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A comprehensive review of HIV/STI prevention and sexual and reproductive health services among sex Workers… Ferguson, Alyssa; Shannon, Kate; Butler, Jennifer; Goldenberg, Shira M Dec 4, 2017

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RESEARCH Open AccessA comprehensive review of HIV/STIprevention and sexual and reproductivehealth services among sex Workers inConflict-Affected Settings: call for anevidence- and rights-based approachin the humanitarian responseAlyssa Ferguson1, Kate Shannon1,2, Jennifer Butler3 and Shira M. Goldenberg1,4,5*AbstractBackground: While the conditions in emergency humanitarian and conflict-affected settings often result in significantsex work economies, there is limited information on the social and structural conditions of sex work in these settings,and the impacts on HIV/STI prevention and access to sexual and reproductive health (SRH) services for sex workers. Ourobjective was to comprehensively review existing evidence on HIV/STI prevention and access to SRH services for sexworkers in conflict-affected settings globally.Methods: We conducted a comprehensive review of all peer review (both epidemiological and qualitative) and greyliterature published in the last 15 years (2000–2015), focusing on 1) HIV/STI vulnerability or prevention, and/or2) access to SRH services for sex workers in conflict-affected settings. Five databases were searched, usingcombinations of sex work, conflict/mobility, HIV/STI, and SRH service terms. Relevant peer-reviewed and greyliterature were also hand-searched, and key papers were cross-referenced for additional material.Results: Five hundred fifty one records were screened and 416 records reviewed. Of 33 records describingHIV/STI prevention and/or access to SRH services among sex workers in conflict-affected settings, 24 werefrom sub-Saharan Africa; 18 studies described the results of primary research (13 quantitative, 3 qualitative,2 mixed-methods) and 15 were non-primary research (e.g., commentaries, policy reports, programmaticmanuals). Available evidence indicated that within conflict-affected settings, SWs’ capacity to engage in HIV/STI prevention and access SRH services is severely undermined by social and structural determinants includingwidespread violence and human rights violations, the collapse of livelihoods and traditional social structures,high levels of displacement, and difficulties accessing already scant health services due to stigma,discrimination and criminalization.(Continued on next page)* Correspondence: gshi@cfenet.ubc.ca1Gender and Sexual Health Initiative, British Columbia Centre for Excellencein HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada4Faculty of Health Sciences, Simon Fraser University, Blusson Hall, 8888University Drive, Burnaby V5A 1S6, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Ferguson et al. Conflict and Health  (2017) 11:25 DOI 10.1186/s13031-017-0124-y(Continued from previous page)Discussion/Conclusions: This review identified significant gaps in HIV/STI and SRH research, policy, andprogramming for conflict-affected sex workers, highlighting a critical gap in the humanitarian response. Sexworker-informed policies and interventions to promote HIV/STI prevention and access to HIV and SRH servicesusing a rights-based approach are recommended, and further research on the degree to which conflict-affected sex workers are accessing HIV/STI and SRH services is recommended.A paradigm shift from the behavioural and biomedical approach to a human rights-based approach to HIV/STI prevention and SRH is strongly recommended.Keywords: Sex work, Conflict, Post-conflict, Sexual and reproductive health, HIV/Aids, STIsBackgroundForty armed conflicts were active in 2014, an 18%increase when compared to the 34 reported in 2013,with many additional countries currently consideredfragile states, or involved in post-conflict rehabilitation[1]. Armed conflicts have resulted in unprecedentedwaves of population displacement as well as other dele-terious human rights, public health, and social impacts,including the disruption of traditional social structures,a breakdown in security, and weakened or collapsedhealth systems [2–5].Roughly 50% of the estimated 43 million people maderefugees or displaced by conflict are women [6]. Whilethe relationship between conflict and HIV/STI preva-lence in the general population is greatly shaped bycontextual factors [7, 8], and has been found to vary bysetting, women have been shown to often be dispropor-tionately vulnerable to the negative health and socialconsequences of displacement [9, 10]. The economic, so-cial and political instability of conflict and post-conflictenvironments, including social and physical displace-ment, loss of traditional economic options, cultural up-heaval, family separation and increased women-headedhouseholds, often result in conditions that facilitate sig-nificant engagement in sex work as a source of income,particularly for women. Further, armed conflict and thehighly policed and militarized environment characteristicof post conflict have been linked to widespread gender-based violence (including rape as a weapon of war; forcedabductions), rights violations of women [3, 11–17], and re-duced access to, or the interruption of, HIV and sexualand reproductive health (SRH) programmes [4, 18–21].For example, previous research has shown that withinconflict settings, the interruption of condom distribution,disruption of HIV diagnostic services, and shortages ofHIV antiretroviral therapy (ART) may drastically impedediagnosis and care [18]. Together, these dimensions ofconflict create a complex and challenging situation forprevention of HIV/STIs and delivery of care to conflict-affected populations [10], yet the lived experiences of sexworkers, conditions within post-conflict environments,and barriers to accessing HIV and SRH services havelargely been unaddressed in research and policy. Further-more, that programmers and development partners inhumanitarian settings may be uninterested in sex work ormay conflate issues of sexual exploitation with sex workfor ideological or political reasons, creates perversebarriers in the protection of human rights for this group.Sex workers are a key population disproportionatelyaffected by HIV/STIs [22]. While the majority of sexworkers globally are women, there are sizable popula-tions of men and transgender sex workers in many set-tings [23–25]. HIV/STI prevalence among sex workersvaries both across and within regions due to structuralfactors related to the social, political, economic, legal, andcultural conditions in which sex workers operate, in con-junction with local HIV and STI epidemics [9, 22, 26].Despite this, research and programmes in the past decadehave largely focused on behavioural and biomedical inter-ventions among SWs, which alone, have had only modesteffects on the reduction of HIV at the population-level[22, 27]. A recent global review identified a critical needfor further studies examining structural HIV/STI risks oraccess to care for sex workers in the highest-HIV burdencountries [9], to inform the design, adaptation and imple-mentation of effective HIV/STI programmes, particularlyneeded within conflict-affected settings of sub-SaharanAfrica. While sex workers are often highly marginalizedeven in non-conflict settings, in conflict-affected environ-ments they may face elevated social and structural risksand barriers to care, including abuses of human rights bymilitary and police, gender-based inequities, widespreadviolence, discrimination and stigma, social and physicalisolation, breakdowns in health service delivery systems,and other structural risks that often accompany or followa crisis [11, 14, 26, 28, 29]. Despite this, little is knownabout conflict-affected sex workers’ vulnerability to HIV/STIs or access to HIV and SRH services, or their socialand structural drivers within conflict-affected settings.Given the paucity of existing data regarding HIV/STI risksand access to HIV and SRH services within the context ofsex work in conflict-affected settings, this comprehensivereview aimed to broadly explore and synthesize currentevidence on HIV/STI risk, access to HIV and SRHFerguson et al. Conflict and Health  (2017) 11:25 Page 2 of 20services, and their social and structural determinantswithin the context of sex work in conflict-affected settings(i.e., conflict and post-conflict conditions).MethodsSearch strategyFrom May to July 2015, we comprehensively searchedthe peer-reviewed and grey literature for materialdescribing HIV/STI risk or prevention and/or access toHIV or SRH services for sex workers in conflict-affectedsettings in the last ten years. Five databases (PubMed,Global Health, PAIS International, Social SciencesCitation Index, and Web of Science Core Collection)were searched using combinations of terms related tosex work, conflict, HIV/STI risk or prevention, and HIVand SRH services access related terms (Table 1).Relevant journals and organizational websites werehand-searched, and key papers were cross-referenced.Due to the limited number of relevant peer-reviewedstudies available, grey literature (e.g., governmental andnon-governmental reports) was searched. Studiesconducted with populations of relevance other than sexworkers (e.g., Internally Displaced Persons (IDPs), clientsof sex workers) were also considered and included wherethey provided useful context and insight regarding sexwork and HIV, STI, or SRH issues in conflict-affectedsettings. The first and second rounds of screening in-volved reviewing titles and abstracts, respectively, toidentify potentially relevant studies. The third-level ofscreening consisted of a full-review of remaining recordsto ascertain relevance in relation to the inclusion cri-teria. We used the PRISMA guidelines as a reference(Fig. 1).Inclusion criteriaEligible records included peer-review publications(qualitative, quantitative, or review articles) or greyliterature (e.g., policy documents, community reports,commentaries, issue