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Complexities of short-term mobility for sex work and migration among sex workers : Violence and sexual… Goldenberg, Shira M.; Chettiar, Jill; Nguyen, Paul; Dobrer, Sabina; Montaner, Julio; Shannon, Kate Aug 31, 2014

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Title: Complexities of short-term mobility for sex work and migration among sex workers: Violence and sexual risks, barriers to care, and enhanced social and economic opportunities  Running head: Mobility, violence, and the health of sex workers  Authors: Shira M. Goldenberg,1,2 Jill Chettiar,1 Paul Nguyen,1 Sabina Dobrer, 1 Julio Montaner, Kate Shannon1,2   1. Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, CANADA 2. Department of Medicine, University of British Columbia, Vancouver, BC, CANADA  Corresponding Author:  Kate Shannon, PhD, MPH Associate 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 Email: gshi@cfenet.ubc.ca   Project Support: This research was supported by operating grants from the US National Institutes of Health (R01DA028648) and Canadian Institutes of Health Research (HHP-98835). SG is supported by fellowships from the Canadian Institutes of Health Research and Michael Smith Foundation for Health Research/Women’s Health Research Initiative. KS is supported by US National Institutes of Health (R01DA028648), Michael Smith Foundation for Health  1 Research, and the Canadian Institutes of Health Research. The authors declare no conflict of interest.  Word count: 3,818 text ; abstract 339  Keywords (max. 4-5): mobility, migration, sex workers, HIV, violence  Target journal: Journal of Urban Health   2 ABSTRACT Despite research on the health and safety of mobile and migrant populations in the formal and informal sectors globally, limited information is available regarding the working conditions, health, and safety of sex workers who engage in short-term mobility and migration. The objective of this study was to longitudinally examine work environment, health and safety experiences linked to short-term mobility/migration (i.e., worked or lived in another city, province or country) among sex workers in Vancouver, Canada, over a two-and-a-half year study period (2010-2012). We examined longitudinal correlates of short-term mobility/migration (i.e., worked or lived in another city, province or country over the three-year follow-up period) among 646 street and off-street sex workers in a longitudinal community-based study (AESHA).  Of 646 sex workers, 10.84% (n=70) worked or lived in another city, province or country during study. In a multivariate GEE model, short-term mobility/migration was independently correlated with older age (Adjusted Odds Ratio (AOR): 0.95, 95% Confidence Interval (CI): 0.92-0.98), soliciting clients in indoor (in-call) establishments (AOR: 2.25, 95% CI: 1.27-3.96), intimate partner condom refusal (AOR: 3.00, 1.02-8.84) and barriers to health care (AOR: 1.77, 95% CI: 1.08-2.89). In a second multivariate GEE model, short-term mobility for sex work (i.e., worked in another city, province or country) was correlated with client physical/sexual violence (AOR: 1.92, 95% CI: 1.02-3.61). In this study, mobile/migrant sex workers were more likely to be younger, work in indoor sex work establishments, and earn higher income, suggesting that short-term mobility for sex work and migration increase social and economic opportunities. However, mobility and migration also correlated with reduced control over sexual negotiation with intimate partners and reduced health care access, and mobility for sex work was associated with enhanced workplace sexual/physical violence, suggesting that mobility/migration may confer risks through less control over work environment and isolation from health services. Structural and community-led interventions, including policy support to allow for more formal organizing of sex work collectives and access to workplace safety  3 standards, remain critical to supporting health, safety and access to care for mobile and migrant sex workers.   