workers in low-income and middle-income countries: a systematic review and meta-analysis. The Lancet infectious diseases. 2012; 12:538–549. [PubMed: 22424777]13. Sarkar K, Bal B, Mukherjee R, Saha M, Chakraborty S, Niyogi S, et al. Young age is a risk factorfor HIV among female sex workers--An experience from India. Journal of Infection. 2006;53:255–259. [PubMed: 16386307]14. Shannon K, Rusch M, Shoveller J, Alexson D, Gibson K, Tyndall MW. Mapping violence andpolicing as an environmental-structural barrier to health service and syringe availability amongsubstance-using women in street-level sex work. International Journal of Drug Policy. 2008;19:140–147. [PubMed: 18207725]15. Weber AE, Boivin JF, Blais L, Haley N, Roy É. Predictors of initiation into prostitution amongfemale street youths. Journal of Urban Health. 2004; 81:584–595. [PubMed: 15466840]GOLDENBERG et al. Page 9J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript16. Kerr T, Marshall B, Miller C, Shannon K, Zhang R, Montaner J, et al. Injection drug use amongstreet-involved youth in a Canadian setting. BMC Public Health. 2009; 9:171. [PubMed:19493353]17. Urada LA, Malow RM, Santos NC, Morisky DE. Age Differences among Female Sex Workers inthe Philippines: Sexual Risk Negotiations and Perceived Manager Advice. AIDS Research andTreatment. 201218. Shannon K, Kerr T, Strathdee SA, Shoveller J, Montaner JS, Tyndall MW. Prevalence andstructural correlates of gender based violence among a prospective cohort of female sex workers.BMJ: British Medical Journal. 2009:339.19. Simic M, Rhodes T. Violence, dignity and HIV vulnerability: street sex work in Serbia. SociolHealth Illn. 2009; 31:1–16. [PubMed: 19144087]20. Strathdee SA, Lozada R, Martinez G, Vera A, Rusch M, Nguyen L, et al. Social and StructuralFactors Associated with HIV Infection among Female Sex Workers Who Inject Drugs in theMexico-US Border Region. PLoS One. 2011; 6:e19048. [PubMed: 21541349]21. Shannon K, Strathdee SA, Shoveller J, Rusch M, Kerr T, Tyndall MW. Structural andenvironmental barriers to condom use negotiation with clients among female sex workers:implications for HIV-prevention strategies and policy. American Journal of Public Health. 2009;99:659–665. [PubMed: 19197086]22. Yi HS, Mantell JE, Wu RR, Lu Z, Zeng J, Wan YH. A profile of HIV risk factors in the context ofsex work environments among migrant female sex workers in Beijing, China. Psychology Health& Medicine. 2010; 15:172–187.23. Goldenberg S, Strathdee S, Gallardo M, Patterson T. “People Here Are Alone, Using Drugs,Selling their Body”: Deportation and HIV Vulnerability among Clients of Female Sex Workers inTijuana. Field Actions Science Reports. 2010:1–7.24. Bautista C, Mosquera C, Serra M, Gianella A, Avila M, Laguna-Torres V, et al. ImmigrationStatus and HIV-risk Related Behaviors among Female Sex Workers in South America. AIDS andBehavior. 2008; 12:195–201. [PubMed: 17587171]25. Ferguson AG, Morris CN. Mapping transactional sex on the Northern Corridor highway in Kenya.Health Place. 2007; 13:504–519. [PubMed: 16815730]26. Harcourt C, Donovan B. The many faces of sex work. Sexually Transmitted Infections. 2005;81:201–206. [PubMed: 15923285]27. Decker M, McCauley H, Phuengsamran D, Janyam S, Silverman J. Sex trafficking, sexual risk,sexually transmitted infection and reproductive health among female sex workers in Thailand.Journal of epidemiology and community health. 