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Client demands for unsafe sex : the socio-economic risk environment for HIV among street and off-street… Deering, Kathleen N.; Lyons, Tara; Feng, Cindy X.; Nosyk, Bohdan; Strathdee, Steffanie A.; Montaner, Julio; Shannon, Kate Aug 1, 2013

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Client demands for unsafe sex: the socio-economic riskenvironment for HIV among street and off-street sex workersKathleen N DEERING, PhD1,2, Tara LYONS, PhD1,2, Cindy X FENG, PhD3, Bohdan NOSYK,PhD1, Steffanie A STRATHDEE, PhD1,4, Julio SG MONTANER, MD, and Kate SHANNON,PhD1,2,51BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC2Department of Medicine, Faculty of Medicine, University of British Columbia Vancouver, Canada3School of Public Health, Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada4Department of Medicine, Faculty of Medicine, University of California, San Diego, San Diego,USA5School of Population and Public Health, Faculty of Medicine, University of British Columbia,Vancouver, CanadaAbstractObjective—Among sex workers (SWs) in Vancouver, Canada, this study identified social, druguse, sex work, environmental-structural and client-related factors associated with being offeredand accepting more money after clients' demand for sex without a condom.Design—Cross-sectional study using baseline (February/10-October/11) data from a longitudinalcohort of 510 SWs.Methods—A two-part multivariable regression model was used to identify factors associatedwith two separate outcomes: (1) being offered and (2) accepting more money for sex without acondom in the last six months, among those who had been offered more money.Results—The sample included 490 SWs. In multivariable analysis, being offered more moneyfor sex without a condom was more likely for SWs who used speedballs, had higher averagenumbers of clients per week, had difficulty accessing condoms and had clients who visited otherSWs. Accepting more money for sex without a condom was more likely for SWs self-reporting asa sexual minority and who had experienced client violence and used crystal methamphetamine useless than daily (vs. none), and less likely for SWs who solicited for clients mainly indoors (vs.outdoor/public places).Conclusions—These results highlight the high demand for sex without a condom by clients ofSWs. HIV prevention efforts should shift responsibility toward clients to reduce offers of moremoney for unsafe sex. Programs that mitigate the social and economic risk environments of SWsCorresponding author/ reprints: Dr Kate Shannon Assistant Professor, Department of Medicine Associate Faculty, School ofPopulation and Public Health University of British Columb Director, Gender and Sexual Health Initiative British Columbia Centre forExcellence in HIV/AIDS St Paul's Hospital 608-1081 Burrard St Vancouver, BC, V6Z 1Y6 t: 604-806-9459: f: 604-806-9044gshi@cfenet.ubc.ca.CONFLICTS OF INTEREST: None to declarePublisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.NIH Public AccessAuthor ManuscriptJ Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.Published in final edited form as:J Acquir Immune Defic Syndr. 2013 August 1; 63(4): 522–531. doi:10.1097/QAI.0b013e3182968d39.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptalongside the removal of criminal sanctions on sex work to enable condom use within safer indoorwork spaces are urgently required.Keywordscondom use; sex workers; Canada; HIV risk; clientsINTRODUCTIONMale condoms decrease the per-contact probability of male-to-female transmission of HIVby about 95% [1]. Increasing public health calls to focus on the `feminization of the HIVpandemic', and theoretical work on gender, women and HIV [2], point to the need for morenuanced analyses of negotiation of male condom use, recognizing the important role ofgendered power dynamics. Condom use within commercial sex transactions has typicallybeen framed as the responsibility of sex workers (SWs), with research overwhelminglyaimed toward identifying SWs at high risk for condom non-use and implementingbehavioural interventions (e.g., education, counseling) to increase condom use. Influencedby the `risk environment' framework, which conceptualizes that individual HIV risk ismediated by environmental factors exogenous to the individual [3], a growing body ofresearch has acknowledged the importance of structural factors in shaping SWs'vulnerability to HIV, including poverty and unstable housing, structural violence andgovernment policies surrounding the regulation of sex work [4–8].In the context of these structural factors, clients of SWs play a substantial and frequentlyunacknowledged role in determining the use of condoms for the prevention of HIV andother sexually transmitted infections (STIs) within commercial sex transactions.Negotiations for condom use between SWs and clients are situated within the