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CORK Bibliography: Prostitution

66 citations. January 2006 to present

Prepared: March 2009

Azim T; Chowdhury E; Reza M; Ahmed M; Uddin M; Khan R et al. Vulnerability to HIV infection among sex worker and non-sex worker female injecting drug users in Dhaka, Bangladesh: Evidence from the baseline survey of a cohort study. Harm Reduction Journal 3(article 33), 2006. (39 refs.)

Background: Very little is known about female injecting drug users (IDU) in Bangladesh but anecdotal evidence suggests that they are hidden and very vulnerable to HIV through both their injection sharing and sexual risk behaviors. In order to better understand the risks and vulnerability to HIV of female IDU, a cohort study was initiated through which HIV prevalence and risk behaviors was determined. Methods: All female IDU (those who had injected in the last six months and were 15 years or older) who could be identified from three cities in the Dhaka region were enrolled at the baseline of a cohort study. The study was designed to determine risk behaviors through interviews using a semi-structured questionnaire and measure prevalence of HIV, hepatitis C and syphilis semiannually. At the baseline of the cohort study 130 female IDU were recruited and female IDU selling sex in the last year (sex workers) versus those not selling sex (non-sex workers) were compared using descriptive statistics and logistic regression. Results: Of the 130 female IDU enrolled 82 were sex workers and 48 were non-sex workers. None had HIV but more sex workers (60%) had lifetime syphilis than non-sex workers (37%). Fewer sex worker than non-sex worker IDU lived with families (54.9% and 81.3% respectively), but more reported lending needles/syringes (29.3% and 14.6% respectively) and sharing other injection paraphernalia (74.4% and 56.3% respectively) in the past six months. Although more sex workers used condoms during last sex than non-sex workers (74.4% and 43.3% respectively), more reported anal sex (15.9% and 2.1% respectively) and serial sex with multiple partners (70.7% and 0% respectively). Lifetime sexual violence and being jailed in the last year was more common in sex workers. Conclusion: Female IDU are vulnerable to HIV through their injection and sexual risk behaviors and sex worker IDU appear especially vulnerable. Services such as needle exchange programs should become more comprehensive to address the needs of female IDU.

Azim T; Rahman M; Alam MS; Chowdhury IA; Khan R; Reza M et al. Bangladesh moves from being a low-prevalence nation for HIV to one with a concentrated epidemic in injecting drug users. International Journal of STD & AIDS 19(5): 327-331, 2008. (26 refs.)

Bangladesh has been conducting annual serological surveillance for HIV and syphilis since 1998 among most at-risk populations including sex workers, males having sex with males, injecting drug users (IDUs) and heroin smokers. During the seventh round conducted between January and June 2006, 10,368 people were sampled and the overall HIV prevalence was 0.9%. The highest HIV rate was recorded in male IDUs from the capital city Dhaka (7%), and the rates have risen significantly over the rounds (P < 0.001). In Dhaka, most of the HIV-positive IDUs (10.5%) were localized in one neighbourhood, while in the remaining neighbourhoods 1% were positive (P < 0.001). In all other groups, HIV prevalence was < 1%. Active syphilis rates were highest in female IDUs (9.9%) followed by female street-based sex workers (8.6%). However, rates in female sex workers in Dhaka declined significantly over the years (P < 0.001). Bangladesh has to act urgently to prevent escalation of the epidemic.

Bautista CT; Sanchez JL; Montano SM; Laguna-Torres A; Suarez L; Sanchez J et al. Seroprevalence of and risk factors for HIV-1 infection among female commercial sex workers in South America. Sexually Transmitted Infections 82(4): 311-316, 2006. (29 refs.)

Objective: Assessment of HIV prevalence and associated risk behaviours among female commercial sex workers (FCSW) across major cities in South America. Methods: Seroepidemiological, cross sectional studies of 13 600 FCSW were conducted in nine countries of South America during the years 1999-2002. Participants were recruited in brothels, massage parlours, hotels, and streets where anonymous questionnaires and blood samples were collected. HIV infection was determined by enzyme linked immunosorbent assay (ELISA) screening and western blot confirmatory tests. Results: The overall HIV seroprevalence was 1.2% (range 0.0%-4.5%). The highest HIV seroprevalences were reported in Argentina (4.5%) and Paraguay (2.6%); no HIV infected FCSW were detected in Venezuela and Chile. Consistent predictors of HIV seropositivity were: (1) a previous history of sexually transmitted infections (STI, AORs = 3.8-8.3), and (2) 10 years or more in commercial sex work (AORs = 2.2-24.8). In addition, multiple (>= 3) sexual contacts (AOR = 5.0), sex with foreigners (AOR = 6.9), use of illegal drugs (AOR = 3.2), and marijuana use (AOR = 8.2) were associated with HIV seropositivity in Southern Cone countries. Conclusions: Consistently low HIV seroprevalences were detected among FCSW in South America, particularly in the Andean region. Predictors of HIV infection across the continent were STI and length of commercial sex work; however, use of illegal drugs, especially marijuana, and sexual contacts with foreigners were also found to be associated risk factors in the Southern Cone region. Interventions for the control of HIV and other STI need to be region and country specific; drug use appears to have an ever increasing role in the spread of HIV among heterosexually active populations.

Beckerleg S. Khat in East Africa: Taking women into or out of sex work? Substance Use & Misuse 43(8/9): 1170-1185, 2008. (31 refs.)

Women's drug use is often associated with sex work as a means of raising money for consumption. Similarly, in Kenya and Uganda, journalists, the general public and aid agencies associate female consumption of the stimulant drug, khat (Catha edulis), as pulling women into prostitution. In contrast to Yemen and Ethiopia, these views are expressed by people living in areas where there are no rituals or traditions of female khat consumption. This paper presents data from a study carried out in Kenya and Uganda in 2004 and 2005 that documents that the majority of women engaging in khat chewing are not sex workers. Frequently, however, women who retail khat are often assumed by men to be sexually immoral. The role of women in the retail and wholesale khat trade is examined. The stigma attached to selling khat is linked to the overall situation of independent women in East Africa and the place of commercial sex in urban life.

Bellis MA; Watson FLD; Hughes S; Cook PA; Downing J; Clark P et al. Comparative views of the public, sex workers, businesses and residents on establishing managed zones for prostitution: Analysis of a consultation in Liverpool. Health & Place 13(3): 603-616, 2007. (56 refs.)

Drug addiction, violence and anti-social behaviour are characteristics of street prostitution. An alternative approach to zero tolerance is establishing a managed zone where sex workers operate according to regulations and can access health services. Using a consultation with sex workers (n = 50), businesses (n = 51), residents (n = 179) and the public (n = 789) we examined where a zone might be established in a UK city (Liverpool) and characteristics of the zone required by these stakeholders. All groups believed a zone would improve sex workers' safety and reduce prostitution elsewhere. Sex workers (96%) agreed to work in a zone. Location criteria from all groups were used to identify two potential business areas to host a zone but businesses in or near these areas rejected plans through fear for staff safety and reduced business. We discuss the consultation process, difficulties in locating services for marginalised groups in cities and the implications for health and judicial policy relating to prostitution.

Brawn KM; Roe-Sepowitz D. Female juvenile prostitutes: Exploring the relationship to substance use. Children and Youth Services Review 30(12): 1395-1402, 2008. (39 refs.)

This study examines the incidence of substance use and the differences in life characteristics, such as family relationships, demographics, and abuse history in a sample of 128 adolescent females charged with prostitution. The purpose of this study was to explore the relationship between drug and alcohol use and juvenile prostitution as well as looking at the differences between the juvenile female prostitutes who use drugs and alcohol compared to those who did not. Differences included the users of alcohol and drugs experienced a greater lack of supervision at home, more associated with negative peers, had higher rates of childhood abuse and neglect, and more often had been suspended or expelled from school. Implications for assessment, interventions and future research are discussed.

Brewer DD; Dudek JA; Potterat JJ; Muth SQ; Roberts JM; Woodhouse DE. Extent, trends, and perpetrators of prostitution-related homicide in the United States. Journal of Forensic Sciences 51(5): 1101-1108, 2006. (44 refs.)

Prostitute women have the highest homicide victimization rate of any set of women ever studied. We analyzed nine diverse homicide data sets to examine the extent, trends, and perpetrators of prostitution-related homicide in the United States. Most data sources substantially underascertained prostitute homicides. As estimated from a conservative capture-recapture analysis, 2.7% of female homicide victims in the United States between 1982 and 2000 were prostitutes. Frequencies of recorded prostitute and client homicides increased substantially in the late 1980s and early 1990s; nearly all of the few observed pimp homicides occurred before the late 1980s. These trends may be linked to the rise of crack cocaine use. Prostitutes were killed primarily by clients, clients were killed mainly by prostitutes, and pimps were killed predominantly by pimps. Another conservative estimate suggests that serial killers accounted for 35% of prostitute homicides. Proactive surveillance of, and evidence collection from, clients and prostitutes might enhance the investigation of prostitution-related homicide.

Burnette ML; Schneider R; Timko C; Ilgen MA. Impact of substance-use disorder treatment on women involved in prostitution: Substance use, mental health, and prostitution one year after treatment. Journal of Studies on Alcohol and Drugs 70(1): 32-40, 2009. (30 refs.)

Objective: Prostitution is common among women with substance-use disorders (SUDs). However, little is known about the outcomes of SUD treatment for women involved in prostitution relative to their peers or the impact of SUD treatment on subsequent prostitution. Method: Participants were 1,287 women from a national study of SUD treatment sites. Women completed a baseline interview at entry to SUD treatment and a follow-up interview roughly I year after discharge. We compared the substance-related and mental health outcomes at follow-up of women involved in prostitution and women not involved in prostitution, and determined if prostitution declined significantly at follow-up. Among women reporting prostitution at baseline (n = 533), we examined whether receipt of specific ancillary services (medical, mental health, psychosocial) was associated with cessation of prostitution and whether cessation of prostitution was associated with better substance-related and mental health outcomes. Results: Women reporting prostitution at baseline had more frequent drug and alcohol use, reduced abstinence rates, and more mental health symptoms at follow-up compared with their peers. However, the rate of prostitution declined from baseline to follow-up. Receipt of more mental health and psychosocial services during treatment was associated with the cessation of prostitution at follow-up, and cessation of prostitution was associated with lower substance use, higher rates of abstinence, and fewer mental health symptoms at follow-up. Conclusions: Comprehensive services may be needed to effect significant reductions in substance use and mental health symptoms among women engaged in prostitution.