reports and briefs, position reports,practical guides for staff working in conflict/post-conflictenvironments) that met the following criteria: 1) Englishliterature; 2) published from January 2000–July 2015; 3)discussed sex workers (or their clients) working withinconflict or post-conflict settings (e.g., refugee or intern-ally displaced sex workers); and 4) included data onHIV/STI risk, prevention, or HIV and SRH services forsex workers in conflict-affected settings. Other reviewswere included, as they synthesized key insights in a do-main with a paucity of empirical studies. For the purposeof this review, the United Nations definition of sex workwas adopted, defined as the sale or exchange of sex foraccommodation, protection, food, gifts and other itemsor services. Studies which were explicitly and solelyfocused on transactional sex (i.e., broader populations ofthose who exchange sex for favours or gifts, or who donot necessarily self-identify as sex workers) were ex-cluded. Studies of the trafficking in human beings forthe purposes of sexual exploitation were also excluded,unless they included the experiences of sex workers.Conflict-affected sex workers included those who identi-fied as refugees or IDPs from conflict or post-conflictsettings (defined as ≤10 years post-conflict) as well assex workers currently operating in conflict-affected (i.e.,current or post-conflict) settings.Data extraction and analysisEndnote was used to manage retrieved items. A MicrosoftExcel database was developed to organize and chart studycharacteristics (authors, year, country, design, population,sample size), key findings, and the following data, whereapplicable: HIV/STI prevalence, conflict-related variables,qualitative findings, and key programme and policyrecommendations. We began by grouping the findings ofthe epidemiologic studies according to common topicsand structural determinants, comparing them across stud-ies. Next, we elicited common themes from the qualitativedata and compared these across settings. Lastly, we ana-lyzed existing refugee and sex worker HIV/STI preventionand SRH programme and policy recommendations inconflict settings, seeking to draw lessons and exemplarsfor future programmes and interventions.ResultsFive hundred and fifty-one titles and abstracts werescreened by the first author to determine eligibility. Fourhundred and sixteen eligible records were reviewed. Ofthe 33 records which met the criteria to be included inthis review, the majority (n = 22) described conflict orTable 1 Search termsSex work “sex work*” OR “prostitute*”OR “transactional sex” OR“commercial sex” OR “sex trade” or “FSW*”Conflict environment “conflict” OR “emergenc*” OR “IDP” OR“displaced” OR “displaced person*” OR“displaced people” OR “refugee*” OR“humanitarian” OR “war”HIV/STI risk or prevention,and HIV and SRH services“HIV” OR “human immunodeficiencyvirus” OR “HIV infections” OR “AIDS” OR“acquired immunodeficiency syndrome”OR “acquired immune deficiencysyndrome” OR “sexually transmittedinfections” OR “STIs” OR “Sexual healthservices” OR “sexual health” OR“reproductive health” OR “testing” OR“test” OR “treatment” OR “ART” OR “ARVs”OR “sex education” OR “sexual healtheducation” OR “safer sex” OR“contraceptives” OR “birth control” OR“family planning” OR “pap smear” OR“condoms” OR “health services” OR“health care” or “healthcare”Ferguson et al. Conflict and Health  (2017) 11:25 Page 3 of 20post-conflict environments in sub-Saharan Africa, 4 werefrom other settings (e.g., Afghanistan, Bangladesh/Myanmar, Sri Lanka, and Nepal), and 7 were globallyfocused. Eighteen studies described the results of peer-reviewed primary research articles (13 quantitative, 3qualitative, 2 mixed methods) (Table 2), and 15 werenon-empirical research (e.g., review articles, commentar-ies, issue reports and briefs, position reports, and prac-tical guides for staff working in conflict/post-conflictenvironments). A summary of practical guides for staffworking in conflict/post-conflict environments (n = 5)are described in Table 3. Twenty four of the 33 recordswere peer-reviewed, while 9 were classified as grey litera-ture/non-peer reviewed. Of the 33 included studies, 14focused primarily on sex workers in conflict/post-con-flict settings, while others discussed broader dynamics ofsex work (e.g., sex purchasing) among the generalconflict-affected population (n = 17), sex workers’ clients(e.g., migrants, combatants) (n = 5), or a combination ofthese groups. While eligibility was inclusive of all genderand sexual orientations, the majority of studies reportedon cis-gender female sex workers. One study reportedon sexual and gender minority sex workers in displace-ment and post-conflict settings [23].Sex work context and links to HIV/STI prevention and riskin conflict-affected settingsSex workers in conflict and post-conflict settings werefound to face an extraordinarily high HIV and STIburden. The burden of HIV among sex workers in studiesreviewed ranged considerably, with prevalence rates of70% reported among Nepalese sex workers returning fromIndia [30], and 22.3% among conflict-affected sex workersin Gulu, northern Uganda [31]. STI prevalence alsoranged considerably, with an acute self-reported STIprevalence of 40.3% in Gulu, Uganda [31], and 17% of sexworkers in northern Ethiopia self-reporting history of anSTI [32]. Gonorrhea was the most common STI reportedin this study, accounting for 45.8% of the total [32].Gendered economic impacts of conflict and sex work entryAvailable data indicated high rates of sex work inconflict and post-conflict settings globally [11, 30, 33]. Astudy in Nepal revealed that roughly 19.0% of sexworkers reported having entered sex work directly be-cause of subsistence needs attributed to local conflict[30]. Our review of both the qualitative and the quanti-tative literature pointed to the ways in which poverty,diminished employment opportunities, difficulty meet-ing subsistence needs, and challenges to sustainablelivelihoods in contexts of displacement influencedengagement in sex work within conflict-affected set-tings [3, 5, 11, 17, 23, 30, 32–41].Within the context of family separation resulting fromarmed conflict, increases in female-headed householdswere common, and women often experienced reducedaccess to traditional economic livelihoods, particularly inthe absence of male support [36, 37]. Stemming from551 records identified through database searching21 records identified through other sources156 duplicates removed416 unique records screened331 records excluded based on title screen; 37 records excluded based on abstract screen48 full-text records assessed for eligibility15 full-text records eliminated:• 7 not focused on conflict/post-conflict setting• 4 not focused on sex work in conflict/post conflict setting• 2 were conference abstracts• 1 did not stratify results of sex workers• 1 included only historical data33 records included in reviewIdentificationScreeningEligibilityIncludedFig. 1 PRISMAFerguson et al. Conflict and Health  (2017) 11:25 Page 4 of 20Table2CharacteristicsofprimarystudiespertainingtosexworkandHIV,STIs,andSRHinconflict-affectedsettingsReferenceLocationDesignPopulation(N)StageofconflictstudiedKeyFindingsQuantitative(13)Alemayehuetal.(2015)[32]MekelleCity,EthiopiaCross-sectionalSWs(N=250)Post-conflictSTIhistory:17%reportedhistoryofanSTI,gonorrhea(45.8%)syphilis(41.7%),andchancroid(12.5%)STItesting:9.6%ofthosewithanSTIreportedhavingsoughttreatmentReproductivehealth:27%ofSWsreportedahistoryofatleastoneelectiveabortion,with35.3%ofthesewomenreportingmorethanonepregnancytermination.Contraceptiveuse:69%ofSWsacknowledgedanytypeofcontraceptiveuseViolence:PrevalenceofsexualviolenceamongSWs=75.6%,correlatesincludedlowereducation,sexworkduration,anddruguse.SWswithlowermonthlyincomewerethemostlikelytoexperiencesexualviolence.Bingetal.(2008)[50]AngolaCross-sectional(Behaviouralsurveillancestudy)Militarypersonnel(N=1710)Post-conflictCombatantsassexbuyers:9%ofcombatantsreportedhavingsexwithaSWinpast12monthsCondomuse:54.2%ofmilitarypersonnelreportedusingacondomatlastsexwithaSWSTIs:CombatantswhohadcasualsexpartnersorwhohadsexwithaSWduringthepastyearweresignificantlymorelikelytoreportSTIsymptomsthanthosewithoutsuchsexualpartners.Dupasetal.(2012)[43]KenyaRetrospectivestudy-SWs(N=248)-Self-employedentrepreneurs(N=230)-Shopkeepers(N=325)Activeandpost-conflictcomparisonInfluenceofpoliticalviolenceonunprotectedsex:SWsengagedinhigherrisk(unprotectedvaginaloranal)sexbothduringandafterthepost-electioncrisis,tomakeupforincomeshortfall.Overalllevelsofhigherrisksexdeclinedduringthecrisis,butwomenrespondedtothenegativeincomeshockbysignificantlyincreasingtheamountofunprotectedsextheyhad,conditionalonbeingabletofindclients.Ericksonetal.(2015)[31]Gulu,UgandaCross-sectionalSWs(N=400)Post-conflictHIV/STIprevalence:22.3%SWsreportedHIVinfectionand40.3%reportedSTIsContraceptiveuse:45.0%ofSWsusedmalecondomsandnon-barrierfamilyplanningmethods.Policing:Havingtorushsexualnegotiationsowingtopolicepresencewasnegativelyassociatedwithdualcontraceptiveuse(AOR0.65,95%CI0.42–1.00;P=0.050).HIVtesting:DualcontraceptiveusewaspositivelyassociatedwithHIVtesting(AOR5.22,95%CI1.75–15.57;P=0.003),suggestingthepotentialimportanceofbetterintegrationofHIV/SRHservices.Goldenbergetal.(2015)[11]Gulu,UgandaCross-sectionalSWs(N=400)Post-conflictHIVinfection:33.75%ofSWswereHIV-seropositive(comparedto8.51%ofwomenofreproductiveageingeneralpop);ofwhom33.3%werenew/previouslyundiagnosedHIVinfections.Abductionbyrebels:War-relatedabductionwasassociatedw/HIV(AOR:1.62,95%CI:1.00–2.63).Criminalization:Incarceration(AOR:1.93,95%CI:1.17–3.20)associatedw/HIVFerguson et al. Conflict and Health  (2017) 11:25 Page 5 of 20Table2CharacteristicsofprimarystudiespertainingtosexworkandHIV,STIs,andSRHinconflict-affectedsettings(Continued)ReferenceLocationDesignPopulation(N)StageofconflictstudiedKeyFindingsHarrisonetal.