interpersonalsocial environment of SWs and are influenced by a number of factors exogenous toindividual SWs (e.g., sex work environment; client-related factors). Client reticence tocondom use is widespread, with men resisting condom use even when they are aware theymay face their own increased potential risk of acquiring HIV/STIs. Offers to SWs by clientsfor sex acts without condoms in exchange for financial incentives are common [9–11].While SWs may face opposition and pressure to not use condoms by clients in the context ofstructural inequities, it is important to acknowledge SWs' agency and the complexnegotiation process within transactions. SWs often have to make difficult micro-leveldecisions regarding their health and safety in the face of financial pressures and structuralinequities, and face pressure to agree to sex without a condom in exchange for a higher fee[9, 10]. While most SWs who understand the personal risks would rather use condoms, someSWs may be prepared to make a trade-off in terms of their own health and safety.While qualitative research has elucidated the complex relationships between economicincentives related to sex work and risk environments of HIV and violence [10, 12, 13],quantitative studies are rare, and largely focused on SWs who use drugs [9, 14]. The fewstudies have focused on economic costs to women when they practice safer sex (e.g., theamount women could lose by using condoms), or have presented theoretical economicmodels describing how compensation for sex work is linked with future health and socialcosts (e.g. stigma, forgone marriage opportunities, social exclusion, risks to health, safetyand well-being)[15–18]. The objective of our study was therefore to identify the associationsbetween social, drug use, sex work, environmental-structural and client-related factors andbeing offered and accepting more money after clients' pressure for sex without a condomamong a large sample of SWs in Vancouver, British Columbia. These relationships areexamined in the context of Canada's quasi-criminalized approach to sex work; in most ofDEERING et al. Page 2J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptCanada, including British Columbia, while sex work per se is legal, many of the activitiessurrounding sex work are criminalized (which apply equally to male, female and transgendersex workers and include communicating/soliciting for the purposes of prostitution; owningand operating a brothel/bawdy house; and living off the avails of prostitution), making thepractice of sex work nearly impossible without breaking laws. To our knowledge, our studyis the first to examine these relationships, which are critical in the understanding of howcondom non-use can be addressed in public health interventions.METHODSSurvey design and sampleBeginning in January 2010, youth and adult women (14 years+) were enrolled in alongitudinal cohort known as `An Evaluation of Sex Worker's Health Access' (`AESHA').This study is based on substantial community collaborations (e.g., sex work agencies andservice providers) existing since 2005, and is monitored by a Community Advisory Boardwith representatives from 15+ agencies. Using time-location sampling,[19] women whoexchanged sex for money within the last 30 days (SWs) were recruited through outreach tooutdoor sex work locations (i.e. streets, alleys), indoor sex work venues (i.e. massageparlours, micro-brothels, and in-call locations) and independent/self-advertising SWs (e.g.online, newspapers) in Metropolitan Vancouver. Our eligibility is inclusive of transgenderindividuals (male-to-female, MTF) who identify as women, based on our previous work [20]and community guidance, as MTF transgender individuals work in similar spaces as thefemale SW population, and access the same services as the female SWs (directed towardself-identifying women, transgender inclusive). Interviews were conducted in places wherewomen felt comfortable (i.e., three office site locations across Vancouver; within indoor sexwork venues). As executed previously, outdoor sex work `strolls' and indoor venues wereidentified through a participatory mapping exercise conducted with current/former SWs,[20]and continuously updated by the outreach team. The study holds ethical approval throughProvidence Health Care/University of British Columbia Research Ethics Board. Allparticipants receive an honorarium of $40CAD at each bi-annual visit for their time,expertise and travel.Questionnaires and measuresFollowing informed consent, at baseline and each semi-annual follow-up visit, participantscompleted questionnaires by trained interviewers (both SW and non-SW interviewers) thatelicited responses relating to socio-demographics, sex work patterns/client experiences,work environments; occupational violence and interactions with policing, characteristics ofnon-commercial or regular partnerships, violence and trauma, and drug