Burnette ML; Schneider R; Ilgen MA; Timko C. Women's past-year prostitution status and receipt of substance abuse treatment services. Psychiatric Services 59(12): 1458-1461, 2008. (15 refs.)

Objective: The study compared services received in substance abuse treatment programs by women who reported involvement in prostitution and by those who did not. Methods: Women (N=1,604) in a national study of substance abuse programs completed a structured interview assessing substance abuse, demographic characteristics, and past-year prostitution at program entry. At discharge, information was gathered on treatment modality (residential including inpatient, or outpatient), duration, and amounts of medical, mental health, and psychosocial services received during treatment. Analyses compared women involved in prostitution and those not involved. Results: Women involved in prostitution were more likely to enter residential treatment. No differences between involvement groups were found in residential treatment duration, services received in residential treatment, or length of outpatient enrollment. In outpatient programs, women involved in prostitution received more psychosocial services. Conclusions: Substance abuse treatment programs appear responsive to the greater needs of women involved in prostitution. However, more research is needed on outcomes.

Chersich MF; Luchters SMF; Malonza IM; Mwarogo P; King'ola N; Temmerman M. Heavy episodic drinking among Kenyan female sex workers is associated with unsafe sex, sexual violence and sexually transmitted infections. International Journal of STD & AIDS 18(11): 764-769, 2007. (41 refs.)

This study examined patterns of alcohol use and its association with unsafe sex and related sequelae among female sex workers in Mombasa, Kenya. A community-based cross-sectional study was conducted using snowball sampling. Binge drinkers (>= 5 alcoholic drinks on >= 1 occasion in the previous month) were compared with non-binge drinkers. Of 719 participants, 22.4% were lifetime-alcohol abstainers, 44.7% non-binge and 33.0% binge drinkers. Compared with non-binge drinkers, binge drinkers were more likely to report unprotected sex (adjusted odds ratio (AOR) = 1.59, 95% confidence interval [CI] = 1.00-2.53; P = 0.047) and sexual violence (AOR = 1.85, 95% Cl = 1.27-2.71; P = 0.001) and to have either syphilis, Neisseria gonorrhoeae or Trichomonas vaginalis infection (AOR = 1.56, 95% Cl = 1.00-2.41; P = 0.048). HIV prevalence was higher among women having ever drunk (39.9%) than lifetime abstainers (23.2%; P < 0.001), but was not associated with drinking patterns. Interventions are needed to assist female sex workers adopt safer drinking patterns. Investigation is needed for the effectiveness of such interventions in reducing unprotected sex, sexual violence and sexually transmitted infections.

Chiao C; Morisky DE; Rosenberg R; Ksobiech K; Malow R. The relationship between HIV/sexually transmitted infection risk and alcohol use during commercial sex episodes: Results from the study of female commercial sex workers in the Philippines. Substance Use & Misuse 41(10-12): 1509-1533, 2006. (64 refs.)

The HIV-Sexually Transmitted Infection (STI) risk associated with alcohol use between female commercial sex workers (FCSWs) and their customers has been understudied. We examined this relationship for 1,114 FCSWs aged 15-54 with data collected during the baseline study period (1994 to 1998) in four southern provinces of the Philippines. Two alcohol-related risk situations during commercial sex episodes were examined: prior alcohol use by an FCSW and perceived intoxication in a customer. The influence of sociodemographic variables on sexual risk behaviors was also studied. Multiple sexual risk behaviors were observed with more frequency for FCSWs if alcohol was used before commercial sex or if the episode involved a customer perceived to be intoxicated. Forty-two percent of FCSWs who had sex with an intoxicated customer were STI positive, significantly more than FCSWs who did not have sex with an intoxicated customer (28%, p < .01). Similar significant differences were found for FCSWs who did not consume alcohol before having sex and were STI positive (29%) versus FCSW who did consume alcohol before sex and were STI positive (33%, p < .01). Our analyses reinforce accumulating evidence in the field that sexual risk reduction interventions need to go beyond the behaviors of individual FCSWs to meet the layering of risks such as observed in this study. Multilevel strategies targeting customer substance use and other situational and structural factors have proven to be pivotal mediators in our other research with this population. These experiences and the limitations of this study are discussed.

Clatts MC; Giang LM; Goldsamt LA; Yi H. Male sex work and HIV risk among young heroin users in Hanoi, Vietnam. Sexual Health 4(4): 261-267, 2007. (25 refs.)

The present study describes complex drug and sexual risk in a group of male sex workers (n = 79) who were recruited in the context of a larger study of young heroin users in Hanoi, Vietnam (n = 1270). Male sex workers were significantly more likely than male non-sex workers to be migrants (P < 0.001) and to have unstable housing (P < 0.001), to have lifetime exposure to marijuana (P < 0.001), 3,4 methylenedioxymethamphetamine (MDMA, ecstasy) (P < 0.01), amphetamines (P < 0.05), cocaine (P < 0.01) and morphine (P < 0.001). Male sex workers are more likely to currently use MDMA (P < 0.05), amphetamines (P < 0.001), morphine (P < 0.05) and to 'smoke' as their most frequent mode of heroin administration (P < 0.01). Male sex workers are more likely to have both male and female concurrent sex partners (P < 0.001), to have a history of sexual victimisation (P < 0.001), to have had more than three different sex partners in the past 30 days (P < 0.001), and to have had partners who injected drugs before sex (P < 0.001) or who used drugs during sex (P < 0.01). In their last sexual encounter with a client partner, approximately one-third (31.1%) reported having had receptive anal sex. In nearly three-quarters of these exchanges (71.4%), no condom was used. Similarly, in their last sexual encounter with a client partner, 42.2% reported having had insertive anal sex and in nearly half (47.4%) of these encounters no condom was used. Consistent with recent data from elsewhere in the region, there is an urgent need for additional research on male sex work in South-east Asia in order to properly situate behavioural interventions for male sex workers in this region.

Cusick L. Widening the harm reduction agenda: From drug use to sex work. International Journal of Drug Policy 17(1): 3-11, 2006. (146 refs.)

Harm reduction emerged in the 1980s as a public health response to HIV and injecting drug use. This paper reviews the literature to structure the harms associated with sex work and expand the domains of harm reduction. Sex work-related harms are often rooted in debates where moral arguments and health and criminal justice policies compete for priority. Like drug users, sex workers have a social history in which they have been stigmatised, criminalised, pathologised, and on occasion, celebrated. Yet, by focusing on drug-related harm specifically, the 'harm reduction movement' is missing opportunities to better promote health among sex workers. Harms associated with sex work include: the vulnerabilities that may lead to sex work; harms that are introduced by sex work; and mutually reinforcing harms such as problematic drug use. These harms are overwhelmingly concentrated in street sex markets and where sex workers' pre-existing vulnerabilities can be most exploited. They include predation and victimisation, violence and child abuse, trafficking and slavery, stigma, sanctions and penalties, STIs, exposure to mutually reinforcing harms and public nuisance. Existing interventions and policy developments to reduce these harms are discussed.

Dalla RL. "You can't hustle all your life": An exploratory investigation of the exit process among street-level prostituted women. Psychology of Women Quarterly 30(3): 276-290, 2006. (25 refs.)

Between 1998 and 1999, 43 street-level prostituted women were interviewed regarding their developmental experiences, including prostitution entry, maintenance, and exit attempts. Three years later, 18 of the original 43 participants were located and interviewed. This exploratory follow-up investigation focused on the women's life experiences between the two points of contact, with emphasis on sex-industry exit attempts. Five women had maintained their exit efforts and had not returned to prostitution, nine had returned to both prostitution and drug use, and one had returned to prostitution only. Three additional women had violated parole and been reincarcerated. Themes evident among those who were able to stay out of prostitution and refrain from substance use are compared to those whose exit attempts had not been successful. Suggestions for intervention and outreach are presented, as are directions for future work.

Davey-Rothwell MA; Latkin CA. An examination of perceived norms and exchanging sex for money or drugs among women injectors in Baltimore, MD, USA. International Journal of STD & AIDS 19(1): 47-50, 2008. (22 refs.)

Injection drug users who exchange sex for money or drugs may serve as a bridge group for transmitting HIV between injectors and non-injectors. While many individual characteristics have been linked to exchanging sex, little attention has been given to the influence of social network members. The present study assessed the relationship between exchanging sex and perceptions of peers' sex exchange behaviour and attitude toward sex exchange. The sample was composed of 267 women heroin and cocaine injectors in Baltimore, MD. The results indicate that women who believed that their friends exchanged sex were more twice as likely to exchange sex in the past 90 days (95% CI: 1.49-2.70). Also, participants who thought their peers disapproved of sex exchange were 20% less likely to exchange sex (95% CI: 0.67-0.95). These findings suggest the need for peer education interventions that promote norms about safer behaviours.

DeBeck K; Shannon K; Wood E; Li K; Montaner J; Kerr T. Income generating activities of people who inject drugs. Drug and Alcohol Dependence 91(1): 50-56, 2007. (44 refs.)

Background: Injection drug users (IDU) commonly generate income through prohibited activities, such as drug dealing and sex trade work, which carry significant risk. However, little is known about the IDU who engage in such activities and the role of active drug use in perpetuating this behavior. Methods: We evaluated factors associated with prohibited income generation among participants enrolled in the Vancouver Injection Drug Users Study (VIDUS) using logistic and linear regression. We also examined which sources of income respondents would eliminate if they did not require money to pay for drugs. Results: Among 275 IDU, 145 (53%) reported engaging in prohibited income generating activities in the past 30 days. Sex work and drug dealing accounted for the greatest amount of income generated. Non-aboriginal females were the group most likely to report prohibited income generation. Other variables independently associated with prohibited income generation include daily heroin injection (AOR = 2.3) and daily use of crack cocaine (AOR = 3.5). Among these individuals, 68 (47%) indicated they would forgo these earnings if they did not require money for illegal drugs, with those engaged in sex trade work (62%) being most willing to give up their illegal source of income. Conclusion: These findings suggest that the costs associated with illicit drugs are compelling IDU, particularly those possessing markers of higher intensity addiction, to engage in prohibited income generating activities. These findings also point to an opportunity to explore interventions that relieve the financial pressure of purchasing illegal drugs and reduce engagement in such activities, such as low threshold employment and expansion of prescription and substitution therapies.