(2009)[45]OruchingaandNakivalerefugeesettlements,UgandaCross-sectional(Standardisedbehaviouralsurveillancesurvey(BSS))-Settlementrefugeeswhosoldsexinlast12months(N=93)-Ugandansinsurroundingsettlementareawhosoldsexinlast12months(N=47)Post-conflictSexworkfollowingdisplacement:Morerefugeesthannationalsreportedexchangingsexformoney,drugsorothergoods(10%versus6%;p<0.01),whichmostlyoccurredpost-displacement.Sexworkengagementhigherintherefugeepopulationvs.Ugandannationals(4.7%vs.2%).Condomuse:Condomusewaslowinbothpopulations,butloweramongrefugees.Condomuseatlastsexwithalltypesofpartners(non-regular,paid,andhigherrisk)four-timeshigheramongthenationalsthanrefu-gees,butconfidenceintervalsoverlapped.Sexualviolence:Percentageofwomenaged15–59forcedtohavesexinthepastyearwasroughlythesameforrefugees(1.3%)asnationals(1.2%).Kriitmaaetal.(2010)[54]Hargeisa,Somaliland,SomaliaCrosssectional(Integratedbio-behaviouralsurveillance(IBBS))SWs(N=237)Post-conflictHIVinfection:HeterosexualcommercialsexsuggestedasdominantmodeofHIVtransmissionCondomuseandaccess:24.0%SWsreportedusingacondomatlastSWtransactionandonly4.3%reportedconsistentcondomusewithclientsinthepastmonth.Ofthe24.0%whodiduseacondomatlastsexwithaclient,80.5%saiditwassuggestedbytheclient.29.5%didn’tusecondomswithclientsduetonotknowingwheretoobtaincondoms.Almostnone(0.4%)receivedcondomsthroughaclinicoroutreachinthepastyear.HIVtesting:Only2.6%SWsknewwheretogoforaconfidentialHIVtest.4%reportedeverhavinghadanHIVtest,andnoneofthemreceivedtheirtestresults.HIVprevention:6.9%SWscorrectlyansweredall5questionsonHIVfactualknowledge;only38.4%hadeverheardofanSTI.Larsenetal.(2004)[36]SierraLeonePre-posttestintervention-SWs(N=202)-Military(N=205)Post-conflictHIVknowledge:Only8.5%SWsand22.8%militaryknew>3modesofHIVtransmissionCondomknowledge/access:14.9%ofSWsand12.4%ofmilitaryknewnosourcestopurchasecondomsInternationalOfficeofMigration(2008)[35]Hargeisa,SomaliaCross-sectional(IBBS)SWs(N=219)ActiveconflictHIVknowledge:NoSWsknewtheirHIVstatus,93%SWslackedcorrectHIVpreventionknowledge.Condomuse:28%SWshadneverusedamalecondomMigration:69%SWsweremigrantsMuldoonetal.(2015)[14]Gulu,UgandaCross-sectionalSWs(N=400)Post-conflictHIVseroprevalance:33.8%SWdemographics:Samplewasgenerallyyoung,themajoritybetweentheagesof19–25yrs.,manywithdependentchildren.65%ofSWshadlessthanprimaryschooleducationViolence:49.0%ofSWsreportedextremephysicaland/orsexualworkplaceviolenceintheprevioussixmonths,includingphysicalassault,rape,andgangrape.Among196SWswhoreportedclientviolence,themostcommonformsincludedbeingphysicallyassaulted(58.7%),raped(38.3%),theclientattemptingsexualassault(18.4%),andbeinggangraped(15.8%).Condomuse:84.0%SWsreportedinconsistentcondomusewithregularorone-timeclients.Policing:Rushingnegotiationsduetopolicepresencecontributedtoclientviolence(AOR:1.61,95%CI:1.03–2.52).Highlightsnegativeconsequencesofpolicingpracticesforconflict-affectedSWs.Ferguson et al. Conflict and Health  (2017) 11:25 Page 6 of 20Table2CharacteristicsofprimarystudiespertainingtosexworkandHIV,STIs,andSRHinconflict-affectedsettings(Continued)ReferenceLocationDesignPopulation(N)StageofconflictstudiedKeyFindingsNtumbanzondoetal.(2007)[44]Kinshasa,DemocraticRepublicoftheCongo(DRC)Cross-sectionalSWs(N=136)ActiveconflictSexualdecisionmaking:96.3%SWsfelttheywereabletonegotiatesafersexwithclients.Condomuse:81.6%SWsalwaysusedacondomwithclients,but26.5%reportedchargingextraforunprotectedsexwithclientsuponrequest.Unprotectedsexformoremoney:SWswhoengagedinunprotectedsexformoremoneyweresignificantlymorelikelytoliveorworkatnon-downtownsites(OR=3.07),andtohaveatleastonechildlessthansixyearsofage(OR=2.95).Theychargedamedianof2.90USD(IQR:1.54USD4.61USD)forprotectedintercourse.Themedianratiooftheirchargeforunprotectedintercoursetotheirchargeforprotectedintercoursewas3.5(IQR:2.55.0).HIVKnowledge:~75%ofSWsfearedcontractingHIVasaresultofunprotectedintercourse.Rowleyetal.(2008)[49]TanzaniaCross-sectionalRefugees/IDPsaged15–24exchangingsex(N=16)Surroundingvillagersaged15–24exchangingsex(N=32)Post-conflictSWengagementamongrefugees:40%ofrefugee/IDPs15-25yrs.reportedexchangingsexformoney,gifts,orfavorsduringthelastyear,comparedwith21%ofvillagerespondents(χ233.83,p=.000).Condomuse:Condomuseatlastsexwithnon-regularorpaid/transac-tionalpartnersamongstrefugees/IDPs(40%),comparedtovillagerespon-dents(21%).Toddetal.(2011)[53]AfghanistanCross-sectionalSWs(N=520)ActiveconflictSWdemographics:76.9%SWshadnoformaleducationDisplacement/mobility:37.7%SWslivedoutsideAfghanistaninthelastfiveyears.HIVknowledge:Only17.4%SWshadcomprehensiveHIVknowledge.Condomknowledge:<60%SWsheardofcondoms;ofthosewhohad,onlyhalfhadusedacondom.Condomuse:Consistentclientcondomusewasreportedby11.5%SWsandwasindependentlyassociatedwithhavingmoreclientspermonth.Qualitative(3)Maclinetal.(2015)[37]Goma,BukavuandKalehe,DRCFocusgroupdiscussions-Vulnerablewomen-MalesinvolvedincommunitygroupsPost-conflictPost-conflictSWseentobreakdowntraditionalsocialstructures/familydynamics:Discussantsdetailedhowexchangingsex(i.e.,commercialortransactionalsex)post-conflictwaslinkedtopoverty.Thiswasseentounderminetraditionalsocialstructuresandfamilydynamics,andwasportrayedasbothasymptomof,andacatalystfor,changeswithinfamilydynamicsresultingfromconflict-relatedexperiencesineasternDRC.Familieswerephysicallyseparatedbecauseoftheconflict–fromdeath,displacementandmarriagedissolution,accordingtostudyparticipants.Muhwezietal.(2010)[38]KatakwiandAmuria,UgandaFocusgroupdiscussionsKeyinformantinterviewsIn-depthcasestudyinterviews-FGD(4men,4women)-KI(16men,16women)-Casestudies(8men,8women)Post-conflictSexworkasaconsequenceofconflict:Breakdownofthesocialstructureduetoconflictresultedineconomicdestructionandaperceivedsoaringofvulnerablepeoplewhosepropensitytoengageinhigh-risksexualbehaviourwasincreased.Highrisksexualbehaviorduetorefugeecampenvironment:Highrisksexualbehaviour(lifestyleoractivitythatplacesapersonatincreasedriskofsufferingorbeinginfectedwithHIV/AIDS,asexuallytransmitteddiseaseand/oranunwantedpregnancy)wasassociatedwithconcentrationofpeopleincampswhereidlenessandunemploymentwerethenorm.Ferguson et al. Conflict and Health  (2017) 11:25 Page 7 of 20Table2CharacteristicsofprimarystudiespertainingtosexworkandHIV,STIs,andSRHinconflict-affectedsettings(Continued)ReferenceLocationDesignPopulation(N)StageofconflictstudiedKeyFindingsNyanzi(2013)[23]Kampala,UgandaRepeatindividualin-depthinterviewsRepeatfocus-groupdiscussions-54wacheche(SWsandsame-sex-lovingorgendernon-conformingpeople)Post-conflictCriminalizationperpetuatesviolenceagainstSWs:Perpetratorsof‘hate-crimes’againstSWs,wentunpunishednumeroustimesbecausethevictimrefusedtoreportthecase.Criminalizationcreatesbarriersinaccesstoservices:IncriminalizedstateswhereSWsarepoliced,individualsmayfailtoaccessavailableservicesforfearofdisclosingtheirso-called‘non-conformingsexualpractices’.Displacementimpedeslegalknowledge:DisplacedpersonsinUgandafoundtohavevaryinglevelsofawarenessofthelegalframeworksgoverningsexualconductandrelationshipswithintheircontextsofdisplacement.Mixed-Methods(2)Gazietal.(2008)[47]Teknaf,Bangladesh/MyanmarCross-sectionalsurvey&KIinterviewsBoatmen(N=433)ActiveconflictMigrantsassexbuyers:17%ofBangladeshimigrantboatmenreportedhavinghadsexwithaSWwhileinMyanmar.Prolongeddisplacementandsexbuying:Significantcorrelationfoundbetweenthenumberofnightsspentawayfromhomeandengaginginpaidsex.Condomuse:CondomusebymigrantswithSWsandotherpartnerswasrare(0–4.7%inthelastmonth),anddidnotvarywithtypesofsexpartners.InternationalOfficeofMigration(2012)[48]SomaliaHIVHotspotMapping-SWs(N=143)-Maleclients(N=73)Violence:SWscommonlyreportedassault,threats,violations,illtreatment,rape,andrefusaltopaybyclients,resultingininjuryanddamagetoproperty,reducedabilitytowork,andlossofincome.Mobility:SWsreportedhighlevelsofmobilitybeforeandafterengagementinpaidsex.Manylefthomeafterlosingparents/caregivers,orexperiencingconflictanddomesticviolence.Transactionalsexmoreprominentduetopopulationmovements:SWsinSomalilandandSouth-centralmorelikelytoreportexchangingsexforgiftsorfavorsratherthanmoney.SWentrylinkedtoeconomicsurvival:SWinitiationtypicallyreferredtoasameansofsurvivalduringconflict.HIVtesting:MostSWshadneverbeentestedforHIVanddidnotknowtheirstatus;mainbarriertotestingwasalackofriskperception.ManydoubtedtheconfidentialityofVCTservices.ThosewhosoughttotestweremotivatedbyillnessamongafellowSW.HIVknowledge:AlmostallmigrantSWshadheardofHIV,butknowledgearoundpreventionandtransmissionwasmixed,withmanymisconceptionsstillpresent.Migrantsassexbuyers:Mostcommonsexclientsweretruckdrivers,seafarers,portworkers,uniformedservices,businessmen,tradersandunemployedmen.Ferguson et al. Conflict and Health  (2017) 11:25 Page 8 of 20Table 3 Summary of evidence on HIV/STI and SRH policies and programmes for conflict-affected sex workersReference Document title Population Key programmes, policies and/or recommendationsInter-Agency Working Group(IAWG) on ReproductiveHealth in Crises [55]Inter-agency FieldManual onReproductiveHealth in HumanitarianSettingsRefugee/IDPs Sex worker sensitive HIV VCT programmes: Behavioursthat put people at a higher risk of exposure to HIV,such as sex work or injecting drug use, also makepeople more susceptible to coercion, discrimination,violence, abandonment, incarceration or other negativeconsequences upon disclosure of an HIV-positive test.Healthcare providers require special training andsupervision to uphold standards of informed consentand confidentiality for these populations. HIV VCT forthese groups should be accompanied by theimplementation of a supportive social, policy and legalframework.Condom availability/distribution: Consult with local staffabout how condoms can be made available in aculturally sensitive way, particularly for most at-riskgroups, such as SWs and their clients, MSM, IDUs andyoung people. Ensure the consistent availability ofquality male and female condoms. To see an effectivereduction of HIV transmission through SW requires>90% compliance of correct use of condoms amongSWs and their non-regular sex partners.Spermicides: Not recommended for SWs, as theyincrease risk of HIVSW specific services: Recommended at health servicelevel, RH officers recommended to hot-spot areaswhere SWs congregate totarget interventions and servicesSTI screening: Service providers recommended to offerregular