use. Participants alsocompleted a nurse-administered questionnaire that elicited responses relating to overallphysical, mental and emotional health, sexual and reproductive health and HIV testing andtreatment. As part of the nursing visit, SWs were also provided with extensive pre/and post-test counseling, testing for HIV, Hepatitis C Virus (HCV) and STIs, and referral for care andsupport services. Biolytical INSTI rapid tests were used for HIV screening, with reactivetests confirmed by blood draw for western blot. Urine samples were collected for gonorrheaand chlamydia, and blood was drawn for syphilis, HSV-2 antibody, and HCV. Treatmentwas provided for symptomatic STI infections by an on-site nurse, and free serology andPapanicolaou testing were also available for those in need, regardless of study enrollment.OutcomeTwo outcomes were included: (1) being offered more money for sex without a condom; and(2) accepting more money for sex without a condom, by both regular and one-time clients;both outcomes were assessed in a six-month timeframe. Participants were considered toDEERING et al. Page 3J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscripthave positive (`yes') responses for each outcome if their responses included “always”,“usually”, “often” and “sometimes”, as opposed to “never” (`no'). The outcome variableswere dichotomized since conceptually, women who reported being offered or acceptingmore money more frequently than `never' could potentially be exposed to HIV/STIs.Explanatory variablesThe relationships between the study outcomes and a number of explanatory variables wereexplored. All factors were self-reported and most factors, with the exception of age, sexualminority status and ethnicity, were reported on for the last six months. Table 1 provides afull list of explanatory variables. These included individual-level variables that captureeffects within the social environment. For example, these include age, reporting being asexual minority (lesbian, gay, bisexual, transgender, transsexual, two-spirit versusheterosexual and non-transgender), and ethnicity (Indigenous/Aboriginal ancestry, includingFirst Nations and Métis, Inuit and visible minority, primarily comprised of Asian newimmigrant/migrant SWs, versus Caucasian/white). These also included drug use and sexwork-related factors (e.g., non-injection and injection drug use; exchanging sex while high),client-related factors (e.g., violence by clients) and environmental-structural variables (e.g.,main place of soliciting for clients [Independent, including self-advertised, online, phone/texting; Indoor, including bars, brothels, massage/beauty parlours, dance/strip clubs; versusOutdoor/public, including streets and outdoor public spaces]).AnalysisIn bivariate analysis, categorical variables were compared using the Chi-square test and theFisher's exact test, while continuous variables were compared using Wilcoxon rank-sumtest. A two-part modeling approach was used. First, using multivariable logistic regression,we fitted an explanatory model for the relationship between the explanatory variables andthe outcome `being offered more money for sex without a condom'. Then, for SWs who hadbeen offered more money for sex without a condom, we fitted a multivariable logisticregression explanatory model for the relationship between the explanatory variables and theoutcome `accepting more money for sex without a condom. Odds ratios (ORs), adjustedodds ratios (AOR) and 95% confidence intervals (95%CIs) were presented. As in previousresearch [21, 22], a backward stepwise technique was used in the selection of covariates foran explanatory model. This modeling approach is well-suited for understanding whichfactors/explanatory variables best explain a high probability of our outcomes, being offeredmore money for sex without a condom and accepting more money for sex without acondom. The final model was selected by minimizing Akaike Information Criterion (AIC) ina step-wise manner, with selection starting with a model including only a constant andadding predictor one at a time. At each step, the effect on AIC is checked by removing apreviously added variable, with a lower value suggesting a better fit. Missing data weredropped prior to model selection. Unadjusted (bivariate) odds ratios (ORs), adjusted(multivariable) odds ratios (AOR), 95% confidence intervals (95%CIs) and p-values werereported. All statistical analyses were performed using SAS software version 9.2 [23].RESULTSOf 510 SWs who completed baseline, 490 SWs provided valid responses to the outcome`being offered more money for sex without a condom' and were included in the analyses.The sample had a median age of 35 years (interquartile range [IQR]: 28–42 years) and amedian age at first sex work of 20 years (IQR: 15–30 years). Overall, 120 (24.5%) reportedidentifying as a sexual minority. The sample included 190 individuals (38.8%) ofIndigenous/Aboriginal ancestry, 124 (25.3%) were visible minorities (of these, 97.5% EastAsian, namely Chinese; 2.5% other visible minority) and 176 (35.9%) Caucasian/white. OfDEERING et al. Page 4J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptnote, Aboriginal SWs were highly overrepresented in our sample relative to the generalCanadian population of women and girls (3%)[24]. Overall, 266 (54.3%) reported solicitingfor clients independently, 127 (25.9%) in indoor sex work places and 347 (70.8%) outdoorsex work places, highlighting the substantial overlap in terms of sex work solicitationenvironments. Of the 490 respondents, 356 (72.6%) reported being offered more money forsex without a condom by clients in the last six months, with 75/302 (19.2%) reportingaccepting more money after client demand (54 missing, or 11.0%). Overall, 11.4% of SWsin the sample were HIV-positive and prevalence of STIs (including chlamydia, gonorrheaand active syphilis) was 10.4%.Offered more moneyVariables associated with being offered more money for sex without a condom in bivariateanalysis (p<0.05) are detailed in Table 1.In multivariable analysis, significantly higher oddsof being offered more money for sex without a condom were found for SWs who had, in thelast six months: used speedballs (AOR: 6.93, 95%CIs: 1.60–29.94); higher average numbersof clients per week (AOR: 1.03, 95%CIs: 1.01–1.06, a 3% increase in the odds of theoutcome for each one-client increase); difficulty accessing condoms (AOR: 2.72, 95%CIs:1.09–6.77); and had clients who visited other SWs (AOR: 2.72, 95%CIs: 1.09–6.77).Accepted more moneyVariables associated with accepting more money for sex without a condom in bivariateanalysis (p<0.05) are detailed in Table 2. In multivariable analysis, significantly higher oddsof accepting more money for sex without a condom were found for SWs self-reporting as asexual minority (AOR: 2.72, 95%CIs: 1.35–5.46), and who had, in the last six months:experienced client violence (AOR: 2.18, 95%CIs: 1.10–4.34); were displaced (i.e., moved toanother place) by security (AOR: 2.01, 95%CIs: 0.95–4.26) and had higher intensity ofcrystal meth use (Daily, AOR: 2.58, 95%CIs: 0.39–17.17; Less than daily, AOR: 2.95,95%CIs: 1.27–6.87; versus none). Significantly reduced odds of accepting more money forsex without a condom was found for older SWs (AOR: 0.96, 95%CIs: 0.93–1.00, a 4%decrease in the odds of the outcome for each one-year increase) and SWs who solicited forclients indoors (vs outdoor/public places)(AOR: 0.15, 95%CIs: 0.04–0.54).DISCUSSIONOur study confirms the high demand by clients for unprotected sex among SWs in an urbanCanadian setting. Overall, nearly three-quarters of hidden street- and off-street SWs reportedbeing offered more money for sex without a condom by clients within the last six months,with one-fifth reporting accepting more money according to client demand. We identified anumber of social, drug use, sex work, environmental-structural and client-related factors andbeing offered and accepting more money after clients' pressure for sex without a condomamong a large sample of SWs in Vancouver, British Columbia.More frequent drug use (e.g., use of speedballs, non-injection crystal methamphetamine)was strongly associated with being offered or accepting more money for sex without acondom. These findings are consistent with other studies, which have suggested that clientslooking for unprotected sex may seek out SWs who are particularly vulnerable to coercion,including women who are experiencing acute withdrawal and the immediate need to usedrugs [9, 13, 25]. Despite this relationship, as well as demonstrated quantitative linkagesbetween sex work income earned and money spent on drugs [14], it may be surprising thatsome measures of drug use were not associated with accepting more money due to clientdemand. These results may reflect how SWs with increased drug use vulnerabilitysometimes provide sexual services in direct exchange for drugs instead of financialDEERING et al. Page 5J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptincentives [13], or may suggest that SWs agree to other higher-risk sex acts (e.g., anal sex)after client demand in exchange for increased earnings.The relationship between experiencing physical or sexual violence by clients and acceptingmore money for sex without a condom supports research suggesting a link between violenceand HIV risk among sex workers [26]. Violence against SWs in many settings is high, asevidenced by a recent systematic review on the factors shaping risk environments forviolence among SWs globally (ranging from 50–75% lifetime to 32–55% in the last year),and has been linked to reduced condom use by clients [27]. During experiences of directviolence, including physical assault and rape, condom use is unlikely. Fear or threat ofviolence can result in SWs' heightened reluctance