4 INTRODUCTION  Globally, population migration and mobilitya represent important determinants of health. Although women represent over half of migrants globally, there remains a paucity of information regarding the impacts of mobility and migration on women’s health and safety of, particularly among those working in the sex industry. Drivers of mobility and migration among women engaged in sex work are diverse and include new economic opportunities, subsistence needs, family obligations, and a desire for social mobility; some women may also engage in mobility for the purposes of sex work1-5. Migration and mobility often result in substantial changes in health, working conditions, and economic and social opportunities. Migrant and mobile populations may experience changes in health status related to exposure to new infectious diseases, social networks (e.g., new sex partners), norms (e.g., regarding substance use and sexual behaviour), and barriers to accessing healthcare;6-19 exposure to new working conditions, including unsafe work environments20-23; and other social and economic changes, such as access to higher-paying work and new employment options, as well as social and economic displacement among some populations of recent migrants1, 5, 13, 18, 24, 25. Female sex workers (FSWs) are often highly mobile6, 11, 26 and experience substantial health and social inequities, including HIV and sexually transmitted infections (STIs)27, 28 and violence29-33. However, limited information is available regarding the impacts of migration and mobility on the health and working conditions of sex workers, especially in high-income countries such as Canada. Despite the significant number of women who migrate, most research pertaining to the health and safety of mobile and migrant workers in the formal and informal sectors has focused on males, including resource-extraction workers, migrant farmworkers, and truck drivers7, 13, 34-41.                                                         a Mobility broadly refers to the movement of populations, including temporary and circular movements, whereas migration refers to movement from one country, city, or locality to another.  5 Globally, much research on migration and mobility among sex workers has focused on international migration and its impact on enhanced HIV and STI risk in low- and middle-income countries in Africa24, 34, 42, Asia2, 8, 9, 43-46, and Latin America1, 5, 10, 47-49, whereas very limited attention has been paid to short—term mobility and migration patterns (e.g., recently living or working in other cities) and changes in working conditions, health, and safety in the context of such mobility and in higher-income countries.   Existing evidence suggests heterogeneity in the health and social consequences of migration and mobility. Among mobile and migrant sex workers, social isolation and exposure to violence (i.e., in the workplace and from intimate partners), coupled with barriers to health care access (e.g., interruption of care, limited familiarity with services), may enhance health and social vulnerabilities1, 5, 8, 22, 31, 46. In India, recent research has shown that mobility and violence interact, whereby working or living in other cities for short periods (i.e., <1 month or for temporary events) to access new economic and social opportunities was associated with enhanced violence and lower client condom use, as compared to those who engaged in mobility for longer periods31. The researchers hypothesized that lack of control over working conditions in destination settings, the absence of peer social networks and social/cultural isolation increased health and safety risks, including violence and HIV/STI infection, among sex workers. In South Africa, cross-border migration facilitated increased social and economic opportunities (e.g., higher income) for sex workers, as well as reduced contact with health providers and lower condom use as compared to internal migration24. In the European Union, where movement between countries is relatively easy, mobility and migration are common and may facilitate enhanced income, as well as health risks and barriers to care. For example, a study in the United Kingdom found that migrant FSWs from Eastern Europe were younger and had a greater number of clients, but at the same time were less likely to use contraception than non-migrants, although this study did not examine recent or internal mobility patterns50.   