screening to people with frequent exposure toSTIs, such as SWsSTI treatment: Presumptive treatment of SWsrecommended at first visit followed by regular visits forspeculum/bimanualexamination and Gram stain of cervical smear.Right to equality and non-discrimination: Protected byproviding access to STI services for the entirepopulation, including adolescents, SWs and MSM,regardless of the legal status of prostitution andhomosexuality in a countryInclusion of SWs in programming: Involve vulnerablegroups encouraged to be involved from the start inprogramme design,implementation and monitoring.Violence reduction strategies: Should be integrated in SWsettings. Programmes recommended working with lawenforcement to ensure SW’s ability to protectthemselves and to ensure safer sex practices by theirclients.SW and child protection: Communities and SWs shouldbe engaged in child protection policies andregulations.Offer exit-strategies: Programmers encouraged to linkSWs and their families to support mechanisms,including the provision ofassistance and incentives for women to leave sex workthrough a range of legal, economic and social services.Address sex buyers: Work to change the behaviour ofSWs’ clients (humanitarian staff, peacekeepers, police,general population)HIV prevention for vulnerable groups: Involve groupsfrom the start in programme design, implementationand monitoring; locateprogramme activities in places frequented by thegroup (clubs, neighbourhoods, etc.); create safe virtual(telephone hotlines) orphysical (drop-in centres) spaces tailored to the group;train health and social workers to provide high-quality,client-friendly, HIV-related services; address structuralFerguson et al. Conflict and Health  (2017) 11:25 Page 9 of 20Table 3 Summary of evidence on HIV/STI and SRH policies and programmes for conflict-affected sex workers (Continued)Reference Document title Population Key programmes, policies and/or recommendationsbarriers, including policies, legislation and customarypractices, that discriminate against the group andprevent access and utilization of appropriate HIVprevention, treatment and care services.UNAIDS Inter-Agency TaskTeam on Gender andHIV/AIDS (2001) [16]HIV/AIDS, Gender andConflict SituationsRefugee/IDPs HIV/STI programmes: National governments, nationaland international NGOs and UN agencies encouragedto incorporate STI and HIV prevention measures into allhumanitarian assistance. Donors strongly encouragedto support these interventions.Conflict, displacement, HIV and gender inequality research:Assessments encouraged to be carried out, incollaboration between government and agencies, todetermine the links these factors in each humanitariansituation. Steps encouraged to be taken to ensure thatall humanitarian programmes are responsive to issuesdocumented in these assessments.Focus on women: All HIV/AIDS programmes andfunding in conflict situations encouraged to addressthe disproportionate disease burden carried by women.Effective approaches include sensitisation, training andbehaviour change communication programmestargeting men and boys as well as women and girls.International guidelines for peacekeepers: Stepsencouraged to be taken to ensure the implementationof internationally agreed guidelines for the preventionof HIV transmission during peacekeeping operations.Peacekeepers encouraged to receive training onwomen’s rights and gender-based violence as well asHIV prevention. Because peacekeepers have sometimesbeen implicated in abuses against women and girls,mechanisms of accountability encouraged to also beincluded.Sexual violence programming: Programmes encouragedto be designed to support the victims of sexualviolence through medical care, counselling, supportgroups and related activities. Health service packagesfor girls and women who have been raped encouragedto include post-exposure HIV prophylaxis.Military HIV/STI programming: Programmes encouragedto be undertaken to improve HIV/STI awareness andtreatment within the regular military and rebel forces,where these are systematically demobilised. This willhave important impacts on sexual health risks tocivilians from ex-combatants. Civilians, including SWsnear military installations, encouraged be included inthese awareness raising and treatment programmes.UNHCR (2010) [67] HIV and sex work in refugeesituations: A practical guideto launching interventionsan issue affecting women,men, girls, boys andcommunitiesConflict-affectedSWsThis guide is intended to assist those working to slowtransmission of HIV and other STIs in humanitariansettings. The focus is on intervening where HIV has thepotential to spread quickly – with SWs and their clients.Practical, step-by step activities are recommended foraddressing HIV in sex work within refugee situations,including:1. Sensitization and buy-in: Engage agencies responsiblefor refugees, community groups, and leaders.2. Identification, hotspot mapping and snowballing:Collect baseline and risk information, provide condoms,and assess need through snowball sampling, mappinghotpots, and estimating numbers of SWs and clients.3. Protection: Support registration, ensure safe access tobasic needs, and reinforce GBV prevention and childprotection activities4. Profiling and case management: Gain deeperunderstanding of sex work in the community, identifythose most at vulnerable/risk, and develop casemanagement plans to address urgent problemsFerguson et al. Conflict and Health  (2017) 11:25 Page 10 of 20Table 3 Summary of evidence on HIV/STI and SRH policies and programmes for conflict-affected sex workers (Continued)Reference Document title Population Key programmes, policies and/or recommendations5. Forming Multi-Functional teams (MFTs): Guideprogramme implementation, identify roles andresponsibilities, strengthen partnerships, and ensurecoordination and monitor progress6. Building peer-led systems with SWs: Meet and reviewprogramme objectives, introduce verbal contract aboutparticipation in peer group, ask SWs to choose theirleaders and agree to meet regularly, provide peerleaders with training, condom education, promotionand distribution kits7. Health services: Assess services looking at HIV/STI-related areas, advocate and ensure SWs have access tonon-judgmental services8. Male and venue-based interventions: Engage men andboys, and offer simple venue-based interventions9. MonitoringUNFPA & UNHCR – Burton etal. (2010) [3]Addressing HIV and sex work Conflict-affectedSWsInterventions to respond to HIV and sex work inhumanitarian settings are both necessary and feasible,even during an emergency. In situations wherecomprehensive HIV programmes have already beenestablished but where SWs have not yet been reached,a basic set of sustainable multisectoral activities can beestablished within six months.Key Activities per phase include:Preparedness1. Integrate HIV and sex work into contingency planning:Identify existing SW networks and programmes, mapservices, and develop contingency plans for rapidrestoration if disruptedEmergency phase2. Expedite registration, risk identification and protection:Identify those most at risk, ensure protection, establishGBV services, and promote codes of conduct3. Ensure safe shelter and access to food and basicnecessities4. Provide basic SRH and HIV services: Implement MISP,establish basic STI/SRH services and outpatient clinics,and implement basic HIV services5. Start outreach: Begin mapping and engagement withSWs, identify sex-work venues, and distribute condomsand informationStabilised phase6. Build supportive environments and partnerships:Establish peer groups, support SW-led approaches,strengthen existing women’s groups to reach non self-identified SWs, conduct rapid assessments, and planinterventions7. Reinforce protection: Strengthen prevention of GBVand sexual exploitation, and find ways to involve men8. Expand to comprehensive HIV and SRH servicesincluding STI services9. Expand targeted services: Support transition of peeractivities to broader community mobilisation,strengthen venue-based and special clinics foridentified SWs, and work with clients to reducedemand for unprotected paid sex10. Provide social/economic/legal services: Strengthenlegal protections and establish self-regulatory boards,increase livelihood and educational opportunities forthe most vulnerable, and prepare for appropriatedurable solutionsInter-Agency Task Teamon HIV and Young People(n.d) [12]HIV Interventionsfor Young Peoplein HumanitarianEmergenciesConflict-affectedyouthProvision of basic health care and support: Providingbasic health care and support to younger, most-at-riskgroups, such as people who inject drugs (PWID), SWsand MSM. Special attention is needed to address theneeds of younger age groups, particularly during theminimum response stage.Ferguson et al. Conflict and Health  (2017) 11:25 Page 11 of 20unequal gender norms and limited economic opportun-ities for women, existing evidence highlighted howwomen were particularly likely to exchange sex formoney, accommodation, or other goods (e.g., food,clothing, healthcare, favours, gifts, access to educationfor their children, protection), and even passage across aborder [3, 23, 33, 36, 41]. The following testimonial froma Somalian sex worker highlighted how the unequalgendered socio-economic impact of conflict influencedher choice to engage in sex work:"[The first time I sold sex] I was 12 years old ... myfather and mother had died … I didn’t have anyone totake care of me, and [didn’t] have anything to eat ordress in. Being a sex worker was the only choice."