Degenhardt L; Day C; Conroy E; Gilmour S. Examining links between cocaine use and street-based sex work in New South Wales, Australia. Journal of Sex Research 43(2): 107-114, 2006. (40 refs.)

We examined potential links between cocaine use and street-based sex work in New South Wales, Australia, following reports of increased cocaine use among injection drug users (IDU). Police data on prostitution and possession/use of cocaine was analysed using time series analysis. Interviews with key informants and IDU were also conducted, and data on cocaine use from ongoing monitoring systems targeted at IDU were analyzed. There was a clear increase in cocaine use among IDU which occurred in 2001. This occurred at the same time as an increase in prostitution offenses. Qualitative data suggested a greater number of primary heroin users were engaging in street-based sex work, which was driven in part by the increases in cocaine use among this group. Subsequent reductions in cocaine availability led to decreased cocaine use and possession offenses, along with reductions in prostitution offenses.

DeRiviere L. A human capital methodology for estimating the lifelong personal costs of young women leaving the sex trade. Feminist Economics 12(3): 367-402, 2006. (52 refs.)

This article combines case study interviews with the tools of economic cost-benefit analysis to estimate the lifelong effects for individuals in Manitoba, Canada, who began engaging in prostitution as youths. The empirical findings reveal that sex workers retain only a small portion of their earnings from prostitution after feeding drug addictions and third-parties extortions of net residual earnings. The sex-trade worker typically suffers from debilitating addictions and health conditions that are symptomatic of the stress and danger of engaging in this lifestyle. After leaving prostitution, the former sex worker faces major challenges in rejoining the mainstream labor market. The issues engender multiple reasons for policy-makers to direct their attention to counteracting the conditions of vulnerability that bring youth into this lifestyle and, thereby, effectively disrupting the supply of sex workers.

Dickson-Gomez J; Bodnar G; Gueverra A; Rodriguez K; Gaborit M. Childhood sexual abuse and HIV risk among crack-using commercial sex workers in San Salvador, El Salvador: A qualitative analysis. Medical Anthropology Quarterly 20(4): 545-574, 2006. (69 refs.)

This article explores the relationship between childhood sexual abuse (CSA) and later HIV risk. It draws on qualitative, in-depth interviews with 40 women who either used crack or engaged in commercial sex work in the greater metropolitan area of San Salvador, El Salvador, 28 of whom experienced CSA. Although the relationship between CSA and later HIV risk has been clearly demonstrated, the processes that lead women who have experienced CSA to experience HIV risk are unclear. The theoretical model presented here incorporates the psychological effects of CSA, particularly stigmatization, as well as its social consequences and the larger context of poverty in which these women live. The meanings women draw from past abuse experiences and their rationale for choices made help explain the association between CSA and later risk as mediated through sex work and crack addiction. Self-report data gathered in this study indicate that HIV prevalence may be considerably higher in this high-risk population than Salvadoran national rates.

Edwards JM; Halpern CT; Wechsberg WM. Correlates of exchanging sex for drugs or money among women who use crack cocaine. AIDS Education and Prevention 18(5): 420-429, 2006. (27 refs.)

This study examined the correlates of trading sex for drugs or money among women who use crack cocaine. Using baseline data (n = 669) from a woman-focused HIV intervention study among African American women who use crack cocaine, we conducted logistic regression analysis to examine the odds of trading sex associated with distal and proximal factors. The results indicate that heavier crack use, homelessness, and unemployment are associated with trading sex. In addition, childhood abuse is associated with trading sex and this relationship is, in part, mediated by psychological distress. This suggests that distal factors may underlie the relationship between current variables and sex trading. These findings underscore the importance for public health interventions to address both distal and proximal factors that contribute to and/or co-occur with women's drug use which, in turn, may affect their HIV risk and overall well-being.

Emmanuel F; Fatima M. Coverage to curb the emerging HIV epidemic among injecting drug usersin Pakistan: Delivering prevention services where most needed. International Journal of Drug Policy 19(Supplement 1): s59-s64, 2008. (25 refs.)

Background: HIV Surveillance data from IDUs is suggestive of an escalating epidemic in major cities of Pakistan. The relatively widespread presence and interlinking of IDU and high-risk sexual networks, combined with low levels of HIV knowledge and prevention methods, indicate that there is potential for a rapid spread of HIV to other high-risk groups and its further expansion to general population through bridging groups. Methods: We reviewed Second Generation Surveillance data which provides mapping, biological and behavioural information from IDUs in eight major cities across Pakistan. Geographic mapping provided information about the location and size of the population, which was followed by a behavioural survey, conducted with a representative sample of 2432 IDUs. In addition, blood samples were also obtained which were tested for HIV. Results: Despite availability of syringe and needle exchange programmes in larger cities, drug users continued to reuse syringes (78.1%),injected in groups (73.3%) where extensive sharing of needle and injecting paraphernalia took place (50%). 12.6% of the respondents reported to having sexual relationships with female sex workers and 14.7% had sex with males in the past 6 months. 65% never used condoms. In addition 5.3% reported exchange of sex for money and drugs. Fairly low levels of coverage were reported from most of the cities. Conclusion: Despite an existing nationwide harm reduction programme, increasing rates of HIV infection among IDUs underscore the need to identify gaps in the existing prevention strategy. Data available on coverage shows that effective harm reduction activities are unable to reach a substantial number of IDUs to actually avert or delay the emerging IDUs epidemic. There is an urgent need to expand coverage, and to integrate harm reduction in the mainstream of public health.

Firestone M; Fischer B. A qualitative exploration of prescription opioid injection among street-based drug users in Toronto: Behaviours, preferences and drug availability. Harm Reduction Journal 5(1): e-article 130, 2008. (56 refs.)

Background: There is evidence of a high prevalence of prescription opioid (PO) and crack use among street drug users in Toronto. The purpose of this qualitative study was to describe drug use behaviours and preferences as well as the social and environmental context surrounding the use of these drugs among young and old street-based drug injection drug users (IDUs). Methods: In-depth interviews were conducted with 25 PO injectors. Topics covered included drug use history, types of drugs used, how drugs were purchased and transitions to PO use. Interviews were taped and transcribed. Content analysis was conducted to identify themes. Results: Five prominent themes emerged from the interviews: 1) Combination of crack and prescription opioids, 2) First injection experience and transition to prescription opioids, 3) Drug preferences and availability, 4) Housing and income and 5) Obtaining drugs. There was consensus that OxyContin and crack were the most commonly available drugs on the streets of Toronto. Drug use preferences and behaviours were influenced by the availability of drugs, the desired effect, ease of administration and expectations around the purity of the drugs. Distinct experiences were observed among younger users as compared to older users. In particular, the initiation of injection drug use and experimentation with POs among younger users was influenced by their experiences on the street, their peers and general curiosity. Conclusions: Given the current profile of street-based drug market in Toronto and the emergence of crack and POs as two predominant illicit drug groups, understanding drug use patterns and socio-economic factors among younger and older users in this population has important implications for preventive and therapeutic interventions.

Gangamma R; Slesnick N; Toviessi P; Serovich J. Comparison of HIV risks among gay, lesbian, bisexual and heterosexual homeless youth. Journal of Youth and Adolescence 37(4): 456-464, 2008. (53 refs.)

Youth who are homeless and gay, lesbian or bisexual (GLB) are one of the most disenfranchised and marginalized groups in our society. The purpose of this study is to examine and compare HIV in GLB homeless youth with their heterosexual counterparts. Participants for this study included 268 youth involved in treatment outcome studies with substance abusing homeless youth. Results suggest that GLB youth have greater HIV risks and that these risks are greater among bisexual females. In examining the predictors of sexual health risks, survival sex emerged as the most significant. Survival sex was high among females regardless of their sexual orientation and also among gay males. Implications of these findings suggest that a greater emphasis needs to be paid to preventive interventions among this population.

Geiger B. Crime, prostitution, drugs, and malingered insanity: Female offenders' resistant strategies to abuse and domination. International Journal of Offender Therapy and Comparative Criminology 50(5): 582-594, 2006. (59 refs.)

Mizrahi female offenders have been described as passive victims propelled into crime, prostitution, and drug abuse as a result of traumatic childhood and life course experiences. This qualitative study adopts a postmodern critical orientation and Foucault's bottom-up microsocial analysis of power to examine the trajectories of resistance of 8 female offenders who break the silence to tell their life story. Analysis of narratives, informal conversations, and more focused, in-depth interviews with these women allow the deconstruction of the stereotype of the passive and helpless female offender. Using the sensitizing concepts of control, agency, and resistant efforts and letting the data speak, this research reconstructs female offending as a hidden script of resistance against intolerable socioeconomic deprivation and extreme forms of abuse.

Golder S; Logan TK. Correlates and predictors of women's sex trading over time among a sample of out-of-treatment drugs abusers. AIDS and Behavior 11(4): 628-640, 2007. (73 refs.)

This research addressed two research questions: (a) controlling for crack use, what are the factors associated with women's engagement in ever having traded sex? and (b) controlling for crack use, what are the factors associated with women's engagement in sex trading in the past 90 days? The sample included 149 sexually active, crack using women selected from a subsample of participants in the Kentucky NIDA AIDS Cooperative Agreement. Bivariate analyses indicated that in addition to the pattern of crack use, 13 of the candidate variables were significantly related to sex trading, ever and 11 related to sex trading in the past 90 days. The multivariate models accounted for more than 40% of the variance in sex trading, ever and almost 59% of the variance in sex trading over the past 90 days. Suggestions for HIV /AIDS prevention and intervention among drug-involved women are discussed; implications for future research are suggested.

Gray R; Hoffman L; Gray R; Hoffman L. Tracking coverage on the silk road: Time to turn theory into practice (editorial). International Journal of Drug Policy 19(Supplement 1): s15-s24, 2008. (10 refs.)