6 Ultimately, evidence suggests that the health and safety of migrant and mobile sex workers is influenced by factors at multiple levels of causation, including structural factors such as safety and exposure to violence (e.g., from clients and other sex partners), health care access, stigma and discrimination, and the enforcement of policies governing sex work and immigration2, 5, 6, 10, 13, 16, 21, 23, 31, 47, 51; interpersonal factors, such as barriers to gendered condom negotiation and risk patterns (e.g., substance use and sexual practices) of sex partners, including both clients as well as intimate partners4, 22, 24, 31, 45, 50; and individual influences such as substance use and socio-demographic factors (e.g., age)5, 45, 47, 50. In Canada, while there is substantial variation by work environments, sex workers often experience heightened vulnerabilities to HIV and STIs, drug use, and violence, as well as barriers to accessing care, which have been largely attributed to structural conditions33, 52-55. However, these structural vulnerabilities (e.g., client and intimate partner violence) have not been previously examined in relation to recent mobility patterns, despite evidence from other settings suggesting that changes in safety and social networks could result in enhanced violence for mobile FSWs. As in most settings globally, sex work in Canada is criminalized. Recent studies from Canada and other international settings have highlighted the importance of structural factors shaping sex workers’ health, including violence and criminalization2, 33, 55-58. Yet, epidemiological evidence regarding the health and working conditions of mobile sex workers is lacking, with limited evidence on structural factors such as work environments, violence, and health risks within the context of recent migration and mobility. Moreover, whereas the vast majority of prior studies pertaining to migrant and mobile sex workers have been cross-sectional50, longitudinal data remain limited, which are needed to better elucidate recent and ongoing mobility patterns and their impacts on health and safety over time. Therefore, we undertook this study to longitudinally investigate structural, interpersonal and behavioural, and individual factors linked to short-term mobility and migration (i.e., engaged in sex work or lived in another city, province or country in the past six months); and secondly, factors linked to short- 7 term mobility for sex work among a cohort of female sex workers in the city of Vancouver, Canada.  METHODS  Data collection Data were drawn from an open prospective cohort study, An Evaluation of Sex Workers Health Access (AESHA). Between January 2010 and August 2012, 646 sex workers completed surveys and biological testing for HIV and STIs at enrolment and on a bi-annual basis. The AESHA study was is based on collaborations with sex work agencies which have existed since 200559 and monitored by a Community Advisory Board of >15 organizations. All study procedures were approved by the Providence Health Care/University of British Columbia Research Ethics Board.  Participants As previously described (Shannon et al., under review), eligibility criteria included self-identifying as female (including male-to-female transgender), being 14 years of age or older, having exchanged sex for money within the last 30 days and providing written informed consent. Time-location sampling was used to recruit FSWs through outreach to street- (e.g., streets, alleys) and off-street settings (e.g., online, newspaper, massage parlours, micro-brothels, other in-call locations) across Metro Vancouver. Sex work venues (‘strolls’) were identified through community mapping59 and updated regularly. Study participants completed questionnaires at study offices in Metro Vancouver or at their work or home location. Participants received $40 CAD at each visit for their time, expertise and travel.   Measures  8 Dependent Variable: The dependent variable, short-term mobility or migration, was defined as having engaged in sex work or lived in another city, province, or country outside of Metro Vancouver in the past six months. Short-term migration outside of Metro Vancouver was assessed by asking participants to list the places outside of Metro Vancouver that they had lived in during the last 6 months, whereas short-term mobility for sex work was based on asking about other places that participants had worked in the sex industry during the last 6 months. For both questions, all locations listed outside of Metro Vancouver (e.g., other BC city, province, or country) were coded as “yes.” Independent Variables of Interest: Participants completed interviewer-administered questionnaires in English or Mandarin by trained interviewers and HIV/STI testing by a project nurse. The baseline questionnaire covered socio-demographic characteristics such as age, education, birthplace, ethnicity, languages spoken, and income. Sexual risks (e.g., condom negotiation, client volume) and drug use (e.g., non-injection and injection