(Somalian sex worker aged 25 [35].Inconsistent condom use within conflict-affectedsettings was commonly elucidated as a consequence ofreduced negotiating power due to financial constraintsduring times of social unrest [30, 36, 39, 40]. Conflict-affected sex workers in sub-Saharan Africa commonlysupported dependent children [14, 42], and havingchildren (especially young children) was associated withincreased HIV risks including engaging in unprotectedsex for more money [14]. Although further research isneeded in this area, two studies suggested increasedneed/opportunity to charge extra money for unprotectedintercourse during or following a crisis [43, 44], includ-ing a study of Kenya’s 2008 post-election violence on sexworkers and their clients, where dramatic declines in in-come, expenditures, and consumption in the generalpopulation resulted in more unprotected sex [43]. Thesefindings elucidate potentially important effects of activevs. post-conflict settings on the sex industry, whereconflict environments with a large presence of military/peacekeeping personnel as potential clients may increasedemand for sexual services, (while reducing sex workers’control to safely negotiate condom use with clients),whereas smaller social and economic crises (representedby dramatic declines in income) may result in more sexworkers willingly offering unprotected sex to make upfor income shortfalls. Authors further highlight the in-creased risk for sex workers during times of political andeconomic crisis, where financial gains of unprotectedsex may outweigh the known risk of HIV/STI acquisi-tion. Although sex workers in non-conflict settings alsooften report economic pressures for unprotected sex forhigher pay, our review suggested that these pressuresmay be amplified within conflict-affected settings.Displacement and mobilityDisplacement and high mobility were commonexperiences reported by conflict-affected sex workers[11, 35, 45, 46], and clients of sex workers [35, 41, 45, 47],across diverse geographical and socio-political contexts.Within the studies reviewed, displacement and mobilitywere consistently associated with increased engagement insex work [35, 41, 45, 48, 49], particularly in the post-conflict stage [35, 45, 48, 49]. While military/peacekeeperscommonly purchase sex in conflict-affected environments[2, 16, 34, 38, 41] displacement may increase demand forsex work from other clients particularly during the re-habilitation stages of a conflict, due to men travellinggreater distances for employment, and spending greateramounts of time separated from family [37]. Further, insub-Saharan Africa, the geographical areas most heavilyaffected by HIV are often those linked with high long-term mobility, adjacent to main transport routes or inborder regions [46].Findings from numerous contexts, predominantlywithin sub-Saharan Africa, indicated that women intransit or temporarily displaced due to war or violencewere more likely to report having received money orgoods for sex than their non-mobile counterparts [26],and this was often linked to enhanced challenges andbarriers accessing HIV and SRH services. In a studyseeking to understand the relationship between armedconflict and HIV infection among conflict-affected sexworkers in Gulu, northern Uganda, 66.5% of respon-dents reported living in IDP camps, among whom HIVprevalence was 71.9% compared to 63.8% of non-mobilesex workers [11]. In Somalia, mobility of sex workerswas further associated with increased HIV/STI risk due toporous borders with countries that have higher HIV prev-alences (Djibouti, Ethiopia, Kenya), and the presence ofmobile populations associated with other HIV epidemicsin the region (e.g., truck drivers and the military) [35].Presence of military and peacekeepersThe presence of military and peacekeepers withexpendable incomes represent unique aspects ofconflict-affected settings which strongly shape thecontext of sex work and HIV/STI prevention in such con-texts [2, 3, 5, 16, 29, 33, 34, 36, 38, 39, 41, 50]. Combatantsand peacekeepers stationed far from home were morelikely to frequent sex workers during war and migration[5], had higher rates of STIs than the general population[16], and were more likely to engage in higher-risk behav-iour while participating in missions than within theirhome communities [2]. Even during peacetime, STI ratesamong armed forces are generally 2–5 times higher thanin civilian populations; in times of conflict, the differencecan be 50 times higher or more [39]. The circumstancesof military service were said to make soldiers both morevulnerable to HIV/STI infection and more likely to trans-mit such infections – for example, soldiers are typicallyyoung, male, sexually active, and separated from theirFerguson et al. Conflict and Health  (2017) 11:25 Page 12 of 20normal partners, which has been shown to facilitate sexpurchasing [39]. Peacekeepers may also originate fromcountries with higher HIV prevalence rates than the localcommunity in conflict, potentially exposing sex workersto further risk [36]. In Gulu, northern Uganda, exposureto war and conflict related events, such as abduction bythe Ugandan Lord’s Resistance Army (LRA), was found tosignificantly increase the likelihood of HIV seroprevalencein sex workers (AOR: 1.62, 95% CI: 1.00–2.63) [11].ViolencePhysical, sexual, and emotional violence against sexworkers in conflict-affected settings, by both clientsand intimate partners was alarmingly high withinstudies [11, 14, 31, 32, 35, 37, 38]. Among sex workers inpost-conflict northern Uganda, almost 50% experiencedextreme physical and/or sexual workplace violence in theprevious six months, including physical assault, rape, andgang rape [14]. Reports of assault, poor treatment, andthreats were commonly reported by sex workers inSomalia, as were rape and refusal to pay [35]. An epi-demiological study of 250 sex workers in post-conflictMekelle, northern Ethiopia, demonstrated high rates ofviolence, with 46–60% of sex workers reporting rape orforced sex [32]. In Somalia, incidents of violence mostoften led to physical injuries and damage to property, re-ducing sex workers’ ability to work, creating medical costs,and leading to a loss of income [35], which in turn, maylead to a greater likelihood of engaging in sex for moremoney. In conflict-affected Gulu, northern Uganda, 74.7%of sex workers reported that they would experienceviolence from clients, and 60.8% from intimate partners, ifthey asked them to wear a condom [31]. Prolongedexposure to traumatic conflicts was found to belinked to severe mental distress, including persistentfeelings of despair, hopelessness, pathological fear, andsuicidal inclinations, which may have indirect effectson conflict-affected sex workers’ vulnerability to HIVinfection, as it not only predisposes women to ex-ploitation or HIV risk, but may also hinder uptake ofHIV preventative and treatments services [16, 38].Police/ criminalization of sex workIn Uganda, Ethiopia, and Sri Lanka, criminalization ofsex work led to rushed negotiations with clients due topolice presence [11, 29, 31], which significantly increasedthe odds of client violence [14], further undermininguptake of HIV/STI and SRH services [31]. Among sexworkers working in post-conflict Uganda, over one-third(37.3%) reported having to rush negotiations with clientsas the result of police presence in the last six months[31], and exposure to incarceration (AOR: 1.93, 95% CI:1.17–3.20) was found to be positively and independentlyassociated with HIV infection [11]. For refugee sexworkers in particular, an arrest for sex work couldgreatly jeopardize an asylum claim, or result in deport-ation. As a consequence, the high stakes of gettingcaught force sex workers to take greater risks with theirsafety, such as working alone or in secluded areas."When I entered the circle of refugees who sell sex,the first thing I learnt was to avoid places the policepatrol. When a Ugandan prostitute is arrested, the policehave sex with her if she wants to be released withouttrying. What will happen to me, a refugee?" (31-year-oldsex worker from Congo) [23].Criminalization further propagates an environment inwhich violence against sex workers is tolerated, result-ing in severe vulnerabilities in which sex workers areunable to seek protection from law enforcementauthorities [11, 23, 29, 31, 32]. In Uganda, many sexworkers revealed that they failed to report humanrights violations to police, for fear of re-victimizationfrom public disclosure of their sex work [23]. Numer-ous instances were documented in which perpetratorsof ‘hate-crimes’ against sex workers went unpunishedbecause the victim refused to report the case. In thisway, current legal responses to sex work may inadvert-ently protect perpetrators of violence, and simultaneouslyexpose sex workers to injustice by curtailing access tomechanisms of legal redress [23].Displaced persons in Uganda were found to have vary-ing levels of awareness of the legal frameworks govern-ing sexual conduct and relationships within theircontexts of displacement [23]. In post-conflict states,criminalization has been revealed to undermine effectiveHIV and harm reduction programmes, by driving keypopulations underground, and creating environments inwhich abuses against sex workers’ human rights aretolerated [51, 52]. Further, incarceration may elevate therisk of HIV transmission through a lack of access tocondoms, harm reduction supplies, or antiretroviralmedicines, as well as through increased vulnerability tohuman rights violations or sexual assault during deten-tion [52].Access and uptake of HIV/STI and SRH servicesDuring acute stages of conflict when food insecurity,sanitation, and related infectious diseases (e.g., cholera)remain pressing priorities, provision of HIV/STI andSRH services may be negatively impacted, both for thegeneral population and for key populations, includingsex workers. Unfortunately, our review identified veryfew studies describing the nature of HIV/STI or SRHservices offered or utilized by sex workers within conflictor post-conflict settings. Available evidence generally in-dicated that conflict-affected populations face uniqueFerguson et al. Conflict and Health  (2017) 11:25 Page 13 of 20obstacles to accessing HIV/STI information, treatment,condoms, and other SRH services. For example, migrantpopulations often face substantial barriers to access, in-cluding the potential for being turned away by providerson account of their status as foreigners [26]. In additionto these already pervasive barriers, evidence suggeststhat access to HIV and SRH services in