Scaling up coverage of programs that effectively reduce the spread of HIV among vulnerable populations, including injecting drug users (IDUs), sex workers (SWs), and men who have sex with men (MSM), is a critically important issue for many countries today. However, in addition to the lack of a commonly accepted definition of coverage, there are currently no universally accepted standards, methodologies, or tools to track coverage among these groups. Globally, most programs working to prevent HIV among vulnerable populations are not using monitoring & evaluation (M&E) systems that accurately track numbers of clients and frequency of contact with those clients. Nor do most programs have targets on the frequency of contact needed to effectively promote healthy behaviours. This article presents a narrative of how one program in Central Asia developed a simple M&E system to track the extent and frequency of contacts among clients. The system uses a simple and anonymous "Unique Identifier Code" (UIC) that is assigned to each client and recorded into a simple database to track the client's interaction with the program. The system allows program managers to track numbers of clients served and at what frequency and to better monitor progress towards goals. The data produced by the UIC system, when compared against HIV and sexually transmitted infection (STI) sentinel surveillance data by site, allows programs to test theorized definitions of the quantity of coverage needed to reduce the risk behaviours that spread HIV among vulnerable populations. Such systems can then provide urgently needed data to help national HIV/AIDS programs understand current coverage levels and gaps in coverage that need to be filled in order to reduce the spread of HIV Such a system provides valuable data to enable decision makers to make evidence-based decisions on how to allocate resources to reach sufficient coverage to reduce the spread of HIV among populations most at risk of HIV.

Gu J; Chen HY; Chen X; Lau JTF; Wang RF; Liu CL et al. Severity of drug dependence, economic pressure and HIV-related risk behaviors among non-institutionalized female injecting drug users who are also sex workers in China. Drug and Alcohol Dependence 97(3): 257-267, 2008. (50 refs.)

Background: Female injecting drug users (IDUs) who are also sex workers (FSW-IDUs) is an important bridge population transmitting HIV from the IDU population to clients of FSWs. Little is known about the relationships between severity of drug dependence, economic pressure and relevant HIV-related risk behaviors. Methods: 281 non-institutionalized participants were recruited using snowball sampling methods. Anonymous face-to-face interviews were administered by trained doctors. Results: 64.1% of participants used condoms inconsistently with their clients in the past 6 months; 28.5% served at least 2 clients per day and 48.4% practiced at least one of the three studied needle sharing behaviors. Severity of drug dependence (adjusted OR = 1.05, p < 0.01) and economic pressure (adjusted OR = 1.07 to 2.52, p < 0.05) were significantly associated with inconsistent condom use with clients in the last 6 months. Severity of drug dependence (adjusted OR = 1.15, p < 0.01) and variables related to perceived economic pressure (adjusted OR = 1.09-3.05, p < 0.05) were significantly associated with higher frequency of commercial sex transaction. Severity of drug dependence (adjusted OR = 1.07, p < 0.01) were also associated with needle sharing behaviors. In summary models, severity of drag dependence (OR = 1.17, p < 0.001), economic pressure (OR = 1.39, p < 0.001) and their interaction term (OR = 0.98, p < 0.001) were all associated with inconsistent condom use with clients in the last 6 months. Conclusions: Prevalence of unprotected commercial sex was high and was independently associated with severity of drug dependence and economic pressure: severity of drug dependence was also associated with needle sharing behaviour such issues need to be fully considered when planning research studies and interventions.

Hasnain M; Levy JA; Mensah EK; Sinacore JM. Association of educational attainment with HIV risk in African American active injection drug users. AIDS Care 19(1): 87-91, 2007. (28 refs.)

This study explored the association between educational attainment and HIV/AIDS risk among African American active injection drug users (IDUs) in Chicago, US. Using snowball sampling techniques, 813 African American active IDUs were recruited for semi-structured interviewing and HIV counseling, testing and partner notification. Logistic regression examined the relationship between level of education attained (three categories: less than high school; equivalent to high school; and greater than high school) and HIV risk behaviors (12 unsafe sex and drug-related practices) and HIV serostatus (positive or negative). Compared with the reference category (less than high school education), those with education equal to high school were less likely to share water, p = 0.044, OR= 0.70 (95%CI: 0.50-0.99). Compared with the reference category, those with education greater than high school were less likely to receive money for sex, p = 0.048, OR = 0.62 (95%CI: 0.38-0.99); share needles with person having HIV or AIDS, p = 0.015, OR =0.58 (95%CI: 0.37-0.90); and test positive for HIV, p=0.0273 OR =0.58 (95%CI: 0.36-0.94). The significant associations found between educational attainment and certain HIV risk behaviors and HIV serostatus have implications for tailoring HIV prevention efforts for less educated African American IDUs.

He N; Wong FY; Huang ZJ; Thompson EE; Fu C. Substance use and HIV risks among male heterosexual and 'money boy' migrants in Shanghai, China. AIDS Care 19(1): 109-115, 2007. (22 refs.)

There is a growing awareness that internal migration in China might shift the HIV epidemic by broadening the social and sexual mixing of its population. However, little is known about how drug use/abuse might contribute to the spread of HIV. This qualitative study aims to elucidate factors for preventing substance abuse and HIV among two types of male migrants living in the Shanghai metropolitan area; the general migrant population and so-called 'money boys' (those who engaged in same-sex activities for money). Compared to most male migrants, the 'money boys' had a slightly better economic situation,rarely visited their hometowns; used alcohol less but drugs more; had more knowledge about HIV and sexually transmitted diseases; higher HIV/STD testing rates and fewer HIV risk behaviors. The general male migrants had more misconceptions about HIV (e.g. the need to pay for HIV testing) than the 'money boys'. However, it was noted that 'money boys' who were new to the enterprise and men who have sex with men but did not engage in commercial sex often lacked HIV knowledge and protective skills. Given the needs of various sub-types of 'migrants', differential approaches to HIV prevention are needed.

Jeal N; Salisbury C. Health needs and service use of parlour-based prostitutes compared with street-based prostitutes: A cross-sectional survey. BJOG: An International Journal of Obstetrics and Gynaecology 114(7): 875-881, 2007. (24 refs.)

Objectives To compare the health needs of prostitutes (sex workers) working in massage parlours with that of those working on the streets. Design Cross-sectional survey. Setting Inner city, UK. Population Women aged 16 years and older selling sex in massage parlours. Methods Interviewer-administered questionnaires were undertaken with 71 parlour workers, and results were compared with our previous findings for street sex workers. Main outcome measures Self-reported experiences of health and service use. Results In comparison with street sex workers, parlour sex workers were less likely to report chronic (43/71 versus 71/71; P < 0.001) and acute (10/71 versus 35/71; P < 0.001) illnesses but more likely to be registered with a GP (67/71 versus 59/71; P = 0.06). They were more likely than street sex workers to have been screened for sexually transmitted infections in the previous year (49/71 versus 33/71; P = 0.011) and more likely to use contraception in addition to condoms (34/71 versus 8/71; P < 0.001). They were less likely to be overdue for cervical screening (5/46 versus 19/48; P = 0.001), and more of those booked for antenatal care in the first trimester attended all follow-up appointments (28/37 versus 14/47; P < 0.001). Fewer parlour sex workers used heroin (4/71 versus 60/71; P < 0.001), crack cocaine (5/71 versus 62/71; P < 0.001) or injected drugs (2/71 versus 41/71 versus; P < 0.001) They reported fewer episodes of intercourse per week (mean 14 versus 22; P < 0.001) with fewer different men (mean 11 versus 19; P < 0.001), less of whom were new (mean 8 versus 13; P < 0.001). Conclusions The two groups had very different health experiences, risk-taking behaviour and use of services. To be effective in improving health, different types of service delivered in different settings for different groups are required.

Jung YE; Song JN; Chong JY; Seo HJ; Chae JH. Symptoms of post-traumatic stress disorder and mental health in women who escaped prostitution and helping activists in shelters. Yonsei Medical Journal 49(3): 372-382, 2008. (63 refs.)

Purpose: This study compared the mental symptoms, especially symptoms of posttraumatic stress disorder (PTSD), of women who escaped prostitution, helping activists at shelters, and matched control subjects. Materials and Methods: We assessed 113 female ex-prostitutes who had been living at a shelter, 81 helping activists, and 65 control subjects using self-reporting questionnaires on demographic data, symptoms related to trauma and PTSD, stress-related reactions, and other mental health factors. Results: Female ex-prostitutes had significantly higher stress response, somatization, depression, fatigue, frustration, sleep, smoking and alcohol problems, and more frequent and serious PTSD symptoms than the other 2 groups. Helping activists also had significantly higher tension, sleep and smoking problems, and more frequent and serious PTSD symptoms than control subjects. Conclusion: These findings show that engagement in prostitution may increase the risks of exposure to violence, which may psychologically traumatize not only the prostitutes themselves but also the people who help them, and that the effects of the trauma last for a long time. Future research is needed to develop a method to assess specific factors that may contribute to vicarious trauma of prostitution, and protect field workers of prostitute victims from vicarious trauma.

Kaye K. Sex and the unspoken in male street prostitution. Journal of Homosexuality 53(1-2): 37-73, 2007. (41 refs.)

Although the overwhelming majority of male prostitutes work through agencies or by placing their own ads, most studies of male prostitution focus upon young men who work on the street. Remarkably, these studies seldom identify the dynamics of poverty and street-level violence as important elements of their examination. Investigations of male sex work -- few though they are -- focus almost exclusively upon sexual aspects of "the life." Despite the importance of these networks in shaping the contours of street life, and often in enabling one's very survival, the primary research focus has remained on questions of sexual identity, sexual practices with clients, and sexual abuse as a causative factor. Meanwhile, studies that do examine the dynamics of male street life typically do not examine questions of prostitution or other issues related to sexuality. A dominant theme within this literature consists of specifying the social mores of the most aggressive and socially problematic participants within street society, particularly gang members and drug dealers. The dissimilar nature of these images relates directly to the political projects of the dominant culture, which, in a very general way, seeks to "rescue" (reintegrate) deviant white youth, while controlling and excluding deviant youth of color. The political aim of reintegrating runaways into middle-class trajectories has the effect of authorizing certain discourses regarding their behavior on the streets, while marginalizing or completely disallowing others. This article seeks to examine and challenge these trends of representation.

Kimber J; Dolan K. Shooting gallery operation in the context of establishing a medically supervised injecting center: Sydney, Australia. Journal of Urban Health 84(2): 255-266, 2007. (46 refs.)

Shooting galleries (shooting galleries) are illicit off-street spaces close to drug markets used for drug injection. Supervised injecting facilities (supervised infecting facilities) are low threshold health services where injecting drug users (IDUs) can inject pre-obtained drugs under supervision. This study describes SG use in Kings Cross, Sydney before and after the opening of the Sydney Medically Supervised Injecting Centre (MSIC), Australia's first SIF. Operational and environmental characteristics of shooting galleries, reasons for SG use, and willingness to use MSIC were also examined. An exploratory survey of SG users (n = 31), interviews with SG users (n = 17), and drug workers (n = 8), and counts of used needles routinely collected from shooting galleries (6 months before and after MSIC) and visits to the MSIC (6 months after MSIC) were triangulated. We found five shooting galleries operated during the study period. Key operational characteristics were 24-h operation, AUS$10 entry fee, 30-min time limit, and dual use for sex work. Key reasons for SG use were to avoid police, a preference not to inject in public, and assistance from SG operators in case of overdose. SG users reported high levels of willingness to use the MSIC. The number of used needles collected from shooting galleries decreased by 69% (41,819 vs. 12,935) in the 6 months after MSIC opened, while MSIC visits increased incrementally. We conclude that injections were transferred from shooting galleries to the MSIC, but shooting galleries continued to accommodate injections and harm reduction outreach should be maintained.

