VIOLENCE PREDICTS SEX RISK AND STIMULANT USE AMONG FEMALE SEX WORKERS

Purposes: We examined data from the Cambodia-based Young Women’s Health Study-2 for associations of prior violence exposures with sexual and drug risk behaviors over time. We hypothesized female sex workers (FSW) with recent violent victimization would be more likely to engage in sexual risk taking and amphetamine type stimulant (ATS) use during the prospective follow-up. Furthermore, we hypothesized heightened sexual risk among those with prior violence exposure would be independent of ATS use.

Background: FSW are disproportionately burdened with HIV. Consistent with syndemics theory, previous cross-sectional studies demonstrate that physical and sexual violence are prevalent in FSW and associated with engagement in sexual risk taking or drug use. Both sexual and drug risk behaviors place FSW at higher risk for HIV. Women may engage in risk behaviors to escape or avoid the psychological effects of violence.  It is also possible that women engaging in risky sex and drug use are more likely to be in circumstances that increase risk for violence. Prospective studies examining violence exposure with subsequent sexual and drug risks will shed light on mechanisms and intervention opportunities.

Methods: Between August 2009 and 2010, 220 FSW age 15-29 were enrolled in a 1-year prospective study. Socio-demographic characteristics, sexual and drug use behaviors and violence exposures were assessed via self-report at baseline and quarterly study visits. Using questions developed by the World Health Organization, violence exposure was characterized as moderate physical violence (i.e., slapped pushed shoved, object thrown at them), severe physical violence (i.e., hit, kicked, beaten up, choked, burnt, threatened with a weapon), or sexual violence. Generalized estimating equations were performed to examine independent associations between baseline violence (in the prior 12 months, measured at baseline) and sexual and drug use behaviors measured over follow-up.

Results: Almost half (48%) the women reported physical or sexual violence in the 12 months preceding the baseline study visit: 35% experienced moderate physical violence, 21% severe physical violence; and 27% sexual violence.

Controlling for sexual and severe physical violence and days of ATS use, baseline moderate physical violence was associated with increased number of sex partners over time (adjusted incidence rate ratio [aIRR] 1.33; 95% CI: 1.04-1.71). Baseline sexual violence predicted decreased odds of consistent condom use with non-paying partners (adjusted odds ratio [aOR] 0.24; 95% CI: 0.10-0.59). Moderate physical violence was independently associated with a higher number of days of ATS use (aIRR 2.74; 95% CI: 1.29-5.84) and increased odds of having sex while high or intoxicated (aOR 2.42; 95% CI: 1.10-5.33).

Implications: Findings from this prospective study are among the first demonstrating that physical and sexual violence are independently associated with subsequent sexual risk taking, even after adjusting for ATS use. Consistent with syndemics theory, the intersection of violence exposure, sexual risk taking, and ATS use has important implications for HIV prevention in FSW. HIV prevention efforts often focus on individual behavior, however violence is not an individually modifiable risk. Nursing interventions targeting structural and social factors contributing to violence are needed to decrease HIV-related health disparities among FSW.