conflict-affectedsettings may be particularly challenging for sex workers,due to the additional marginalization, discrimination,and stigma sex workers face on the basis of their occu-pation [3]. In post-conflict Gulu, northern Uganda, andover half (55.5%) of sex workers reported experiencingdifficulty accessing condoms [11]. In general, HIV,STI and SRH services for conflict-affected sexworkers were found to be extremely limited, or whereavailable, lacking in scope, scale-up, and reach (e.g.,local-level condom distribution, occasional offers ofHIV testing) [3, 11].HIV/STI prevention Limited exposure to HIV/STIprevention information, condom promotion, and lowgeneral HIV knowledge among conflict-affected sexworkers was found across multiple settings, includingSomalia, Uganda, and Afghanistan [31, 35, 48, 53]. In anepidemiological study of 218 female sex workers inHargeisa, Somalia, 93% lacked accurate knowledge onHIV/STI prevention, and 28% had never used a malecondom [48]. In a study seeking to asses HIV awareness,knowledge, and condom use among women sex workersin Jalalabad, Kabul, and Mazar-i-Sharif, Afghanistan,fewer than 60% of the 520 sex workers interviewed hadheard of condoms [53]. Of those who had, only half hadever used a male condom [53]. In a study of 400 youngwomen sex workers in post-conflict Gulu, Uganda,59.25% reported difficulty accessing condoms or contra-ceptives, and approximately one-third had never re-ceived a condom demonstration [31]. A study conductedby the same group in Gulu Uganda, found that 83.3% ofpost-conflict sex workers reported inconsistent condomuse in the prior six months, for both one-time andrepeat clients [11].One study investigating patterns of condom use withpaying sex partners among refugees/IDPs indicated thepotential for increased uptake of HIV/STI preventionservices during the acute stage of conflict, compared tothe post-conflict rehabilitation stage [49]. In a studycomparing refugees in the Lugufu refugee/IDP camp atTanzania’s western border with the DRC to theirsurrounding host villages, condom use with paying sexpartners was quite low (44%) among 15-24 yr. olds inthe camp, but was substantially higher than rates in thesurrounding villages (25%) [49]. As refugee/IDP campsare heavily influenced by UN and international aid orga-nizations, the authors posited this may be due to aninflux of external aid and health services (e.g., condoms,sexual health information) in some camps [49]. However,we did not identify any studies specifically comparingcondom use or other indicators of HIV/STI preventionaccess among sex workers themselves across variousstages of a conflict (i.e., acute, post-conflict).HIV/STI testing and treatment Despite high rates ofSTIs (17.0%) among sex workers in post-conflict north-ern Ethiopia, STI treatment was quite low with only9.6% of those with history of an STI reporting seekingtreatment [32]. In Somalia, the majority of sex workershad never been tested for HIV and were unaware oftheir status. Low awareness of testing locations andconcerns regarding the confidentiality of testing wereidentified as primary barriers [35, 54]. In Gulu, northernUganda, 92% of women sex workers reported havingtested for HIV in the past 6 months, while only 43% re-ported testing for STIs. This aligns closely with the40.25% reporting history of an STI infection in the past6 months, indicating that while testing for HIV may bepracticed preventatively, STI testing appears to be donemore symptomatically [31]. Of note, this study alsofound that HIV testing was more common amongwomen who used dual contraceptives than women whohad not [31].SRH services Despite the likely challenges and uniquebarriers faced by sex workers seeking to access SRH ser-vices within conflict-affected settings, little evidence wasidentified pertaining to this. Only two studies of sexworkers’ access and use of other SRH services such ascontraception or pregnancy terminations were identifiedamongst conflict-affected sex workers. An epidemio-logical study of hormonal contraception use (i.e. birthcontrol pills, Depo-Provera injectables, or implants)among 400 conflict-affected sex workers in Gulu,northern Uganda, found that less than half (49.8%)reported ever using these contraceptives, 10.3% hadnever used condoms for pregnancy prevention, and 45%reported having ever used dual contraceptives (e.g., birthcontrol pills and condoms at the same time) [31]. Innorthern Ethiopia, 27% of sex workers reported a historyof at least one elective abortion, with 35.3% of thesewomen reporting more than one pregnancy termination[32]. In this same study, 69.0% of sex workers acknowl-edged history of any type of contraceptive use [32].Policy and programmatic responses to HIV and SRH in sexwork in conflict-affected settingsSex work specific recommendations are largely absentfrom international guidelines regarding HIV/STIs orSRH in conflict and emergency settings, including thoseof the United Nations High Commissioner for RefugeesFerguson et al. Conflict and Health  (2017) 11:25 Page 14 of 20(UNHCR), The Joint United Nations Programme onHIV and AIDS (UNAIDS), United Nations SecurityCouncil, and the World Health Organization (WHO).Currently, United Nations agencies (such as UNHCRand UNFPA), bilateral donors, and non-governmentalorganizations offer policy and programme support forthe provision of HIV/STI and SRH services to refugeesand IDPs in emergency settings. The Inter-AgencyWorking Group (IAWG) on Reproductive Health inCrisis, spearheaded by UNHCR and UNFPA, has pro-duced a manual specific to humanitarian settings thatserves as a guide to SRH and HIV/STI services begin-ning with the onset of an emergency, and continuing asthe situation stabilizes [55]. The Inter-agency FieldManual on Reproductive Health in Humanitarian Set-tings incorporates technical standards set by the WHO,and advocates for increased HIV/STI and SRH servicesfor displaced populations as part of broader primaryhealth care activities. It has identified programmaticstrategies to facilitate this process, including implemen-tation of the Minimum Initial Service Package (MISP), aset of priority actions in response to the life-saving re-productive health needs of populations at the onset ofan emergency. Services included in the MISP for emer-gency situations include: supplies for infection control,safe deliveries and management of obstetric emergen-cies, treatment for victims of sexual violence, condoms,oral and injectable contraceptives, drugs for the treat-ment of STIs, emergency contraception and HIV post-exposure prophylaxis for survivors of rape, and manualvacuum aspiration equipment for the treatment of post-abortion complications [56]. The manual additionally in-cludes guidance on strategies and priorities that shouldfollow when the situation has stabilizes, including ado-lescent reproductive health, family planning, maternaland newborn health, comprehensive abortion care,gender-based violence, management of sexually trans-mitted infections, and HIV. While the need for tailoredprogramming or policy recommendations specific to keypopulations, such as sex workers are largely absent, anumber of chapters (e.g. family planning, STI, HIV) doprovide insight on how to address the needs of sexworkers most effectively. Examples include suggestionsto integrate violence reduction strategies in sex worksettings, to consult with local staff about how condomscan be made available to sex workers in a culturally sen-sitive way, to offer regular STI screening services, towork with law enforcement to ensure sex workers havethe ability to protect themselves and to ensure safer sexpractices by their clients, and to include them from thestart in programme design, implementation and moni-toring [55]. An overwhelming challenge to provision ofthese services which is also elucidated, is the reality thathealth centres in countries with laws against prostitutionor discriminatory practices against people engaged insex work (i.e., the majority of countries worldwide), donot offer services to sex workers [55].The Prevention and Treatment of HIV and other Sexu-ally Transmitted Infections for Sex Workers in Low- andMiddle-income Countries, the product of a joint consult-ation between the WHO, UNFPA, UNAIDS, and theGlobal Network of Sex Worker Projects (NSWP),summarizes best practices for evidence-based HIV/STIprogramming for the general population of sex workers[57]. Research and consultation with sex work groupsand key humanitarian and global health organizationscould be useful to assess the extent to which key princi-ples and practices described in this document (e.g., vol-untary HIV testing, decriminalization, communityengagement) may be applicable to conflict-affected set-tings, as well as to articulate and develop strategies toaddress the unique challenges faced by sex workers inthese settings.Initial steps have been taken to more explicitly addressHIV/STI and SRH within the context of sex work insome refugee programmes in the East and Horn ofAfrica, Latin America and parts of Asia [3]. Based onthese experiences, and under the overall framework ofthe UNAIDS Guidance Note on HIV and Sex Work,UNHCR and UNFPA produced a brief Technical Noteon HIV and Sex Work in Humanitarian Settings [3]. Itsprimary objective is to inform humanitarian agencies ofsteps that can be taken to integrate sex worker-inclusiveprogramming into emergency responses. Its recommen-dations reflect experience from a number of differentsettings, and are meant to be adaptable to many differ-ent conditions and cultural contexts. The Technical Notehighlights three pillars which aim to: [1] assure sexworkers’ universal access to prevention, treatment, careand support; [2] strengthen partnerships with sexworkers through community consultation; and [3] re-duce vulnerability and address structural issues. TheTechnical Note also addresses “key activities per phase,”which assign importance of activities for the prepared-ness, emergency, and stabilized phases of a conflict orhumanitarian emergency [3]. While these recommenda-tions offer valuable guidance for