drug use) were also measured. Inconsistent condom use was defined as responding that they ‘usually’, ‘sometimes’, ‘occasionally’, or ‘never’ used a condom for vaginal or anal sex with clients (including one-time or regular clients) or non-commercial partners (vs. ‘always’ used condoms). Client condom refusal was defined as responding that they were ‘always’, ‘usually’, ‘sometimes’, or ‘occasionally’ coerced into vaginal, anal or oral sex without a condom by clients (including one-time or regular clients) (vs. ‘never’ coerced into unprotected sex). Condom refusal by intimate partners was defined as a ”yes” response to the question, “In the last 6 months, has your intimate partner coerced you into having sex (vaginal/anal) without a condom?” Questions on structural factors included questions on homelessness and housing instability, health care access, and the work environment in the past six months. Work environment questions covered primary places of solicitation and servicing clients, physical conditions of street and indoor venues, establishment policies, interactions with third parties  9 (e.g., managers), police, security, city licensing, and workplace violence. Primary place of solicitation was based on the question, “In which of the following ways have solicited/hooked up with your clients?” in the last six months, and coded as street/public (e.g., street/outdoor public space), indoor establishment (e.g., massage/beauty parlour, micro-brothel, bar/nightclub, crack/drug house), and independent (e.g., escort agency, newspaper ads, online). Primary place of servicing clients was based on the question, “In which of the following types of places have you ever serviced/taken clients?” in the last six months, and coded as outdoor/public (e.g., street, vehicle, other public areas), informal indoor (e.g., crack/drug house, bar, nightclub, hotel, client’s place, your place, supportive housing), and formal indoor establishment/brothel (e.g., massage parlour, health/beauty enhancement centre, micro-brothel). Violence was assessed by asking if participants experienced physical and/or sexual violence in the last six months by either clients or intimate partners, including abducted/kidnapped, forced unprotected sex, raped, strangled, physical assault, or assaulted with a weapon. Paid a manager was based on asking if participants had shared or had to pay a third party (e.g., manager or administrator) a percentage of their income from clients. Trafficking was defined as reporting having been trafficked/sold into sex work or traded/sold from one pimp to another in the prior six months. Experienced any barrier to health care access was based on the question, “In the last 6 months, what barriers to receiving health care have you experienced?” Response options indicating barriers to health care included limited hours of operation, wait times, don’t know where to go, language barrier, couldn’t get doctor of preferred gender, difficulty keeping appointments, jail/detention/prison, poor treatment by health care professionals (vs. no barriers). HIV/STI measures: Following pre-test counseling, a rapid point-of-care HIV blood-based test [INSTI test, Biolytical Laboratories Inc, Richmond, BC] was done, and reactive tests were confirmed by western blot. Urine samples were collected for gonorrhea and chlamydia, and blood was drawn for syphilis testing. All participants received post-test counselling. STI treatment was provided by a project nurse onsite, and free serology and Papanicolaou testing  10 were made available, regardless of study enrolment. STI/HIV infection was defined as positive for any STI (i.e., syphilis, gonorrhea, or Chlamydia) or HIV in the past six months.  Data analysis As the first step of the analysis, descriptive statistics were calculated for individual, interpersonal behavioural and structural factors, and HIV/STIs at baseline and were stratified by whether participants had been mobile (i.e., did sex work or lived outside of Metro Vancouver) in the past six months. The differences in these characteristics between those who reported any recent mobility and those who did not at baseline were assessed using the Mann-Whitney test for continuous variables and Pearson’s Chi-squared test (or Fisher’s exact test for small cell counts) for categorical variables. Then, using generalized estimating equations (GEE) and an exchangeable correlation structure60, 61, we longitudinally examined correlates of recent mobility (i.e., lived or engaged in sex work outside Metro