to insist on condom use, and to agree touse condoms in exchange for an increased fee to avoid client violence as a safety measure[13]. Inequitable gender-based power relations that favour male clients within environmentsof repeated and sustained `everyday' occupational violence (e.g., by clients, police, pimps/managers) and in the context of criminalization of indoor sex work spaces and publiccommunication limit the agency of women and transgender women to negotiate condom use[13].Our results suggest potential routes of increased HIV risk to SWs through difficultyaccessing condoms and having clients with other SWs as sex partners. SWs who experiencedifficulty accessing condoms may also experience heightened police harassment, lesseningtheir control over negotiations with clients [13, 28]. Finally, our results suggest that SWsworking in indoor settings (e.g., massage/beauty parlours; managed indoor spaces/brothelsare less likely to accept more money based on client demand relative to SWs who work inmore dangerous, outdoor and street-based public settings(. Multiple studies have suggestedworking outdoors places women at greater risk for exposure to violent predators and clientsand can result in difficulty accessing safer sex and harm reduction services, and to clients'demands [5, 6, 29]. Women who work in indoor settings can have more control overnegotiations with clients regarding sexual transactions and can charge increased fees,potentially reducing the need to agree to clients' demands for unsafe sex [13, 30].Our study also suggests key social factors that can help identify SWs who may beparticularly vulnerable to HIV/STIs. Sexual minority SWs experience additional and uniqueforms of stigma and marginalization, including homophobia and transphobia [31–33].Stigma, gender discrimination, homophobia and transphobia, which shape the riskenvironment for HIV through social pathways, factor into power relations between sexworkers and clients and may result in less negotiating power for sexual minority SWs. Forexample, many transgender SWs face high rates of physical and sexual violence [34, 35],which may compromise negotiation of condom use with clients. Further, marginalizationand economic vulnerabilities have also been shown to be instrumental in sexual minoritySWs' ability to negotiate HIV risk behaviours [36], including client condom use [34],suggesting increased economic pressure to accept more money for sex without a condom.Our results also suggest that, since the median age at initiation of sex work initiation in oursample was 20 years (IQR: 15–30 years) while the median age was 35 years (IQR: 28–42),older women with longer duration in sex work may be more experienced in negotiationswith clients or more comfortable refusing demands for higher fees. Moreover, research alsosuggests that youth may be particularly at risk for economic pressures and differential powerrelations favouring older male partners, which may affect their vulnerability to clientdemand for unsafe sex [37, 38]. Importantly, these results also highlight the potentialincreased risk of younger SWs to acquiring HIV/STIs from clients. Finally, results suggestthat having more clients may result in increased opportunities for encountering coerciveclients with a preference for unprotected sex.DEERING et al. Page 6J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptOur study has several limitations. Since sampling frames are difficult to construct for hiddenpopulations, the sample was not randomly generated and may not be representative of allSWs in ours or other settings. To address this, we recruited participants through systematictime-location sampling and targeted outreach to sex work strolls and indoor locations [19],considered the best method of recruitment for mobile/hidden populations and thereforehelping attract a representative sample. The study design is cross-sectional in nature andthus cannot determine causal relationships; however, although it is not possible to confirmthe direction of associations, our study results are situated within a number of other studiessuggesting relationships between social, drug use, sex work, environmental-structural andclient-related factors and condom use. We had a large sample size for both street- and off-street SWs. As with all self-report data, responses may be subject to recall or socialdesirability bias, and the prevalence of being offered and/or accepting more money for sexwithout a condom may be higher than reported. However, we had extensively trainedinterviewers with experience with the sample population, and interviews were conducted inspaces where women were comfortable (i.e., indoor work places), facilitating accurateresponses.Our results point to several important structural and policy gaps in HIV programming andrelated recommendations to support SWs' agency and ability to refuse clients' demands forsex