Kumar MS; Sharma M. Women and substance use in India and Bangladesh. Substance Use & Misuse 43(8/9): 1062-1077, 2008. (74 refs.)

Given the feminization of the HIV epidemic in India and Bangladesh, understanding substance-use-related concerns among women is important for effective HIV prevention. This review is based on published research, reports (2000-2005), and primary data from treatment centers for drug-using women. We identify four main themes: (a) opioid use and injecting drug use in women, (b) alcohol use in sex work settings, (c) sexual transmission of HIV from male-injecting drug users (IDUs) to their regular female sex partners, and (d) sexual violence among female partners of substance-using men. We urge for focused HIV prevention interventions targeting substance-using women and female sex partners of male substance users to reduce vulnerability.

Latka MH; Metsch LR; Mizuno Y; Tobin K; Mackenzie S; Arnsten JH et al. Unprotected sex among HIV-positive injection drug-using women and their serodiscordant male partners: Role of personal and partnership influences. Journal of Acquired Immune Deficiency Syndromes 42(2): 222-228, 2006. (52 refs.)

We investigated the characteristics of human immunodeficiency virus (HIV)-positive injection drug-using women who reported unprotected vaginal and/or anal sex with HIV-negative or unknown serostatus (serodiscordant) male partners. Of 426 female study participants, 370 were sexually active. Of these women, 39% (144/370) and 40% (148/370) reported vaginal and/or anal sex with serodiscordant main and casual partners, respectively. Sixty percent of women inconsistently used condoms with their serodiscordant main partners, whereas 53% did so with casual partners. In multivariate analysis, during sex with main partners, inconsistent condom users were less likely to feel confident about achieving safe sex (self-efficacy), personal responsibility for limiting HIV transmission, and that their partner supported safe sex. Inconsistent condom use was also more likely among women who held negative beliefs about condoms and in couplings without mutual disclosure of HIV status. Regarding sex with casual partners, inconsistent condom users were more likely to experience psychologic distress, engage in sex trading, but they were less likely to feel confident about achieving safe sex. These findings suggest that there are widespread opportunities for the sexual transmission of HIV from drug-using women to HIV-uninfected men, and that reasons vary by type of partnership. Multifaceted interventions that address personal, dyadic, and addiction problems are needed for HIV-positive injection drug-using women.

Lau JTF; Tsui HY; Zhang Y; Cheng F; Zhang LL; Zhang JX et al. Comparing HIV-related syringe-sharing behaviors among female IDU engaging versus not engaging in commercial sex. Drug and Alcohol Dependence 97(1-2): 54-63, 2008. (34 refs.)

Background: To compare the prevalence of syringe-sharing behaviors and other HIV-related characteristics among female injecting drug users (IDU) engaging and not engaging in sex work and to identify factors associated with such risk behaviors in the two groups. Methods: Data were obtained from 1923 female respondents of behavioral surveillance studies conducted in Sichuan, China. Results: The prevalence of having at least one of the three syringe-sharing behaviors (borrowing. lending. or injecting from pre-filled syringes) was 45.3% in the female sex workers (FSW) group and 37.2% in the non-FSW group (adjusted OR = 1.28, p < 0.05). Compared with non-FSW, FSW were more likely to have injected drugs for 3 or more years. have non-regular sex partners, believe that condom use could prevent HIV, and have received free condoms/lubricants (OR = 1.34-5.08. p < 0.05); FSW were less likely to be older. better educated. and have attempted quitting drugs (OR = 0.31-0.68, p < 0.05). Being FSW, older, longer injecting drug use, higher drug injection frequency, and having regular sex partner were associated with injecting with others' used syringes (multivariate OR = 1.26-1.92, p < 0.05) while the reverse was true for education level and voluntary HIV antibody testing (multivariate OR = 0.44-0.64. p < 0.05). Of all sampled FSW. 39.3% did not use a condom in the last episode of sex work. Conclusions: Female IDU involving in sex work are at high risk of HIV transmission and the risk may even be higher than their non-FSW counterparts. The bridging effect poses a threat to the HIV epidemic in China and effective preventive services are warranted.

Liu H; Grusky O; Zhu Y; Li X. Do drug users in China who frequently receive detoxification treatment change their risky drug use practices and sexual behavior? Drug and Alcohol Dependence 84(1): 114-121, 2006. (41 refs.)

Background: Relapse rates among treated drug users in China are high. We examined the associations between frequency of drug detoxification treatment and HIV-related risky drug practices and sexual behavior. Methods: A cross-sectional study was conducted among drug users in two Anhui province detoxification centers in 2003. Results: A total of 312 drug users were recruited. Seventy-seven percent of the subjects had ever received two or more detoxification treatments. The median number of detoxification treatments received was three, with an interquartile range of two to five treatments. More than 7 in 10 (72%) ever injected drugs; 19% shared needles and syringes in the past 30 days; 40% of drug users reported having both regular and commercial sex partners in the past year and 48% reported having only regular sex partners. Multiple Poisson regression analysis documented that the frequency of detoxification treatment was not associated with a decrease in drug practice (injection or sharing needles) and in unprotected sex. Conclusion: Drug users who frequently received detoxification treatment did not change their risky drug use practices and sexual behavior. Effective behavioral interventions and substitution maintenance treatment should become an integral part of detoxification programs in China.

Mallory C. African American women's experience of infection with HIV in the rural southeastern United States. Journal of the Association of Nurses in AIDS Care 19(1): 28-36, 2008. (43 refs.)

The design of effective behavioral interventions to prevent HIV infection among African American women requires a more complete understanding of the context and circumstances that precipitate infection with the virus. A descriptive study was designed to explore African American women's experiences of infection with HIV in the rural southeastern United States. Ten women living with HIV participated in interviews. All were infected through sex with a man or men; three had engaged in high-risk activities associated with HIV infection including sex trading; seven described themselves as at low risk for infection related to serial monogamy, no injection drug use, and no history of addiction. Participants reported that desire for intimacy coupled with inaccurate risk appraisal of sex partners contributed to their infection. These results provide insight into the role of intimacy in sexual risk taking. Inquiry into how women can be assisted to protect themselves in the context of intimate relationships may improve interventions to prevent HIV.

Malta M; Monteiro S; Lima RMJ; Bauken S; De Marco A; Zuim GC et al. HIV/AIDS risk among female sex workers who use crack in Southern Brazil Revista de Saude Publica. Revista de Saude Publica 42(5): 830-837, 2008. (28 refs.)

OBJECTIVE: To understand the social context of female sex workers who use crack and its impact on HIV/AIDS risk behaviors. METHODODOLOGICAL PROCEDURES: Qualitative study carried out in Foz do Iguacu, Southern Brazil, in 2003. Twenty-six in-depth interviews and two focus groups were carried out with female commercial sex workers who frequently use crack. In-depth interviews with health providers, community leaders and public policy managers, as well as field observations were also conducted. Transcript data was entered into Atlas.ti software and grounded theory methodology was used to analyze the data and develop a conceptual model as a result of this study. ANALYSIS OF RESULTS: Female sex workers who use crack had low self-perceived HIV risk in spite of being engaged in risky behaviors (e. g. unprotected sex with multiple partners). Physical and sexual violence among clients, occasional and stable partners was widespread jeopardizing negotiation and consistent condom use. According to health providers, community leaders and public policy managers, several female sex workers who use crack are homeless or live in slums, and rarely have access to health services, voluntary counseling and testing, social support, pre-natal and reproductive care. CONCLUSIONS: Female sex workers who use crack experience a plethora of health and social problems, which apparently affect their risks for HIV infection. Low-threshold, user-friendly and gender-tailored interventions should be implemented, in order to increase the access to health and social-support services among this population. Those initiatives might also increase their access to reproductive health in general, and to preventive strategies focusing on HIV/AIDS and other sexually transmitted infections.

Manzoni P; Fischer B; Rehm J. Local drug-crime dynamics in a Canadian multi-site sample of untreated opioid users. Canadian Journal of Criminology and Criminal Justice 49(3): 341-373, 2007. (84 refs.)

This multi-site study analysed self-reported involvement in property crime, drug dealing, and sex work, across five Canadian cities, among a sample of 677 illicit opioid and other drug users outside of treatment. First, we assessed drug-use patterns and the extent of illegal income-generating behaviour for each city. We then analysed factors and city interactions contributing to engagement in the respective criminal activities, including drug-use patterns, socio-economic characteristics, and other illegal activities. With this approach we explored city-specific patterns of crime prediction; thus we identified local drug-crime associations. The study sample was recruited by outreach and snowball methods and was assessed by standardized study protocols. Findings revealed substantial differences among the cities regarding both the extent and frequency of illegal activities. In regard to local differences, multiple logistic regression models revealed that crack use was strongly associated with property crime in Toronto, while cocaine use was strongly related with sex work in Montreal and Quebec City. This evidence points to local dynamics of drug cultures that are related to specific criminal activities. Implications for further research and intervention efforts are discussed.

McKeganey N. Street prostitution in Scotland: The views of working women. Drugs: Education, Prevention and Policy 13(2): 151-166, 2006. (25 refs.)

At the present time in Europe a range of countries are considering their prostitution laws and looking at whether these should be updated in a number of ways including the possible provision of prostitute tolerance zones. While this is an issue that is subject to heated political debate, and considerable divergence within Europe, it is not one where there has been much research evidence to date. One reason for this is the concentration in much prostitution research on sexual rather than work-related matters. This paper considers the issue of prostitute tolerance zones within the context of an ethnography of street prostitution in Scotland. In particular, the paper describes street-working women's views of their work, their reasons for working, their views as to the impact of their work on their lives, and whether it would be beneficial to provide tolerance zones to enable them to work without fear of prosecution.