Vancouver in the past six months), among FSWs in Vancouver, BC. Sensitivity analyses were also conducted to separately examine the relationship between mobility for sex work and covariates of interest (e.g., physical/sexual violence). Bivariate and multivariate GEE analyses included data from each participant’s baseline and follow-up visits and were conducted with a logit link function for our binary outcome to account for repeated measures among the same individuals. Socio-demographic characteristics were treated as fixed covariates, and all other variables (e.g., homelessness, condom use, drug use, physical/sexual violence, barriers to health care) were treated as time-updated covariates of occurrences within the past six months. Variables that were a priori hypothesized to be related to short-term mobility or migration and with a significance level of p < 10% in bivariate analyses were considered for inclusion in the multivariate model. The backward model selection process was used to identify the model with the best overall fit, as indicated by the lowest quasi- 11 likelihood under the independence model criterion (QIC) value62. Analyses were performed using the SAS version 9.3 (SAS, Cary, NC). All p-values are two sided.  RESULTS The median follow-up duration was 17.7 months (Inter-quartile range (IQR): 11.66-23.89). Of 646 FSWs, 10.84% (n=70) reported short-term mobility or migration (i.e., within the last 6 months) during the study, whereas 89.16% (n=576) did not. Of mobile/migrant women, 7.12% (n=46) engaged in short-term mobility for sex work (i.e., engaged in sex work in another city, province or country), and 6.66% (n=43) reported short-term migration (i.e., lived in another city, province or country) during the study period. Primary mobility/migration destinations included other BC cities (n=30, 4.64%), followed by other Canadian provinces (n=33, 5.11%) and the United States or China (n=17, 2.63%). One quarter of participants had moved to Vancouver from another city, province, or country in the last 5 years. At baseline, the median age was 34 years (IQR: 28-42), and those reporting short-term mobility or migration were younger (median: 29.5 vs. 34.5 years, p=0.002) and earned a higher monthly income (median: $3720 vs. $2500 CAD, p=0.012) than their non-mobile counterparts. Combined prevalence of HIV and STIs was high (21.05%), but there was no significant difference between women reporting short-term mobility or migration and their non-mobile counterparts at baseline (16.67% vs. 21.36%, p=0.473).  In bivariate GEE analysis (Table 2), women who engaged in short-term mobility or migration were more likely to experience health and structural vulnerabilities such as condom refusal by clients (Odds Ratio (OR): 1.76, 95% Confidence Interval (CI): 1.00-3.10) and intimate non-commercial partners (OR: 4.33, 95% CI: 1.54-12.13), physical/sexual violence by clients (OR: 1.92, 95% CI: 1.14-3.23), homelessness (OR: 2.31, 95% CI: 1.49-3.57), paying a manager, pimp or administrator (OR: 3.19, 95% CI: 1.98-5.14), and experiencing barriers to health care (OR: 1.79, 95% CI: 1.12-2.86).  12 In multivariate GEE analysis (Table 2), older age (Adjusted Odds Ratio (AOR): 0.95, 95% CI: 0.92-0.98), soliciting clients in indoor establishments (AOR: 2.25, 95% CI: 1.27-3.96), intimate partner condom refusal (AOR: 3.00, 1.02-8.84) and barriers to health care access (AOR: 1.77, 95% CI: 1.08-2.89) remained independently correlated with short-term mobility and migration. In a separate model examining factors associated with short-term mobility for sex work (Table 3), the same variables were significantly associated, with the exception of soliciting clients in indoor establishments and the addition of physical/sexual violence by clients (AOR: 1.92, 95% CI: 1.02-3.61).  DISCUSSION Over the course of this two-and-a-half year study, a substantial proportion (10.84%) of sex workers in an urban Canadian setting had worked or lived in another city, province, or country. Mobile/migrant workers were less likely to be HIV/STI positive, and were more likely to be younger, work in indoor establishments, and earn higher income, indicating that short-term mobility/migration may increase social and economic opportunities for sex workers. At the same time, short-term mobility/migration was linked to violence and sexual risks, including reduced control over condom negotiation with intimate partners; mobility for sex work was also associated with enhanced workplace violence, which may be related to