2011; 65:334–339. [PubMed: 20515895]28. Dandona R, Dandona L, Gutierrez J, Kumar A, McPherson S, Samuels F, et al. High risk of HIV innon-brothel based female sex workers in India. BMC Public Health. 2005; 5:87. [PubMed:16111497]29. Weitzer R. Sociology of sex work. Annual Review of Sociology. 2009; 35:213–234.30. Cusick L. Widening the harm reduction agenda: From drug use to sex work. International Journalof Drug Policy. 2006; 17:3–11.31. Ramesh S, Ganju D, Mahapatra B, Mishra RM, Saggurti N. Relationship between mobility,violence and HIV/STI among female sex workers in Andhra Pradesh, India. BMC Public Health.2012; 12:764. [PubMed: 22967276]32. Wirth KE, Tchetgen Tchetgen EJ, Silverman JG, Murray MB. How Does Sex Trafficking Increasethe Risk of HIV Infection? An Observational Study From Southern India. Am J Epidemiol. 201333. Wong ML, Chan R, Tan HH, Yong E, Lee L, Cutter J, et al. Sex Work and Risky Sexual Behaviorsamong Foreign Entertainment Workers in Urban Singapore: Findings from Mystery Client Survey.Journal of Urban Health-Bulletin of the New York Academy of Medicine. 2012; 89:1031–1044.[PubMed: 22707309]34. Shannon K, Csete J. Violence, condom negotiation, and HIV/STI risk among sex workers. JAMA:the journal of the American Medical Association. 2010; 304:573–574. [PubMed: 20682941]35. Strathdee SA, Lozada R, Pollini RA, Brouwer KC, Mantsios A, Abramovitz DA, et al. Individual,social, and environmental influences associated with HIV infection among injection drug users inTijuana, Mexico. J Acquir Immune Defic Syndr. 2008; 47:369–376. [PubMed: 18176320]GOLDENBERG et al. Page 10J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript36. Zhang C, Li X, Hong Y, Zhou Y, Liu W, Stanton B. Unprotected sex with their clients among low-paying female sex workers in southwest China. AIDS Care. 201237. Pando MA, Coloccini RS, Reynaga E, Rodriguez Fermepin M, Gallo Vaulet L, Kochel TJ, et al.Violence as a Barrier for HIV Prevention among Female Sex Workers in Argentina. PLoS One.2013; 8:e54147. [PubMed: 23342092]38. Erausquin JT, Reed E, Blankenship KM. Police-related experiences and HIV risk among femalesex workers in Andhra Pradesh, India. J Infect Dis. 2011; 204 (Suppl 5):S1223–1228. [PubMed:22043036]39. Braunstein SL, Ingabire CM, Geubbels E, Vyankandondera J, Umulisa M-M, Gahiro E, et al. HighBurden of Prevalent and Recently Acquired HIV among Female Sex Workers and Female HIVVoluntary Testing Center Clients in Kigali, Rwanda. PLoS One. 2011; 6:e24321. [PubMed:21949704]40. Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee SA. The social structural production ofHIV risk among injecting drug users. Soc Sci Med. 2005; 61:1026–1044. [PubMed: 15955404]41. Rhodes T, Simić M, Baroš S, Platt L, Žikić B. Police violence and sexual risk among female andtransvestite sex workers in Serbia: qualitative study. BMJ: British Medical Journal. 2008:337.42. Strathdee SA, Patrick DM, Currie SL, Cornelisse PGA, Rekart ML, Montaner JSG, et al. Needleexchange is not enough: lessons from the Vancouver injecting drug use study. AIDS. 199743. Shannon K, Bright V, Allinott S, Alexson D, Gibson K, Tyndall MW. Community-based HIVprevention among substance-using women in survival sex work: the Maka Project Partnership.Harm Reduction Journal. 