without a condom. While approximately three-quarters of SWs reported that clientsdemanded sex without a condom, it is positive that only one-fifth reported accepting clients'demands (though this may be under-reported). Our study therefore provides strong evidenceof the importance of acknowledging the role of clients in the spread of HIV/STIs. Althoughthere are limited studies on clients of SWs, [11, 39, 40] such studies are a crucial first step inunderstanding how to reduce demand for unprotected sex with SWs, include clients in HIV/STI programming for SWs and address client responsibility for safer sex practices. Gainingthis understanding is particularly relevant in settings such as Vancouver, where the clientpopulation is highly hidden. Increasing calls are being made to develop HIV/STI programsspecific to clients [41, 42], with some evidence of successful integration of hiddenpopulations of clients demonstrated in international settings using smaller peer-based [43]and large-scale targeted [42, 44] approaches. In addition, structural policy changes thatreduce economic disempowerment among SWs' are critical [45]. For example, practicalinterventions could include scaled-up access to sex worker-driven programs that increaseSWs' financial security, including those that support SWs to engage with regulated and legalbanking institutions as well as those that provide relevant education and training. SWs whowish to remain in sex work as well as those who wish to exit should be supported. Whererelevant, harm reduction and drug treatment modalities, including opiate substitutiontherapies, should be made available for SWs who use drugs to increase economicempowerment. Safer-environment interventions that are designed for SWs and are tailoredfor specific sex work environments (i.e., mobile outreach [46]) can help meet the needs ofSWs for an adequate no-cost condom supply.Finally, alongside global calls [47, 48], our study adds to a growing evidence basesuggesting the potential protective effects of working in indoor spaces and of changes topolicies relating to the criminalization and regulation sex work, including punitive sanctionsand enforcement-based policing approaches that target public solicitation and prevent thedevelopment of safer indoor sex work spaces, to enable condom use in commercial sextransactions. In Ontario, Canada, such sex work laws were recently overturned based onevidence that such laws negatively impact SWs' health and safety, including HIV riskprevention practices (similar court cases are ongoing in British Columbia, Canada)[49, 50].Decriminalized environments support SWs to self-regulate industry practices throughcollectivization processes and re-conceptualization of sex work as work, including settingprices and limiting competition, that drive unprotected sex, as well as maintainingDEERING et al. Page 7J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscriptoccupational health and safety standards [51]. Safer indoor sex work spaces tailored forlocal social and cultural contexts can enhance SWs' agency to decline pressure from clientsto have unprotected sex through buffers of social support, self-regulation and organization.For example, non-exploitative managed brothels in designated areas where sex work istolerated might be appropriate for SWs who prefer a distinction between work and home,while a focus on home-based sex work could work better for SWs who feel their safetycould be compromised if there is an increased risk of disclosure by travelling to designatedareas. Drawing on the experiences and knowledge of SWs is key in identifying the mosteffective HIV prevention approaches for SWs and addressing upstream factors that shapesocio-economic HIV risk environments.AcknowledgmentsKND made key contributions to the conceptual and analytic design of the study and drafted the manuscript. TL,BN, SS and JSGM made key conceptual contributions and reviewed the manuscript. CF performed statisticalanalysis and reviewed the manuscript. KS made key contributions to the conceptual and analytic design of the studyand takes responsibility for the accuracy of the data. We thank all those who contributed their time and expertise tothis project, including participants, partner agencies and the AESHA Community Advisory Board. We wish toacknowledge Peter Vann, Calvin Lai, Eric Fu, Ofer Amram, Jill Chettiar, 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). JSM is supportedby an Avante Garde award from US NIH (DP1DA026182). 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Vancouver Sun. Postmedia Network Inc.; Vancouver, Canada: 2012. Vancouver sexworkers challenge to prostitution laws to go ahead.DEERING et al. Page 10J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript51. Shahmanesh M, Patel V, Mabey D, Cowan F. Effectiveness of interventions for the prevention ofHIV and other sexually transmitted infections in female sex workers in resource poor setting: asystematic review. Trop Med Intl Health. 