reduced control over one’s work environment in destination settings. These findings are supported by a systematic review documenting that migration to higher-income European countries conferred protection against HIV among sex workers6, although the timing of migration and internal mobility were not assessed within this review. These results are also supported by research with indoor sex industry workers in British Columbia and Alberta, which has found that although exotic dancers who work as independent contractors are often younger and have increased earning potential as a result of flexibility in  13 working in different venues63, they are often exposed to poorly maintained workplaces and receive inadequate security or support from management and booking agents63.  Women in this study reported high levels of workplace violence and barriers to condom negotiation, with migrant/mobile women experiencing three-fold higher odds of intimate partner condom refusal. Whereas previous studies have documented enhanced vulnerabilities of mobile sex workers to unprotected sex with clients8, 31, 46, our findings provide unique evidence regarding the crucial role of intimate partners in shaping HIV/STI risks for this population. Although further research is needed to ascertain why mobile sex workers were more likely to experience intimate partner violence and barriers to condom negotiation with these partners, this may be explained by reduced access to social support in mobility/migration destinations, or it may be that mobility itself could be influenced by intimate partners themselves (e.g., mobility to flee intimate partner violence). Future mixed-methods research is needed to understand and develop interventions to address condom refusal and violence by intimate partners and clients among mobile FSWs. This study also found that mobility for sex work related to an increased risk of client violence, which is supported by research from India, where a greater degree of mobility was associated with physical violence by clients8, and mobility and violence interacted to increase the risk of HIV infection31. To the best of our knowledge, this study provides the first longitudinal evidence regarding patterns of violence and mobility among sex workers in higher-income settings. Further research is needed to understand the broader structural factors that place mobile women at elevated risk of violence and health risks, such as limited social networks or poor access to information regarding working conditions in new settings63. In Canada32, 33, 52-55, 64 and elsewhere2, 30, 58, 65-67, the criminalization of sex work has been linked to HIV/STI risk and violence – for example, police arrest and harassment of FSWs has been found to displace women to isolated settings where they are vulnerable to client condom refusal and violence, and are less likely to access healthcare and social supports53, 68. However, the extent to which law  14 enforcement practices may be driving mobility and related impacts on the health and safety of mobile/migrant FSWs remains poorly understood, and requires further research in light of additional concerns for migrant workers around immigration status, cultural norms and language barriers to accessing police protections. In light of upcoming legislative changes that may decriminalize sex work in Canada, further evaluation of the impacts of shifting legal environments surrounding sex work for mobile women in the sex industry remains critical to inform safer workplace policies and practices. Lastly, short-term mobility/migration was linked to reduced health care access. Previous studies from Canada, Mexico, and the United States have found that mobile populations frequently experience difficulty accessing conventional health and social services, both during mobility as well as in migrants’ destination settings1, 69-71. Mobile and migrant populations may experience barriers to health care access due to limited familiarity with local health systems and services, stigma and discrimination, inconvenient or limited hours of operation, and language and insurance-related barriers1, 69-71. To inform ongoing public health programs to improve access to care for marginalized populations in Canada and internationally, including support for violence and efforts to scale-up the ‘cascade of care’ for HIV and STIs for sex workers, further research to reduce the gap in access for mobile and migrant populations remains critically needed.   