200744. Stueve A, O’Donnell LN, Duran R, San Doval A, Blome J. Time-Space Sampling in MinorityCommunities: Results With Young Latino Men Who Have Sex With Men. Am J Public Health.2001; 91:922–926. [PubMed: 11392935]45. Sarkar K, Bal B, Mukherjee R, Chakraborty S, Saha S, Ghosh A, et al. Sex-trafficking, violence,negotiating skill, and HIV infection in brothel-based sex workers of eastern India, adjoining Nepal,Bhutan, and Bangladesh. Journal of health, population, and nutrition. 2008; 26:223–231.46. Wechsberg WM, Luseno WK, Lam WKK, Parry CDH, Morojele NK. Substance use, sexual risk,and violence: HIV prevention intervention with sex workers in Pretoria. AIDS and Behavior.2006; 10:131–137. [PubMed: 16482408]47. U.S. State Department. Trafficking in Persons Report. 2012.48. Goldenberg S, Silverman J, Bojorquez-Chapela I, Engstrom D, Usita P, Rolon M, et al. Exploringthe context of involuntary and adolescent sex industry involvement in Tijuana, Mexico:Consequences for HIV risk and prevention. Violence Against Women. In Press.49. Goldenberg S, Silverman J, Engstrom D, Bojorquez-Chapela I, Strathdee S. “Right here is thegateway”: Mobility, sex work entry and HIV risk along the Mexico-U.S. border. InternationalMigration. In Press.50. DeBeck K, Shannon K, Wood E, Li K, Montaner J, Kerr T. Income generating activities of peoplewho inject drugs. Drug and Alcohol Dependence. 2007; 91:50–56. [PubMed: 17561355]51. Kerrigan D, Moreno L, Rosario S, Gomez B, Jerez H, Barrington C, et al. Environmental-structuralinterventions to reduce HIV/STI risk among female sex workers in the Dominican Republic.American Journal of Public Health. 2006; 96:120–125. [PubMed: 16317215]52. Lippman SA, Donini A, Diaz J, Chinaglia M, Reingold A, Kerrigan D. Social-environmentalfactors and protective sexual behavior among sex workers: the Encontros intervention in Brazil.American Journal of Public Health. 2010; 100:S216–223. [PubMed: 19762673]53. Kerrigan D, Ellen JA, Moreno L, Rosario S, Katz J, Celentano DD, et al. Environmental-structuralfactors significantly associated with consistent condom use among female sex workers in theDominican Republic. AIDS. 2003; 17:415–423. [PubMed: 12556696]54. Jana S, Basu I, Rotheram-Borus MJ, Newman PA. The Sonagachi Project: a sustainablecommunity intervention program. Aids Education and Prevention. 2004; 16:405–414. [PubMed:15491952]55. Cohen J. Sonagachi sex workers stymie HIV. Science. 2004; 304:506–506. [PubMed: 15105470]GOLDENBERG et al. Page 11J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript56. Church S, Henderson M, Barnard M, Hart G. Violence by clients towards female prostitutes indifferent work settings: questionnaire survey. British Medical Journal. 2001; 322:524–525.[PubMed: 11230067]GOLDENBERG et al. Page 12J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptGOLDENBERG et al. Page 13Table 1Characteristics and unadjusted factors associated with early sex work initiation (<18 years old vs. 18+years)among adult sex workers (n=508) in Vancouver, CanadaCharacteristicYesn (%)n = 193Non (%)n = 315Odds Ratio (95% CI)Individual factorsAge (median, IQR) 32 (27–41) 37 (30–43) 0.97 (0.95–0.99)Education level ≥ High School 53 (27.46%) 114 (36.19%) 4.66 (3.15–6.88) < High School 140 (72.54%) 201 (63.81%)Aboriginal ancestry yes 107 (55.44%) 94 (29.84%) 2.93 (2.02–4.25) no 86 (44.56%) 221 (70.16%)Injection drug use* yes 106 (54.92%) 91 (28.89%) 3.0 (2.06–4.36) no 87 (45.08%) 224 (71.11%)Non-injection drug use* yes 174 (90.16%) 180 (57.14%) 6.87 (4.07–11.59) no 19 (9.84%) 135 (42.86%)Interpersonal factorsInconsistent