2008; 13:659–679.DEERING et al. Page 11J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDEERING et al. Page 12Table 1Social, drug use, sex work, structural-environmental and client-related factors of sex workers (SWs) inVancouver, Canada, according to whether or not they were offered more money for sex without a condom.Offered more money forsex without a condomn=356Not offered more moneyfor sex without a condomn=134OR [95% confidenceintervals]p-value(N (Proportion) or median (IQR)SocialAge (years) 35.00 (28.00, 42.00) 35.00 (28.00, 44.00) 0.99 (0.97, 1.03) 0.600Age at first sex work (years) 20.00 (16.00, 30.00) 20.00 (15.00, 29.00) 1.00 (0.98, 1.03) 0.694Sexual identity Sexual minority 83 (23.4%) 37 (27.4%) 0.81 (0.51, 1.27) 0.354 Straight 272 (76.6%) 98 (72.6%)Ethnicity Aboriginal 132(37.2%) 58(43.0%) 0.74(0.46, 1.17) 0.193 Visible minority 90(25.3%) 34(25.2%) 0.86(0.51, 1.44) 0.560 Caucasian/white 133(37.5%) 43(31.8%)Supports someone financially1 Yes 105 (29.6%) 32 (23.7%) 1.35 (0.86, 2.14) 0.196 No 250 (70.4%) 103 (76.3%)Drug useCrack use intensity Daily 135 (38.0%) 32 (23.7%) 1.70(1.03,2.81) 0.038 Less than daily 91 (25.6%) 51 (37.8%) 0.72(0.45,1.15) 0.170 None 129 (36.3%) 52 (38.5%)Crystal meth intensity Daily 9 (2.5%) 2 (1.5%) 1.76(0.37,8.26) 0.475 Less than daily 44 (12.4%) 15 (11.1%) 1.15(0.61, 2.14) 0.668 None 302 (85.1%) 118 (87.4%)Heroin intensity (injection) Daily 63 (17.7%) 19 (14.1%) 1.44(0.82,2.52) 0.207 Less than daily 59 (16.6%) 15 (11.1%) 1.70(0.92,3.15) 0.088 None 233 (65.6%) 101 (74.8%)Cocaine (injection) Yes 62 (17.5%) 11 (8.1%) 2.39 (1.21, 4.68) 0.010 No 293 (82.5%) 124 (91.9%)Speedballs (injection) Yes 33 (9.3%) 2 (1.5%) 6.82 (1.61, 28.81) 0.003 No 322 (90.7%) 133 (98.5%)Sex workNumbers of clients per week 12.00 (6.00, 20.00) 9.00 (4.00, 18.00) 1.03 (1.01, 1.06) 0.002Exchange sex while high Yes 226 (63.7%) 71 (52.6%) 1.58 (1.06, 2.36) 0.025J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDEERING et al. Page 13Offered more money forsex without a condomn=356Not offered more moneyfor sex without a condomn=134OR [95% confidenceintervals]p-value(N (Proportion) or median (IQR) No 129 (36.3%) 64 (47.4%)Sex work main income Yes 297 (83.7%) 103 (76.3%) 1.59 (0.98, 2.59) 0.060 No 58 (16.3%) 32 (23.7%)Has a manager/pimp2 Yes 17 (4.8%) 5 (3.7%) 1.31 (0.47, 3.62) 0.604 No 338 (95.2%) 130 (96.3%)Environmental-structuralPlace of soliciting Independent 51 (14.4%) 21 (15.6%) 0.89(0.50, 1.58) 0.698 Indoor 100 (28.2%) 39 (28.9%) 0.94(0.60, 1.49) 0.799 Outdoor/public 204 (57.5%) 75 (55.6%)Displaced by police Yes 136 (38.3%) 36 (26.7%) 1.71 (1.10, 2.64) 0.016 No 219 (61.7%) 99 (73.3%)Displaced by security Yes 57 (16.1%) 14 (10.4%) 1.65 (0.89, 3.08) 0.110 No 298 (83.9%) 121 (89.6%)Rushed negotiation due to police Yes 138 (38.9%) 40 (29.6%) 1.51 (0.99, 2.31) 0.057 No 217 (61.1%) 95 (70.4%)Difficulty accessing condoms Yes 40 (11.3%) 7 (5.2%) 2.32 (1.01, 5.32) 0.041 No 315 (88.7%) 128 (94.8%)Client-related 3Physical or sexual violence by clients Yes 148 (41.7%) 39 (28.9%) 1.76 (1.15, 2.70) 0.009 No 207 (58.3%) 96 (71.1%)Most clients are regular Yes 65 (18.3%) 34 (25.2%) 0.67 (0.42, 1.07) 0.090 No 290 (81.7%) 101 (74.8%)Most clients have another partner4 Yes 150 (42.3%) 45 (33.3%) 1.46 (0.97, 2.22) 0.071 No 205 (57.7%) 90 (66.7%)Most clients have other SW partners Yes 170 (47.9%) 45 (33.3%) 1.84 (1.21, 2.78) 0.004 No 185 (52.1%) 90 (66.7%)Most clients are from the inner city/drug useepi-centre5J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDEERING et al. Page 14Offered more money forsex without a condomn=356Not offered more moneyfor sex without a condomn=134OR [95% confidenceintervals]p-value(N (Proportion) or median (IQR) Yes 11 (3.1%) 8 (5.9%) 0.51 (0.20, 1.29) 0.148 No 344 (96.9%) 127 (94.1%)Most clients use injection drugs Yes 54 (15.2%) 19 (14.1%) 1.10 (0.62, 1.93) 0.752 No 301 (84.8%) 116 (85.9%)Most clients use non-injection drugs Yes 2 (0.6%) 0 (0.0%) 0.92(0.07, infinity) 1.000 No 353 (99.4%) 135 (100.0%)1e.g., child, family2e.g., including business owner/manager, pimp, or boyfriend3‘most’ was quantified as >75% of the time4e.g., wife, girlfriend5Downtown Eastside neighbourhood in Vancouver, CanadaJ Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDEERING et al. Page 15Table 2Social, drug use, sex work, structural-environmental and client-related factors of sex workers (SWs) inVancouver, Canada, according to whether or not they accepted more money for sex without a condom.Accepted more moneyfor sex without a condomn=75Did not accept moremoney for sex without acondom n=227OR [95% confidenceintervals]p-value(N (Proportion) or median (IQR)Individual-socialAge (years) 31.00 (26.00, 40.00) 36.00 (29.00, 42.00) 0.95 (0.92, 0.98) 0.001Age at first sex work (years) 17.00 (14.00, 22.00) 21.00 (16.00, 33.00) 0.93 (0.90, 