Strengths and limitations As the study from which these findings were generated was not designed to investigate the health consequences of migration and mobility, future research is needed to understand the complexities of migration and mobility-related risks and protective factors, particularly as they relate to violence and sexual risk. Studies that gather detailed information regarding the diverse contexts surrounding recent migration and mobility (e.g., drivers of mobility for sex work, mobility patterns and duration over time) as well as the timing and nature of health-related risks  15 are needed to explore pathways and contexts of risk and risk mitigation. As this study is focused on a transient and largely ‘hidden’ population, it is possible that more vulnerable populations of migrant sex workers and those who are more highly mobile may be under-represented. Future longitudinal and mixed-methods studies with larger populations of migrant and mobile sex workers are recommended to better elucidate the context of risk and risk mitigation within the context of mobility and migration.   Implications for interventions In conjunction with biomedical and behavioral approaches (e.g., condom promotion), community empowerment (e.g., sex worker collectivization, peer-based delivery of services and sharing of information), has been key for achieving reductions in sexual risk and improved working conditions in many settings, notably India and the Dominican Republic72-77. Tailored interventions for mobile/migrant sex workers that incorporate community organizing and sex work-led strategies are recommended to reduce isolation, improve control over working conditions, and link women to health, HIV/STI prevention, and social supports. This could include peer-based outreach to link migrant/mobile SWs to low-barrier health and social services in mobility destinations and facilitate the sharing of health and safety information (e.g., regarding the structure of sex work and safety risks in mobility destinations). Such interventions are promising for migrant/mobile sex workers due to their ability to reduce social isolation, which is a critical determinant of health for mobile populations11, 13, 78. Critical to supporting access to safer workplace standards, both for the general population of sex workers as well as for migrant/mobile women, is the ability of sex workers to more formally collectivize and share information. Supporting this process will continue to be critical for violence and HIV/STI prevention for sex workers in Canada, as it has been in low- and middle-income countries28, 79. By facilitating changes in policy and working conditions, such  16 collectivization would enhance opportunities to access safe and healthy work environments for all women in the sex industry, including highly mobile and migrant populations.  Conclusions In this cohort study, short-term mobility/migration related to enhanced sexual and safety risks, as well as increased social and economic opportunities. There is a need for future migrant health and sex work research to be guided by a broader conceptualization of the diverse (i.e., protective as well as risky) and often complex impacts of migration and mobility on health, safety, and working conditions. The sexual and safety vulnerabilities identified suggest the critical need to develop and evaluate interventions to reduce violence and sexual risks, and improve access to healthcare for mobile and migrant women in the sex industry. Tailored, peer-based interventions to reduce isolation and improve mobile/migrant sex workers’ control over their working conditions are needed, alongside efforts to link women to health and social supports.     17 ACKNOWLEDGEMENTS We thank all those who contributed their time and expertise to this project, including participants, partner agencies and the AESHA Community Advisory Board. We wish to acknowledge Ofer Amram, Ladan Bayani-Mehrabadi, Eva Breternitz, Jill Chettiar, Nadiya Chettiar, Sabina Dobrer, Chantelle Fitton, Julia Homer, Rhiannon Hughes, Andrea Krusi, Emily Leake, Vanessa Lew, Jane Li, Vivian Liu, Sylvia Machat, Jen Morris, Paul Nguyen, Rachel Nicoletti, Tina Ok, Alex Scott, Even Shen, Annick Simo, Chrissy Taylor, Brittney Udall, Peter Vann, Helen Wang and Gina Willis for their research and administrative support. This research was supported by operating grants from the US National Institutes of Health (R01DA028648) and Canadian Institutes of Health Research (HHP-98835). SG is supported by fellowships from the Canadian Institutes of Health Research and the Women’s Health Research Institute/Michael Smith Foundation for Health Research. KS is supported by US National Institutes of Health (R01DA028648), the Michael Smith Foundation for Health Research, and the Canadian Institutes of Health Research.    