staff in the field, it islargely up to programme staff to adopt these strategies,and further development of policy guidance to explicitlyprotect the distinct needs and rights of sex workers inconflict settings may be needed.Strong global evidence indicates that communityempowerment approaches to HIV programming for sexworkers, including specific efforts to carefully involveconsultation, leadership, and partnership with sex workersin the design and provision of services, are linked toimprovements in service uptake and access [3, 58]. Agrowing number of countries that have scaled up sexFerguson et al. Conflict and Health  (2017) 11:25 Page 15 of 20worker-led/inclusive interventions have reportedstabilization, and even reversal, of their HIV epidemics[3]. Despite the demonstrated effectiveness of community-based sex work HIV prevention programmes, few coun-tries have scaled-up such initiatives [59]. In low andmiddle-income countries, HIV programmes have trad-itionally followed generalized approaches, with insufficientattention being paid to the individuals and groups at high-est risk of acquiring and transmitting HIV/STIs.In light of evidence that general-population localhealth services may not be equipped to meet sexworkers’ needs and circumstances [23], there remains aneed for targeted approaches to offering and deliveringHIV, STI and SRH services for sex workers in displace-ment and post-conflict contexts, with a particular needfor programming efforts that acknowledge and addressthe diversity of conflict-affected sex workers, includingboth cis-gender women and those who identify as gen-der/sexual minorities.DiscussionThis review highlighted a paucity of sex worker-focusedresearch and interventions in conflict and post-conflictsettings. Most of the studies identified were from post-conflict sub-Saharan Africa. Despite our best efforts toidentify qualitative or quantitative studies elucidating thespecific challenges to health access faced by sex workersduring the acute stage of conflict, such studies werelargely absent from the peer-reviewed literature, likelydue to the substantial practical and ethical challenges in-volved with collecting such information during complexemergencies. However, available evidence indicated thatwithin conflict-affected settings, sex workers’ capacity toengage in HIV/STI prevention and access SRH servicescan be undermined by social and structural determi-nants including widespread violence and human rightsviolations, the collapse of livelihoods and traditionalsocial structures, high levels of displacement, anddifficulties accessing already scant health services due tostigma, discrimination and criminalization.Unprotected sex between male clients and female sexworkers was posited as the primary means of HIV acqui-sition and transmission in a number of conflict-affectedcountries under study [30, 35, 48]; yet few, if any studies,examined the HIV burden or social and structural con-ditions that shaped HIV vulnerability or reduced accessto SRH services.Evidence highlighted the association of conflict-relatedmobility and displacement with increased engagement insex work, yet failed to explicitly identify the links be-tween displacement/migration and HIV/STI risk oraccess to care among this group. While some womenintentionally migrate for sex work, others engage in sexwork to meet subsistence needs during conflict ormigration [60]. Given that migration and displacementare associated with increased socio-economic impacts,social isolation, gender inequalities, and stigma anddiscrimination [60], HIV/STI risks and barriers in accessto care are likely to be amplified among vulnerablegroups (like sex workers) in conflict and post-conflictenvironments. For example, social isolation may posebarriers to the development of support networks to miti-gate risk among mobile populations. Evidence fromMexico and Central America has suggested that amongsex workers, the formation of community networks - animportant pillar of HIV prevention in other contexts - ishindered by the constant mobility of sex workers, who“cannot establish trusting relationships with each otheror with others […] [and consequently] cannot demandprotected and secure working conditions” [61]. Furtherresearch is required which assesses the unique ways inwhich contexts of mobility and displacement impactHIV/STI risks for sex workers in conflict and post-conflict environments.Sex work is criminalised in 116 countries globally, with27 countries in sub-Saharan Africa having official legisla-tion criminalising sex work and ‘prostitution’ [62]. Thestructures of social stigmatization which criminalisationreinforce inhibit sex workers’ ability to protect them-selves from violence and health risks including HIV andother STIs [63]. The illegality of sex work has addition-ally been understood to lend legitimacy to ongoingabuse and humiliation of sex workers [64]. Numerousqualitative studies reveal the alarming scope and natureof human rights abuses committed against sex workersby local military and police officials themselves:“There was this time when I was arrested by six police-men. They afterwards demanded sex from me. One ofthem threatened to stab me if I refused. I ended up havingsex with all of them and the experience was so painful.”(26 yr. old male sex worker, Mombasa, Kenya) [51].“They were policemen. There’s a car park next to theflat and they took me there and they took turns.” (26 yearold female, Bulawayo, Zimbabwe) [51].This continues to be a major challenge in many post-conflict settings where key populations (e.g., gender/sex-ual minorities such as MSM) are harshly criminalized.For example, numerous sub-Saharan African nations(e.g., Uganda, Kenya, Zimbabwe) have a history ofimpeding sex workers human rights (e.g., the right toassembly) [14] and have imposed increasingly harsh anddraconian criminal laws targeting key populations. Inmany cases, the political persecution and stigmatizationof key populations can foster the perception that anti-retroviral therapy (ART) should not be ‘wasted’ on sexFerguson et al. Conflict and Health  (2017) 11:25 Page 16 of 20workers, a group most in need of treatment [14, 64, 65].In states where sex work is policed, individuals may failto access available services for fear of disclosing their so-called ‘non-conforming sexual practices’. A qualitativestudy of gender/sexual minority refugees engaged in sexwork in Uganda highlighted that often alternative sexualcultures (including sex workers, transgender individuals,and men who have sex with men), are silenced andmarginalized within current structures of programming,policies and service delivery [23].In additional studies, sex workers in non-conflict areashave noted the influence broader contexts ofcriminalization, marginalization, and social exclusionhave had on their experiences interacting with thehealthcare system.“We are despised in the hospitals. They [providers]say, ‘We don’t have time for prostitutes’ and they alsosay that if one prostitute dies then the number reduces.”(27 yr. old female sex worker, Kampala, Uganda) [64].“When I fell sick and went to a health centre and theyrealised that I was a sex worker, they did not treat melike a human being. When the health worker came toattend to me […] I was told that he had no time for me.So I left without getting treatment.” (19 yr. old femalesex worker, Mombasa, Kenya) [64].“We were in the queue with everyone else whensuddenly one of the nurses came out and loudly said ‘thesex workers who have come … please go and queue atthe back of this line, we will attend to you last” (29 yr.old female sex worker, Zimbabwe) [65].We found little information regarding the lived experi-ences of conflict-affected sex workers as they attempt toaccess SRH and HIV services in these challenging envi-ronments, and about how commonly such access iscompromised or even denied outright, information thatis greatly needed to optimise the design of services forthis at-risk population [64]. Given the widespreadacknowledgment of barriers in access to SRH and HIVservices for sex workers in non-conflict environments,paired with the pronounced vulnerability conflict andmobility impart on social isolation and stigmatization ofthis group, this presents a considerable gap within theliterature.Further research focused on social and structuralfactors such as migration and displacement, sex workenvironments, economic contexts, political and legalinequities, and human rights abuses suffered by sexworkers in conflict-affected settings is recommended.Rigorous studies investigating the specific links betweenconflict exposure, these socio-structural forces, andhealth outcomes among conflict-affected women at riskof, or living with HIV, including sex workers, remainurgently needed. Research detailing HIV/STI or SRHservices available during conflict, and the challenges,facilitators, or inequities sex workers face in their inter-actions with these programmes and services is sorelyneeded. Given the paucity of studies explicitly articulat-ing specific conflict experiences or their links to HIV/STI risks and programme access among sex workers,further research focused on better understanding thespecific impacts of conflict experiences (e.g., war-relatedhuman rights violations) are recommended. We see thisreview as a preliminary step in better understandingthese issues, and recommend future research and policywork be focused on evidence-based interventions andthe impact of programmatic changes.Findings from this review suggest an urgent need toscale up access to quality, accessible, and non-stigmatizing SRH and HIV programmes for sex workersin conflict-affected areas. Considerations of the legal andpolicy environments in which sex workers operate, andactions to address the important role of stigma, discrim-ination, social isolation, and violence targeting sexworkers is needed. Criminalized work environmentscontinue to undermine HIV prevention strategies, andpose serious barriers to utilization of SRH servicesamong sex workers globally [9, 11, 14, 23, 31, 66]. Policyshifts away