0.97) <.0001Sexual identity Sexual minority 28 (39.4%) 54 (19.1%) 2.75 (1.57, 4.82) 0.000 Straight 43 (60.6%) 228 (80.9%)Ethnicity Aboriginal 31 (43.7%) 101 (35.8%) 0.79(0.45,1.40) 0.418 Visible minority 7 (9.9%) 96 (34.4%) 0.19(0.08,0.45) 0.000 Caucasian/white 33(46.5%) 85(30.1%)Supports someone financially1 Yes 14 (19.7%) 90 (31.9%) 0.52 (0.28, 0.99) 0.044 No 57 (80.3%) 192 (68.1%)Drug useCrack use intensity Daily 42 (59.2%) 92 (32.6%) 4.90(2.39, 10.03) 0.000 Less than daily 18 (25.4%) 72 (25.5%) 2.68(1.20, 6.00) 0.016 None 11 (15.5%) 118 (41.8%)Crystal meth intensity Daily 3 (4.2%) 6 (2.1%) 2.71(0.65, 11.23) 0.168 Less than daily 21 (29.6%) 21 (7.4%) 5.43(2.75, 10.71) 0.000 None 47 (66.2%) 255 (90.4%)Heroin intensity (injection) Daily 19 (26.8%) 43 (15.2%) 2.33(1.22, 4.43) 0.010 Less than daily 15 (21.1%) 44 (15.6%) 1.80(0.91, 3.56) 0.093 None 37 (52.1%) 195 (69.1%)Cocaine (injection) Yes 15 (21.1%) 46 (16.3%) 1.37 (0.72, 2.64) 0.338 No 56 (78.9%) 236 (83.7%)Speedballs (injection) Yes 9 (12.7%) 24 (8.5%) 1.56 (0.69, 3.52) 0.281 No 62 (87.3%) 258 (91.5%)Sex workNumbers of clients per week 15.00 (6.00, 28.00) 12.00 (6.00, 20.00) 1.018 (1.00, 1.03) 0.011Exchange sex while high Yes 64 (90.1%) 160 (56.7%) 6.97 (3.09, 15.75) 0.000J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDEERING et al. Page 16Accepted more moneyfor sex without a condomn=75Did not accept moremoney for sex without acondom n=227OR [95% confidenceintervals]p-value(N (Proportion) or median (IQR) No 7 (9.9%) 122 (43.3%)Sex work main income Yes 63 (88.7%) 233 (82.6%) 1.66 (0.75, 3.68) 0.211 No 8 (11.3%) 49 (17.4%)Has a manager/pimp2 Yes 6 (8.5%) 11 (3.9%) 2.27 (0.81, 6.38) 0.109 No 65 (91.5%) 271 (96.1%)Environmental-structuralPlace of soliciting Independent 9 (12.7%) 42 (14.9%) 0.54(0.25,1.19) 0.128 Indoor 5 (7.0%) 95 (33.7%) 0.13(0.05,0.35) 0.000 Outdoor/public 57 (80.3%) 145 (51.4%)Displaced by police Yes 37 (52.1%) 97 (34.4%) 2.08 (1.23, 3.51) 0.006 No 34 (47.9%) 185 (65.6%)Displaced by security Yes 23 (32.4%) 34 (12.1%) 3.50 (1.89, 6.45) 0.000 No 48 (67.6%) 248 (87.9%)Rushed negotiation due to police Yes 35 (49.3%) 101 (35.8%) 1.74 (1.03, 2.95) 0.037 No 36 (50.7%) 181 (64.2%)Difficulty accessing condoms Yes 10 (14.1%) 29 (10.3%) 1.43 (0.66, 3.09) 0.361 No 61 (85.9%) 253 (89.7%)Client-related 3Physical or sexual violence by clients Yes 48 (67.6%) 98 (34.8%) 3.92 (2.25, 6.82) 0.000 No 23 (32.4%) 184 (65.2%)Most clients are regular Yes 10 (14.1%) 55 (19.5%) 0.68 (0.33, 1.40) 0.292 No 61 (85.9%) 227 (80.5%)Most clients have another partner4 Yes 23 (32.4%) 125 (44.3%) 0.60 (0.35, 1.04) 0.069 No 48 (67.6%) 157 (55.7%)Most clients have other SW partners Yes 28 (39.4%) 142 (50.4%) 0.64 (0.38, 1.09) 0.100 No 43 (60.6%) 140 (49.6%)Most clients are from the inner city/drug useepi-centre5J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDEERING et al. Page 17Accepted more moneyfor sex without a condomn=75Did not accept moremoney for sex without acondom n=227OR [95% confidenceintervals]p-value(N (Proportion) or median (IQR) Yes 4 (7.1%) 7 (3.1%) 2.43 (0.69, 8.61) 0.157 No 52 (92.9%) 221 (96.9%)Most clients use injection drugs Yes 18 (29.5%) 35 (13.9%) 2.58 (1.34, 4.98) 0.004 No 43 (70.5%) 216 (86.1%)Most clients use non-injection drugs Yes 2 (3.2%) 0 (0.0%) 9.43(0.73, infinity) 0.084 No 60 (96.8%) 239 (100.0%)1e.g., child, family2e.g., including business owner/manager, pimp, or boyfriend3`most' was quantified as >75% of the time4e.g., wife, girlfriend5Downtown Eastside neighbourhood in Vancouver, CanadaJ Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptDEERING et al. Page 18Table 3Multivariable associations between social, drug use, sex work, structural-environmental and client-relatedfactors of sex workers (SWs) in Vancouver, Canada, and being offered and accepting more money for sexwithout a condomOffered more money for sex without acondomAccepted more money for sex without acondomAOR p-value AOR p-valueSocial-demographicAge (years) / 0.96 (0.93, 1.00) 0.048Sexual identity Sexual minority / 2.72 (1.35, 5.46) 0.005 Straight / 1.0 (ref)Drug useCrystal meth intensity Daily / 2.58 (0.39, 17.17) 0.326 Less than daily / 2.95 (1.27, 6.87) 0.012 None / 1.0 (ref)Speedballs (injection) Yes 6.93 (1.60, 29.94) 0.010 / No 1.0 (ref) /Sex workNumbers of clients per week 1.03 (1.01, 1.06) 0.002 /Environmental-structuralPlace of soliciting Independent / 0.56 (0.22 1.41) 0.565 Indoor / 0.15 (0.04, 0.54) 0.047 Outdoor/public / 1.0 (ref)Difficulty accessing condoms Yes 2.72 (1.09, 6.77) 0.031 / No 1.0 (ref) /Client-related 1Physical or sexual violence by clients Yes 1.42 (0.90, 2.25) 0.130 2.18 (1.10, 4.34) 0.025 No 1.0 (ref) 1.0 (ref)Most clients have other SW partners2 Yes 1.83 (1.19, 2.84) 0.006 / No 1.0 (ref) /1`most' was quantified as >75% of the time2e.g., wife, girlfriendJ Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.

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