condom use with clients* yes 41 (21.24%) 40 (12.70%) 1.85 (1.15–2.99) no 152 (78.76%) 275 (87.30%)Number of clients, last month (median, IQR) 48 (20–90) 45 (24–80) 1.00 (1.00–1.01)Anal sex with clients* yes 35 (18.13%) 31 (9.84%) 2.03 (1.21–3.42) no 158 (79.27%) 284 (90.16%)Social-structural factorsEver been homeless yes 173 (89.64%) 172 (54.60%) 7.19 (4.30–12.02) no 20 (10.36%) 143 (45.40%)Birth country Born in Canada 188 (97.41%) 119 (37.78%) 22.83 (9.13–57.10) Foreign-born 5 (2.59%) 196 (62.22%)Migrated to Vancouver in past 5 years yes 31 (16.06%) 102 (32.38%) 0.40 (0.26–0.63) no 162 (83.94%) 213 (67.62%)Primary sex work solicitation venue* Street (ref) 150 (78.53%) 143 (45.40%) Indoor 12 (6.28%) 128 (40.63%) 0.09 (0.05–0.17) Independent 29 (15.18%) 44 (13.97%) 0.63 (0.37–1.06)J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptGOLDENBERG et al. Page 14CharacteristicYesn (%)n = 193Non (%)n = 315Odds Ratio (95% CI)Self-reported police harassment† yes 144 (74.61%) 155 (49.21%) 3.03 (2.05–4.49) no 49 (25.39%) 160 (50.79%)Self-reported police abuse† yes 54 (27.98%) 38 (12.06%) 2.83 (1.78–4.50) no 139 (72.02%) 277 (87.94%)Self-reported police arrest on prostitution charges† yes 84 (43.52%) 50 (15.87%) 4.08 (2.70–6.18) no 109 (56.48%) 265 (84.13%)Worked for a manager/pimp † yes 73 (37.82%) 49 (15.56%) 3.30 (2.17–5.03) no 120 (62.18%) 266 (84.44%)“Turned out”/coerced into sex work† yes 40 (20.73%) 17 (5.40%) 4.58 (2.52–8.35) no 153 (79.27%) 298 (94.60%)HIV/STI outcomesPositive for HIV yes 38 (19.69%) 19 (6.03%) 3.82 (2.13–6.85) no 155 (80.31%) 296 (93.97%)Positive for any STI yes 30 (15.54%) 27 (8.57%) 1.96 (1.13–4.42) no 163 (84.46%) 288 (91.43%)Positive for any STI/HIV yes 64 (33.16%) 42 (13.33%) 3.32 (2.07–5.02) no 129 (66.84%) 273 (86.67%)*In the last 6 months†LifetimeJ Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptGOLDENBERG et al. Page 15Table 2Explanatory model of factors associated with early sex work initiation among adult sex workers (n=506) inVancouver, CanadaEarly sex work entry <18 years (vs. 18+ years)Variable Adjusted Odds Ratio (AOR) 95% Confidence Interval (CI)Age, years 0.97 0.94–0.99< High School Level Education (yes vs. no) 2.81 1.79–4.41Injection drug use* (yes vs. no) 1.59 1.03–2.46Canadian Born (yes vs. no) 6.79 2.42–19.02Primary sex work solicitation venue* Street (ref) Indoor 0.41 0.19–0.92 Independent 0.68 0.38–1.21“Turned out”/coerced into sex work (yes vs. no) 2.25 1.14–4.44Worked for a manager/pimp† (yes vs. no) 2.22 1.35–3.63*In the last 6 months†LifetimeJ Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptGOLDENBERG et al. Page 16Table 3Separate confounder models examining the independent effect of early sex work initiation on HIV infectionand police arrest on prostitution charges among adult sex workers (n=506)OutcomesExposureHIV Infection Police Arrest on Prostitution ChargesAdjusted Odds Ratio (95% CI) Adjusted Odds Ratio (95%CI)Early sex work entry <18 years (vs. 18+ years) 2.49 (1.35–4.64) 2.07 (1.32–3.25)Early sex work entry <16 years (vs. 16+ years) 1.88 (1.03–3.42) 2.75 (1.73–4.36)*Confounder models adjusted for Canadian born (vs. migrant/new immigrant worker), injection drug use history, and worked for a manager/pimp(lifetime)J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2015 January 01.


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics



Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items