Meade CS; Graff FS; Griffin ML; Weiss RD. HIV risk behavior among patients with co-occurring bipolar and substance use disorders: Associations with mania and drug abuse. Drug and Alcohol Dependence 92(1/3): 296-300, 2008. (40 refs.)

Background: Bipolar and substance use disorders frequently co-occur, and both are associated with impulsivity, impaired judgment, and risk-taking. Objectives: This study aimed to: (1) describe the rates of HIV sexual and drug risk behaviors among patients with co-occurring bipolar and substance use disorders, (2) test whether acute mania, psychiatric severity, and drug severity independently predict HIV risk, and (3) examine the relationship between specific substance dependencies and sexual risk behaviors. Method: Participants (N = 101) were assessed for psychiatric diagnoses, substance abuse, and HIV risk behavior using structured clinical interviews and self-report questionnaires. Results: The majority (75%) were sexually active in the past 6 months and reported high rates of sexual risk behaviors, including unprotected intercourse (69%), multiple partners (39%), sex with prostitutes (24%, men only), and sex trading (10%). In a multivariate linear regression model, recent manic episode, lower psychiatric severity, and greater drug severity were independent predictors of total HIV risk. Cocaine dependence was associated with increased risk of sex trading. Conclusions: Results underscore the importance of HIV prevention for this population.

Meade CS; Sikkema KJ. Psychiatric and psychosocial correlates of sexual risk behavior among adults with severe mental illness. Community Mental Health Journal 43(2): 153-169, 2007. (58 refs.)

Persons with severe mental illness (SMI) are disproportionately affected by HIV/AIDS. This study examined multivariate correlates of sexual risk among 152 adults with SMI receiving outpatient psychiatric treatment. Structured interviews assessed psychiatric, psychosocial, and behavioral risk factors. The majority was sexually active (65%), and many reported unprotected intercourse (73%), multiple partners (45%), and sex trading (21%) in the past year. Logistic regression models found that sexual behaviors were differentially associated with non-psychotic disorder, psychiatric symptoms, substance abuse, childhood sexual abuse, romantic partnership, and social support (all ps < .05). Findings underscore the need for targeted HIV prevention interventions that address psychiatric and psychosocial risk factors.

Mehrabadi A; Craib KJP; Patterson K; Adam W; Moniruzzaman A; Ward-Burkitt B et al. The Cedar Project: A comparison of HIV-related vulnerabilities amongst young aboriginal women surviving drug use and sex work in two Canadian cities. International Journal of Drug Policy 19(2): 159-168, 2008. (58 refs.)

Background: In Canada, Aboriginal women and youth continue to be overrepresented amongst new cases of HIV, and are considered at increased risk for sex and drug-related harm. Young women involved in sex work are particularly vulnerable. The purpose of this study is to determine HIV-related vulnerabilities associated with sex work amongst young Aboriginal women in two Canadian cities. Methods: This study is based on a community-based cohort of Aboriginal young people (status and non-status First Nations, Inuit and Metis) between the ages of 14 and 30 who used injection or non-injection illegal drugs (street drugs) in the previous month. Participants lived in Vancouver, Canada, or Prince George, a remote, northern Canadian city. Between October 2003 and July 2005, 543 participants were recruited by word of mouth, posters, and street outreach. A baseline questionnaire was administered by Aboriginal interviewers, and trained nurses drew blood samples for HIV and HCV antibodies and provided pre- and post-test counselling. This study included 262 Young women who participated at baseline. Analyses were conducted to compare socio-demographics, drug use patterns, injection practices, sexual experiences, and HIV and HCV prevalence between young women who reported being involved in sex work in the last 6 months (n = 154) versus young women who did not (n = 108). Logistic regression was used to identify factors independently associated with recent sex work involvement. Results: Both sexual violence and drug using patterns were found to be markedly different for women having recently been involved in sex work. Multivariate analysis revealed daily injection of cocaine (AOR = 4.4; 95% CI: 1.9, 10.1 and smoking crack (AOR = 2.9; 95% CI: 1.6, 5.2) in the previous 6 months, and lifetime sexual abuse (AOR = 2.5; 95% CI: 1.4, 4.4) to be independently associated with sex work. Interpretation: Harm reduction and treatment programs that address historical and lifetime trauma amongst Aboriginal people and prioritize emotional and physical safety for young Aboriginal women involved in sex work are required.

Needle R; Kroeger K; Belani H; Achrekar A; Parry CD; Dewing S. Sex, drugs, and HIV: Rapid assessment of HIV risk behaviors among street-based drug using sex workers in Durban, South Africa. Social Science & Medicine 67(9): 1447-1455, 2008. (46 refs.)

South Africa is experiencing significant changes in patterns of illicit drug Use, including increasing injection and non-injection drug use, and the use of drugs by persons engaged in sex work, both of which could further expand the HIV/AIDS epidemic. In 2005, a rapid ethnographic assessment was conducted in Durban, South Africa. to learn more about patterns of drug use and HIV risk behaviors among drug-using, street-based sex workers. Field teams recruited 52 Current injection and non-injection drug users for key informant interviews and focus groups, and they conducted mapping and observation in identified high-risk neighborhoods. Key informants were offered free, Voluntary counseling and HIV rapid testing. The results of the assessment indicate that in this population. drugs play an organizing role in patterns of daily activities, with sex work closely linked to the buying, selling, and using of drugs. Participants reported using Multiple drugs including crack cocaine, heroin, Ecstasy and Mandrax, and their choices were based on their expectations about the functional role and behavioral and pharmacological properties of the drugs. The organization of sex work and patterns of drug use differ by gender, with males exercising more control over daily routines and drug and sexual transactions than females. Activities of female sex workers are subject to considerable control by individual pimps, many of whom also function as landlords and drug dealers. A strong hold over the overapping economics of drugs and sex work by a few individuals extends to control of the physical and social settings in which sex is exchanged and drugs are sold and used as well as the terms under which sex work is carried out. The potential for accelerated HIV spread is considerable given the evidence of overlapping drug-using and sexual risk behaviors and the mixing patterns across drug and Sexual risk networks.

Ngo AD; Mccurdy SA; Ross MW; Markham C; Ratliff EA; Pham HTB. The lives of female sex workers in Vietnam: Findings from a qualitative study. Culture, Health and Sexuality 9(6): 555-570, 2007. (19 refs.)

To facilitate better understanding of the environment and power structures in which sex work in Vietnam takes place, this study examined the sex workers' social and economic lives, their working environment, social relationships and presentation of self in everyday social contacts and interactions. Thirty in-depth interviews and 14 focus groups were conducted with street-based and venue-based sex workers in the cities of Da Nang and Hanoi. Results show that sex workers live and work within a complex system involving multiple relationships. In any of these relations, women have limited power to protect their personal security and secure payment for services rendered. Economic hardship is a major problem facing street-level sex workers and contributes to unsafe sexual practices. Venue-based sex workers worry less about economic hardships as such, but frequently incur gambling debts. Women also reported incidents of abuse and experiences of social stigma. Although many women exhibited a strong desire to leave sex work, they found themselves trapped in the sex industry by the lack of alternative employment options. This study provides evidence that socio-psychological factors must be addressed along with risky behaviours to promote women's well-being and social integration.

Ohlund LS; Gronbladh L. Patterns of deviant career in the history of female methadone clients: an exploratory study. International Journal of Social Welfare 18(1): 95-101, 2009. (27 refs.)

The aim of this article is to describe the drug career of 71 severely opioid-dependent women who had a history of selling sex and were enrolled in methadone maintenance treatment. Data were collected through semi-structured interviews, from medical records and reports from social agencies and correctional institutions. The sequential pattern could be described in the following order: initiation of the first drug of abuse, opioid onset, initiation of selling sex, first non-methadone treatment episode, first sentence and, finally, methadone maintenance treatment. There were significant age differences and correlations between most of the events. The main correlation (r = 0.70) was the one between debut of opioid use and selling sex, which was confirmed in a stepwise multiple regression analysis. In addition, a history of running away from home advanced the age at which the women started selling sex for those with an onset of opioid use at an older age than the mean of 18.4 years.

Olley BO. Social and health behaviors in youth of the streets of Ibadan, Nigeria. Child Abuse and Neglect 30(3): 271-282, 2006. (31 refs.)

Objectives: This study documents the extent and impact of perceived patterns of behavior in a sample of youths of the streets of Ibadan, Nigeria, with the purpose of implementing a Life Skills Educational (LSE) intervention. Method: The study uses both qualitative and quantitative methods of data collection. Qualitatively, two Focus Group Discussions (FGD) and two in-depth interviews (IDI) with 20 boys and 2 community leaders were conducted on separate occasions for the purpose of eliciting commonly exhibited behaviors and patterns of street youth. Quantitatively, 169 youths (89.3% male) were consecutively interviewed from five subcultural areas in Ibadan, Nigeria. Street youths were accessed through a snowballing technique made possible by "Area boys" (AB, adults, who serve as a symbol of authority for street children). Results: The mean age of participants was 18.4 years. The majority was on the street for financial reasons, had been on the street for more than 1 year, and had not completed their primary schooling. While youths of the street were economically viable, 69% had a history of alcohol abuse, 14% of drug abuse, and 24% operated as drug couriers; 46% reported school refusal, 27% school suspension, and 47% school truancy. Forty-nine percent admitted to being sex workers and 11% had been raped and were, therefore, at risk of contacting sexually transmitted diseases (STD). One-third of youths had been arrested for various offenses, including street fighting and drug use. While females were in the minority, they were more likely to engage in antisocial behaviors compared with boys. Conclusions: Although many youths of the street display antisocial behaviors, they also are an economically viable group. Some of their antisocial behaviors may have been exhibited within the context of economic survival. Implementing a life skill program to address these antisocial behaviors may help to increase the well being of street youths in developing countries in Africa.

Patterson TL; Semple SJ; Fraga M; Bucardo J; De La Torre A; Salazar J. Comparison of sexual and drug use behaviors between female sex workers in Tijuana and Ciudad Juarez, Mexico. Substance Use & Misuse 41(10-12): 1535-1549, 2006. (28 refs.)