18 Table 1: Characteristics of female sex workers (n=646) at baseline, stratified by short-term mobility and migration, 2010-2012  Did sex work or lived in another city, province or country, last 6 months   Variable Yes (n=42) n (%) No (n=604) n (%) Total (N=646) n (%) P-value Individual factors   Age, in years (median, IQR) 29.5 (25-36) 34.5 (28-42) 34 (28-42) 0.002 Average monthly income, in CAD (median, IQR) 3720.00 (2100.00-7600.00) 2500.00 (1400.00-5000.00) 2600.00 (1400.00-5485.00)  0.012 Aboriginal ethnicity 19 (45.24%) 217 (35.93%) 236 (36.53%)  0.226 HIV/STI positive 7 (16.67%) 129 (21.36%) 136 (21.05%)  0.471 Injection drug use 19 (45.24%) 243 (40.23%) 262 (40.56%)  0.523 Non-injection drug use 29 (69.05%) 425 (70.36%) 454 (70.28%)  0.857 Interpersonal factors   Inconsistent condom use with:     Clients (any type) 5 (11.90%) 109 (18.05%) 114 (17.65%)  0.313 Non-commercial partners 17 (40.48%)  235 (38.91%) 252 (39.01%)  0.840 Condom refusal by:     Clients (any type) 12 (28.57%) 131 (21.69%) 143 (22.14%)  0.299 Intimate partners 3 (7.14%) 8 (1.32%) 11 (1.70%)  0.029 Client volume per month (median, IQR) 48 (31-82) 48 (20-84) 48 (20-84)  0.395 Structural factors   Primary place of solicitation     Street/public (ref) 21 (50.00%) 344 (56.95%) 365 (56.50%)  Indoor establishment 9 (21.43%) 167 (27.65%) 176 (27.24%)  0.761 Independent 12 (28.57%) 93 (15.40%) 105 (16.25%)  0.049 Primary place of service     Outdoor/public (ref) 22 (52.38%) 268 (44.37%) 290 (44.89%)  Informal indoor establishment 9 (21.43%) 159 (26.32%) 168 (26.01%)  0.363 Brothel/quasi-brothel 11 (26.19%) 177 (29.30%) 188 (29.10%)  0.466 Homelessness 25 (59.52%) 174 (28.81%) 199 (30.80%) <0.001 Moved to another part of town because felt unsafe 7 (16.67%) 53 (8.77%) 60 (9.29%)  0.098 Physical/sexual violence by:     Clients (any type) 13 (30.95%) 141 (23.34%) 154 (23.84%)  0.263 Intimate partners 12 (28.57%) 127 (21.03%) 139 (21.52%)  0.250 Paid a third party 15 (35.71%) 169 (27.98%) 184 (28.48%)  0.283 Trafficked or traded 0 (0.00%) 7 (1.16%) 7 (1.08%)  1.000 Experienced any barrier to health care access 34 (80.95%) 378 (62.58%) 412 (63.78%)  0.017 All variables refer to the last 6 months, with the exception of age and Aboriginal ethnicity.     19 Table 2: Factors longitudinally associated with short-term mobility and migration among female sex workers (n=646) over time, 2010-2012 Variable Unadjusted Odds Ratio Unadjusted 95% Confidence Interval Adjusted Odds Ratio Adjusted 95% Confidence Interval Age,  per year older 0.94 0.91-0.97 0.95 0.92-0.98 HIV/STI seropositive 0.32 0.15-0.67   Condom refusal by:     Clients (any type) 1.76 1.00-3.10   Intimate partners 4.33 1.54-12.13 3.00 1.02-8.84 Primary place of solicitation     Street/public (ref)     Indoor establishment 1.84 1.07-3.16 2.25 1.27-3.96 Independent 1.23 0.67-2.24 1.34 0.73-2.45 Homelessness 2.31 1.49-3.57   Physical/sexual violence by:     Clients (any type) 1.92 1.14-3.23 1.55 0.88-2.72 Intimate partners 1.21 0.70-2.09   Paid a third party 3.19 1.98-5.14   Experienced any barrier to health care access 1.79 1.12-2.86 1.77 1.08-2.89 All variables refer to the last 6 months, except for age, which was treated as a time-fixed covariate.     20 Table 3: Factors longitudinally associated with recent mobility for sex work among female sex workers (n=646) over time, 2010-2012 Variable Unadjusted Odds Ratio Unadjusted 95% Confidence Interval Adjusted Odds Ratio Adjusted 95% Confidence Interval Age, per year older 0.92 0.88-0.96 0.94 0.90-0.98 HIV/STI seropositive 0.30 0.12-0.76   Condom refusal by:     Clients (any type) 1.88 0.95-3.70   Non-commercial partners 5.55 1.90-16.20 3.48 1.17-10.38 Primary place of solicitation     Street/public (ref)     Indoor establishment 1.21 0.58-2.52 1.54 0.70-3.37 Independent 1.60 0.87-2.95 1.85 0.98-3.50 Homelessness 2.69 1.63-4.44   Physical/sexual violence by:     Clients (any type) 2.61 1.45-4.67 1.92 1.02-3.61 Intimate partners 1.70 0.94-3.09   Paid a third party 2.50 1.37-4.56   Experienced any barrier to health care access 2.36 1.31-4.27 2.18 1.17-4.08 All variables refer to the last 6 months, except for age, which was treated as a time-fixed covariate.     21 REFERENCES 1. 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