from criminalization, towards a humanrights-based model for sex workers, remain criticallyneeded, during armed conflict and in the fragile peacethat follows. As significant barriers in access to care ap-pear to be for sex workers in post-conflict settings, locallevel multilevel strategies which address factors at differ-ent levels, including individual risk factors, partner-level,social determinant, etc., may be most successful to addressthe severe structural barriers impeding sex workers’ healthand human rights in these settings.Future public health interventions in conflict andpost-conflict settings should seek to promote peer-ledprogrammes and initiatives on the ground, in additionto recognizing sex workers as key stakeholders/expertsin high-level policy consultations. In Kenya and Uganda,UNHCR and implementing partners have worked closelywith sex workers in the development of programmes,based on sustainable and improved comprehensive ser-vices including HIV and reproductive health, communitysocial services and livelihood interventions [67]. Bothcases provided evidence that much can be achievedwithin a six-month period: sex worker-led organizationsand community outreach can be established, confidentialand respectful healthcare services can be provided, andprotection systems strengthened. These examples illus-trate how the active engagement and involvement of sexworkers is not only possible, but can also lead toFerguson et al. Conflict and Health  (2017) 11:25 Page 17 of 20improved quality of HIV prevention measures [3]. Fu-ture public health interventions should additionally seekto target other vulnerable groups, including refugees andmigrants broadly, men who have sex with men, trans-gender individuals, and the partners and clients of sexworkers (e.g. military, peacekeepers, and police) in con-flict and post-conflict environments. In Cambodia, forexample, a brand of condoms marketed specifically tothe military since 1997 has helped reduce rates of un-protected sex between Cambodian soldiers and sexworkers, from 70% to 54% [33]. Clients have an import-ant supportive role to play in supporting sex worker pro-grammes, which should not be understated. If left out,they may undermine efforts to reduce safety concerns,sexual exploitation, and gender based violence.Community-led activities should be strengthened withinthe community which promote responsibility not onlyamong sex workers, but also their partners [67]. Lastly,while the importance of better linking HIV and SRH ser-vices in the general population and for sex workers hasbeen previously discussed, demonstrated to be feasible,and linked to improved health outcomes in a number ofsettings (e.g., linked to increased condom use, HIV test-ing, and lowering HIV and STI rates) [45, 68], special ef-forts to develop and implement ‘best practices’ for suchservice integration within the unique challenges faced byconflict-affected settings are required.Limitations and directions for future researchSince too few studies exist in this area to have employeda systematic review or meta-analysis, we employed acomprehensive review methodology to meet ourobjectives. Challenges arose in distinguishing the fluidboundaries between acute conflict and post-conflictstates, and conflations of sex work with transactional sex(i.e., exchange of non-monetary commodities with non-commercial partners) or human trafficking for the pur-poses of sexual exploitation. While many studies definedtransactional sex as the exchange of sex for both monet-ary and non-monetary commodities, when they focusedspecifically on non-monetary exchanges with non-commercial partners they were excluded from this re-view. Most studies did not explicitly articulate the waysin which working and living in conflict and post/conflictsettings may impact risk of HIV/STIs and access to SRHservices for sex workers, creating large gaps in our un-derstanding of distinct pathways in these contexts. Giventhat very few studies employed longitudinal designs,studies incorporating temporal aspects that would moreeasily allow inferences regarding the impacts of conflicton sex workers’ health and access to care, such as stud-ies that compare pre and post-conflict conditions andhealth outcomes, may be particularly useful. In addition,many people who exchange sex to supplement theirincomes in humanitarian and post-conflict settings donot self-identify as sex workers, making research andsurveillance in this area a challenge. To the best of ourknowledge, this review is the first synthesis of evidenceaddressing social and structural drivers of HIV/STIs andSRH among conflict-affected sex workers.ConclusionsResults from this review demonstrate the presence ofnumerous social and structural factors increasingHIV/STI risks, and creating severe barriers in accessto HIV and SRH services for conflict-affected sexworkers. Significant gaps in context specific sexworker-focused research, policy, and programmingwere identified. While recommendations are availableto guide interventions with sex workers in conflictand post-conflict settings, universal, national, regional,and local policies and regulations are largely absent,and the degree to which sex workers are accessingSRH services during emergencies remains unclear. Aparadigm shift from the behavioural and biomedicalapproach to HIV among sex workers, to a health andhuman rights approach, in displacement and post-conflict settings is strongly recommended.AbbreviationsART: Antiretroviral therapy; GBV: Gender based violence; HIV: Humanimmunodeficiency virus; HIV/AIDS: Human immunodeficiency virus /acquired immunodeficiency deficiency syndrome; IAWG: Inter-AgencyWorking Group (IAWG) on Reproductive Health in Crisis; IDP: Internallydisplaced person/people; MISP: Minimum initial service package;NSWP: Global Network of Sex Worker Projects; PMCTC: Prevention of mother-to-child transmission; SRH: Sexual and reproductive health; STIs: Sexuallytransmitted infections; SW: Sex worker; UNAIDS: Joint United NationsProgramme on HIV/AIDS; UNFPA: United Nations Population Fund;UNHCR: UN Refugee Agency; VCT: Voluntary counselling and testing;WHO: World Health OrganizationAcknowledgmentsAF was supported in her placement by a Canadian Institutes for HealthResearch Award. SG is supported by the Canadian Institutes of HealthResearch, and the National Institute of Health. KS is supported by a CanadaResearch Chair in Global Sexual Health and HIV/AIDS and Michael SmithFoundation for Health Research.FundingNot applicable.Availability of data and materialsNot applicable.Authors’ contributionsAF led the searching, screening, and analysis of records and drafted thearticle. Together with SG and KS, she was involved in the design of thereview and early conception of the project. KS and SG conceived of thestudy, were involved in the design of the project, provided direction onconduct of the review, resolved decisions about inclusion criteria, wereclosely involved in intermediate draft revisions, and approved the final paper.JB provided conceptual insight and feedback on revisions, and approved ofthe final paper.Ferguson et al. Conflict and Health  (2017) 11:25 Page 18 of 20Authors’ informationAlyssa Ferguson, BA, MPH, is a graduate of the Master of Public Health inGlobal Health program from the University of Alberta’s School of PublicHealth. Her research interests focus on social and structural determinants ofsexual and reproductive health for marginalized women, particularly in sub-Saharan Africa. This review was carried out as part of her MPH degree fieldpracticum placement hosted and supervised by the Gender and SexualHealth Initiative, BC Centre for Excellence in HIV/AIDS.Kate Shannon, BA, BSc, MPH, PhD, is Director of the Gender & Sexual HealthInitiative at the BC Centre for Excellence in HIV/AIDS and an AssociateProfessor of Medicine and Associate Faculty in the School of Population andPublic Health at University of British Columbia. Her research focuses onsexual health, HIV, and social justice inequities among marginalizedpopulations, including sex workers, migrant and refugee women, andwomen living with HIV.Jennifer Butler, BA, PhD, is senior technical advisor on HIV and keypopulations at UNFPA and leads global United Nations responses to HIV andsex work, men who have sex with men and transgender people, andsupport responses on HIV and people who use drugs and removing punitivelaws, policies and practices.Shira Goldenberg, BA, MSc, PhD, is a Research Scientist with the Gender &Sexual Health Initiative of the BC Centre for Excellence in HIV/AIDS and anAssistant Professor in the Faculty of Health Sciences at Simon FraserUniversity. Dr. Goldenberg’s research largely focuses on the unique health,safety and human rights issues faced by migrant and refugee/internallydisplaced sex workers and women living with HIV in Guatemala, Mexico,Uganda, and Canada.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Competing interestsNone to declare.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1Gender and Sexual Health Initiative, British Columbia Centre for Excellencein HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z1Y6, Canada. 2Department of Medicine, University of British Columbia, St.Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.3United Nations Population Fund (UNFPA), Eastern Europe and Central AsiaRegion (EECAR), Istanbul, Turkey. 4Faculty of Health Sciences, Simon FraserUniversity, Blusson Hall, 8888 University Drive, Burnaby V5A 1S6, Canada.5Faculty of Health Sciences, Simon Fraser University, Gender and SexualHealth Initiative, BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital,608-1081 Burrard St, Vancouver, BC V6Z 1Y6, Canada.Received: 7 September 2016 Accepted: 4 October 2017References1. 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Linking sexual andreproductive health and HIV interventions: a systematic review.J Int AIDS Soc. 2010;13(26).•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Ferguson et al. Conflict and Health  (2017) 11:25 Page 20 of 20


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