Female sex workers (FSWs) have been documented to have high rates of sexually transmitted diseases and HIV in many parts of the world. However, little work has been done to characterize the prevalence of these infections along the U.S.-Mexican border, where sexual tourism and culturally sanctioned sex work among nationals is widespread. The objective of this study was to compare differences in background characteristics, HIV risk behaviors, drug use, and sexually transmitted infection/HIV prevalence between FSWs who participated in a behavioral risk intervention in two U.S.-Mexican border cities. Baseline data were collected from March 2004 through September 2005. Data from 295 FSWs were compared between Tijuana and Ciudad (Cd.) Juarez. Among 155 FSWs in Tijuana and 140 in Cd. Juarez, HIV seroprevalence was 4.8% and 4.9%, respectively. FSWs in Cd. Juarez were more likely to test positive for active syphilis (31.3%) compared with Tijuana (11.8%) but did not differ in terms of the prevalence of gonorrhea and chlamydia. FSWs in both sites reported high levels of unprotected sex and use of drugs; however, FSWs in Cd. Juarez were more likely than those in Tijuana to ever have injected drugs (75% vs. 25%, p < .001). Heroin and cocaine use and injection drug use were significantly more common in Cd. Juarez, whereas methamphetamine use was more common in Tijuana. Injection of vitamins was common in both cities. Logistic regression analyses suggested that being younger, working in Cd. Juarez, and using heroin or cocaine were independently associated with active syphilis infection. In Tijuana, methamphetamine use was strongly associated with active syphilis infection. These preliminary results suggest that risk profiles for HIV/sexually transmitted infection among FSWs in these two Mexico-U.S. border cities differ, suggesting a need to tailor interventions to the specific needs in each city.

Patterson TL; Semple SJ; Staines H; Lozada R; Orozovich P; Bucardo J et al. Prevalence and correlates of HIV infection among female sex workers in 2 Mexico-US border cities. Journal of Infectious Diseases 197(5): 728-732, 2008. (15 refs.)

Background. We examined human immunodeficiency virus (HIV) prevalence and correlates among female sex workers (FSWs) in Tijuana and Ciudad Juarez, 2 large cities on the Mexico-US border. Methods. FSWs aged >= 18 years underwent interviews and testing for HIV, syphilis, gonorrhea, and chlamydia. Logistic regression identified factors associated with HIV infection. Results. In 924 FSWs, the prevalence of HIV, gonorrhea, chlamydia, and syphilis titers >= 1:8 was 6%, 6.4%, 13%, and 14.2%, respectively. Factors independently associated with HIV were the injection of cocaine (odds ratio [OR], 2.96); the smoking, snorting, or inhalation of methamphetamine (OR, 3.32); and syphilis titers >= 1:8 (OR, 4.16). Conclusions. Culturally appropriate interventions are needed to identify and treat ulcerative sexually transmitted infections and reduce HIV risks associated with stimulants among FSWs in the Mexico-US border region.

Peters RJ; Williams M; Ross MW; Atkinson J; Yacoubian GS. Codeine cough syrup use among African-American crack cocaine users. Journal of Psychoactive Drugs 39(1): 97-102, 2007. (17 refs.)

While studies show evidence of a clear problem with the prevalence of crack cocaine and codeine cough syrup use separately, the relationship between these substances of abuse and concurrent polydrug use is unknown. In an attempt to ascertain beyond anecdotal evidence, the authors carried out a cross-sectional study among 482 African-American crack users to investigate the differences between those who were concurrently codeine cough syrup users and those who were not codeine cough syrup users in Houston, Texas. Logistic regression indicated that codeine use was significantly associated with lower participant age and lower education; codeine cough syrup users were significantly more likely than nonusers to not have a main sexual partner. In addition, codeine users had significantly higher odds of ever trading sex for money, marijuana use, and fry use. These findings are important in determining the "cultural novelties" relative to crack and codeine use among younger African Americans.

Reback CJ; Kamien JB; Amass L. Characteristics and HIV risk behaviors of homeless, substance-using men who have sex with men. Addictive Behaviors 32(3): 647-654, 2007. (22 refs.)

During January and February 2003, 20 non-treatment seeking homeless, substance-using MSM accessing community-based prevention services in West Hollywood, California were assessed to characterize demographics, addiction and psychiatric severity using structured and semi-structured clinical interviews, and high-risk drug and sexual behavior. Participants averaged 37 years old, were mostly Caucasian/white (65%) and most identified as bisexual (58%) or gay (37%). Self-reported HIV scroprevalence was 21%. Most (53%) exchanged sex for money and/or drugs within the previous 30 days. All were diagnosed with current DSM-IV Substance Dependence Disorders, primarily alcohol (62%), amphetamine (57%), cocaine (52%), and marijuana (38%). Participants reported many (35.7) positive psychiatric symptoms on the Brief Symptom Inventory and averaged moderate Beck Depression Inventory scores (19.1). Most (75%) met criteria for Mood Disorder, 33% for Major Depressive Disorder, 43% for Antisocial Personality Disorder and averaged low (48.5) Global Assessment of Functioning scores. While the small convenience sample limits generalizability of the findings, these data provide an opportunity to gain insight into this at-risk population and, thereby, assess appropriate intervention strategies.

Risser JMH; Timpson SC; McCurdy SA; Ross MW; Williams ML. Psychological correlates of trading sex for money among African American crack cocaine smokers. American Journal of Drug and Alcohol Abuse 32(4): 645-653, 2006. (14 refs.)

This article compares demographic characteristics, sexual practices, and psychosocial status among 193 African American female crack cocaine users who currently, previously, or never traded sex for money. Current traders were less likely to have a main sexual partner, more likely to have a casual sexual partner, and more likely to smoke larger quantities of crack. There was a significant trend towards current traders reporting lower self-esteem, greater depression and anxiety, poorer decision-making confidence, more hostility, less social conformity, greater risk taking behaviors, and more problems growing up, compared to previous and never traders. These differences suggest that interventions should address self-esteem, risk-taking practices, depression and anxiety as well as other psychosocial factors.

Roxburgh A; Degenhardt L; Copeland J; Larance B. Drug dependence and associated risks among female street-based sex workers in the greater Sydney area, Australia. Substance Use & Misuse 43(8/9): 1202-1217, 2008. (44 refs.)

Background: This study examines drug use and dependence and associated risks among female street-based sex workers. Methods: Cross-sectional data collected from 72 women between April and August 2005 in Sydney, Australia, via face-to-face interviews. Sample: The average age was 34 years. Results: Risk factors associated with developing problematic drug use were prevalent. Child sexual abuse, leaving home before the age of 16, and exposure to multiple traumas was common. Depression and posttraumatic stress disorder were also prevalent. A substantial minority reported cocaine dependence which was associated with engaging in sex and injecting risk behaviors. Conclusions: More targeted interventions for this group are needed. Research on the value of extending existing outreach services to further reduce the harms associated with sex work and drug use is indicated. The study's limitations are noted.

Sena AC; Muth SQ; Heffelfinger JD; O'Dowd JO; Foust E; Leone P. Factors and the sociosexual network associated with a syphilis outbreak in rural North Carolina. Sexually Transmitted Diseases 34(5): 280-287, 2007. (44 refs.)

Objective: An investigation was conducted to determine factors associated with a syphilis outbreak in a rural North Carolina county. Study Design: A retrospective chart review was performed on 61 primary (PS), secondary (SS), and early latent (ELS) syphilis case patients reported in Columbus County between January 2001 and February 2002. Sociosexual network analysis was conducted using electronic contact tracing information. Results: We identified 20 PS, 25 SS, and 16 ELS case patients who were predominantly black. Seventy-two percent had reported >= 1 sexual partner with early syphilis, 51 % used crack cocaine and/or had sex with a crack-using partner, and 31 % exchanged sex for drugs or money. The sexual network exhibited predominantly linear connections between case patients and sexual partners. Adding social connections to the network further demonstrated dense cyclic interactions characteristic of core groups. Conclusions: The syphilis outbreak in this rural community was associated with crack cocaine and exchange of sex for drugs in a densely interconnected sociosexual network.

Shannon K; Bright V; Gibson K; Tyndall MW; Maka Project Partnership. Sexual and drug-related vulnerabilities for HIV infection among women engaged in survival sex work in Vancouver, Canada. Canadian Journal of Public Health 95(6): 465-469, 2007. (37 refs.)

Background: Women engaged in survival sex work face multiple sexual and drug-related harms that directly enhance their vulnerability to HIV infection. Although research on injection-drug-using women has explored predictors of sex work and HIV infection, little information currently exists on the complex vulnerabilities to HIV transmission faced by survival sex workers in this setting. This analysis aimed to determine HIV prevalence among women engaged in survival sex work, and explore sexual and drug-related vulnerabilities associated with baseline infection. Methods: Descriptive and univariate analysis were used to explore associations with baseline HIV infection. Variables found to be associated with baseline infection at the univariate level (p < 0.05) were entered into a fixed logistic regression model, adjusted for age. Results: Of a total of 198 women, baseline HIV prevalence was 26%. In multivariate logistic regression, baseline HIV infection was associated with early age of sex work initiation (< 18 years) (aOR=1.8, 95% CI: 1.3-2.2), Aboriginal ethnicity (aOR=2.1, 95% CI: 1.4-3.8), daily cocaine injection (aOR=2.2, 95% CI: 1.3-3.5), intensive, daily crack smoking (aOR=2.7, 95% CI: 2.1-3.9), and unprotected sex with an intimate partner (aOR=2.8, 95% CI: 1.9-3.6). Interpretation: Innovative and evidence-based strategies are urgently needed that address the sexual and drug-related vulnerabilities to HIV infection among survival sex workers and in particular, interventions targeting the precursors to early initiation into sex work.

Shannon K; Rusch M; Shoveller J; Alexson D; Gibson K; Tyndall MW. Mapping violence and policing as an environmental-structural barrier to health service and syringe availability among substance-using women in street-level sex work. International Journal of Drug Policy 19(2): 140-147, 2008. (60 refs.)

Background: Within street-based sex work and substance-using populations, there is growing evidence to support the role of place, both physical setting and social meanings attached to place, in mediating the effectiveness and reach of health and harm reduction services. Methods: Social mapping was used to explore how health service and syringe availability maybe impacted at the geographic level by avoidance of physical settings due to violence and policing among women in street-level sex work. Through a community-based research partnership and extensive peer-led outreach over a 6-month period, women were invited to participate in interview-questionnaires and mapping of their community, working conditions, and access to resources. Results were compiled used ArcGIS software and GIS street maps. In secondary analysis, logistic regression was used to model the geographic association (using likelihood ratio and significance at p < 0.05) and stratified models were run to assess differential patterns of avoidance based on age, ethnicity and drug use. Results: The findings reveal a significant geographic relationship between a heavily concentrated core area of health and syringe availability and avoidance of physical settings due to violence and policing by 198 women in street-level sex work in Vancouver, Canada. Of particular concern, this correlation is significantly elevated among younger and Aboriginal women, active injection drug users, and daily crack cocaine smokers, suggesting significant environmental-structural barriers to interventions among these vulnerable populations. Conclusions: The resultant displacement of sex work to primarily industrial settings and side streets pushes women further from health and social supports and reduces access to safer injection and drug use paraphernalia. This study offers important evidence for environmental-structural level prevention and safer environment interventions, supported by legal reforms, that facilitate safer sex work environments, including spatial. programming, peer-based prevention, outreach and mobile resources, and peer-supervised safer sex work settings.

Smit J; Myer L; Middelkoop K; Seedat S; Wood R; Bekker LG et al. Mental health and sexual risk behaviours in a South African township: A community-based cross-sectional study. Public Health 120(6): 534-542, 2006. (44 refs.)

Objectives: Despite the high prevalence of both mental illness and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in developing countries, there are few data on the association between different forms of mental illness and sexual risk behaviours in resource-poor settings. The objective of this study was to examine the association between mental illness and HIV risk behaviours in a South African township. Study design: A cross-sectional, study was performed among 645 individuals living in households selected at random. Methods: A self-administered translated questionnaire investigated sexual risk behaviours [including sexual partners, condom use, casual sexual contacts, and sex in exchange for money, drugs or a place to stay (transactional sex)], depression (measured using the Center for Epidemiological Studies Depression Scale), alcohol abuse (from the Alcohol Use Disorders Identification Test), and post-traumatic stress disorder (based on the Life Event Checklist). Results: Of the 645 individuals who completed the survey, 33% reported depression, 17% reported alcohol abuse, and 15% reported post-traumatic stress disorder. After adjusting for demographic characteristics, the presence of any of these three conditions was strongly associated with experiences of forced sex [adjusted odds ratio (AOR) 2.53; 95% confidence intervals (CI) 1.60-4.02], transactional sex (AOR 2.88; 95% CI 1.29-6.48) and increased condom use (AOR 2.07; 95% CI 1.32-3.25). Conclusions: These findings emphasize the substantial burden of mental illness in this setting, and its association with forced and transactional sex. The temporal nature of these associations is not always clear from this cross-sectionat study, and additional prospective research is required. Public health interventions are needed to address the dual burden of HIV/AIDS and mental illness in this and similar settings.

Spittal PM; Hogg RS; Li K; Craib KJ; Recsky M; Johnston C. Drastic elevations in mortality among female injection drug users in a Canadian setting. AIDS Care 18(2): 101-108, 2006. (39 refs.)

The health and social conditions of women living in Vancouver's Downtown Eastside has recently been the focus of substantial international attention. Since few studies have examined rates and correlates of death among addicted women in Canada, we have characterized patterns of mortality among female injection drug users (IDUs) in Vancouver. The Vancouver Injection Drug Users Study (VIDUS) is a prospective open cohort study of IDUs. The analyses presented here, were restricted to women enrolled between May 1996 and May 2002 and who were aged 14 years or older. We estimated cumulative mortality rates using Kaplan-Meier methods and Cox regression was used to calculate univariate and adjusted relative hazards. Between May 1996 and May 2002, 520 female IDUs have been recruited from the Vancouver area among whom 68 died during the study period. Elevated rates of mortality were observed among those who reported, baseline sex-trade involvement, those with HIV-infection at baseline, and those who lived in unstable housing at baseline (all log-rank: p < 0.05). In adjusted analyses, HIV infection (RH = 3.09 [95% CI: 1.86 - 5.11]; p <0.001), unstable housing (RH = 1.74 [ 95% CI: 1.10 = 2.86]; p = 0.029) and sex-trade involvement (RH = 1.82 [95% CI: 0.95 - 3.45]; p = 0.071) were associated with the time to death. When the number of observed deaths was compared to the number of expected deaths based on the general female population of British Columbia using indirect standardization, the rate of death among female IDUs was elevated by a factor of 47.3 (95% CI: 36.1 = 58.5). In Vancouver, female IDUs have rates of mortality almost 50 times that of the province's female population. Our findings are consistent with a growing number of reports from other settings internationally, and demonstrate the need for an appropriate evidence-based strategy to address the health and social needs of addicted women.

Stoltz JAM; Shannon K; Kerr T; Zhang R; Montaner JS; Wood E. Associations between childhood maltreatment and sex work in a cohort of drug-using youth. Social Science & Medicine 65(6): 1214-1221, 2007. (32 refs.)

Although research has examined the impacts of childhood maltreatment among various marginalized populations, few studies have explored the relationship between child abuse and subsequent involvement in sex work among drug-using street-involved youth. In the present study, the relationships between the level of childhood maltreatment and involvement in sex work were examined using the Childhood Trauma Questionnaire (CTQ) as part of an extensive interview protocol in an ongoing prospective cohort study of street-involved youth in Vancouver, Canada. Between September 2005 and June 2006, 361 youth were recruited using extensive outreach methods and snowball sampling. The prevalence rates for abuse in the sample were 73% for physical abuse; 32.4% for sexual abuse; 86.8% for emotional abuse; 84.5% for physical neglect; and 93% for emotional neglect. Univariate and logistic regression analyses demonstrated that not only was sexual abuse independently associated with sex work, but emotional abuse was as well. These findings have implications for early intervention efforts aimed at vulnerable, high-risk youth populations as well as intervention strategies for active sex trade workers.

Taylor A; Hutchinson S; Gilchrist G; Cameron S; Carr S; Goldberg D. Prevalence and determinants of hepatitis C virus infection among female drug injecting sex workers in Glasgow. Harm Reduction Journal 5(1): e-article 11, 2008. (29 refs.)

Background: Few studies of the prevalence of hepatitis C virus (HCV) infection have focussed on women who work as street sex workers to finance their drug use. Methods: The investigators report the survey findings of such a population in Glasgow. All women attending the health and social care drop-in centre, situated in Glasgow's "Red Light Area", during a four-week period in 1999 were invited to participate in a survey involving the provision of a saliva sample for anonymous HCV testing and the self-completion of a questionnaire seeking demographic, sexual and injecting practice data. Results: Of the 223 women who attended, 51% agreed to participate. Of the 98 women who provided a sufficient saliva sample, 64% (95% CI: 54%�74%) tested HCV antibody positive; 98% of those who tested positive had ever injected drugs. Adjusting for the 85% sensitivity of the saliva test, the HCV antibody prevalence among IDU sex workers sampled was 81%; a rate which is considerably higher than those recorded, contemporaneously, among Glasgow IDUs generally. Two factors were independently associated with HCV antibody positivity in saliva: ever shared needles and syringes (adjusted OR 5.7, 95% CI 2�16) and number of times imprisoned (adjusted OR 7.3, 95% CI 1.4�39, for more than five times compared to zero times). Conclusion: Women who engage in street sex work to finance their drug habit are a particularly desperate, chaotic and vulnerable population. This study demonstrates that their HCV infection risk may be greater than that for other IDUs. Those responsible for designing interventions to prevent HCV infection among IDUs should consider the special needs of this group.

Timpson SC; Ross MW; Williams ML; Atkinson J. Characteristics, drug use, and sex partners of a sample of male sex workers. American Journal of Drug and Alcohol Abuse 33(1): 63-69, 2007. (12 refs.)

Some male sex workers (MSWs) are also engaging in a significant amount of illicit drug use and other high risk behavior. The purpose of this study was to examine demographic characteristics, HIV risk behaviors, and sex partner characteristics in a sample of MSW. Data were collected from 179 men who were trading sex for money in Houston, TX. In the past 30 days they reported an average of 56 male partners and 5 female partners. Of the 179 men, 152 had been tested for HIV and knew their status. Twenty-six percent of those tested had tested positive.

Tyler KA; Johnson KA. Trading sex: Voluntary or coerced? The experiences of homeless youth. Journal of Sex Research 43(3): 208-216, 2006. (27 refs.)

This study examined the circumstances surrounding a homeless youth's "decision" to trade sex for food, money, shelter, or drugs. Forty homeless youth in 4 Midwestern states participated in individual, in-depth qualitative interviews. Interviewers recruited youth through both service agencies and street outreach. The findings revealed that approximately one third of the sample had some experience with trading sex, whether it was in the form of having traded sex, having been propositioned to trade sex but having refused, or having friends or acquaintances that had traded sex. Young people's reports indicated that they had traded sex for things they deemed necessary in order to survive (i.e., food, shelter, money, or drugs) and that they did not want to trade sex, but did so because they were desperate and lacked alternatives. Additionally, others were coerced, manipulated, or forced to do so, indicating that the decision to trade sex is not always voluntary. We discuss the implications of these findings in terms of cumulative effects on youths' later development. Directions for future research among this population are also discussed.

Vaddiparti K; Bogetto J; Callahan C; Abdallah AB; Spitznagel EL; Cottler LB. The effects of childhood trauma on sex trading in substance using women. Archives of Sexual Behavior 35(4): 451-459, 2006. (63 refs.)

This article presents a model developed to understand the relationship between childhood victimization, perpetration of violence, and later cocaine dependence and adult sex trading among drug using women. A cohort of heavy drinking and drug using women (N=594) recruited for two on-going community based HIV prevention studies in St. Louis City was analyzed to evaluate this association using path analysis. The women were stratified into two groups: sex traders and non-sex traders. Sex traders were more likely than non-sex traders to report being forced to kiss or touch someone in a sexual way before age 15 (35% vs. 22%), being kissed or touched in a sexual way by others when they did not want to be (42% vs. 31%), and being forced to have sexual intercourse (30% vs. 21%). Sex traders were more likely than non-sex traders to use a weapon or threaten someone with a weapon (29% vs. 18%) and physically hurt others on purpose before age 15 (9% vs. 5%). Path analysis confirmed that childhood victimization had a significant and direct association with both adult cocaine dependence and sex trading. However, the association between childhood perpetration and adult sex trading was mediated by cocaine dependence. This analysis concludes that childhood victimization was the strongest predictor of cocaine dependence and sex trading in adulthood.

Weiser SD; Dilworth SE; Neilands TB; Cohen J; Bangsberg DR; Riley ED. Gender-specific correlates of sex trade among homeless and marginally housed individuals in San Francisco. Journal of Urban Health 83(4): 736-740, 2006. (18 refs.)

Objective: Sex exchange is a well-established risk factor for HIV infection. Little is known about how correlates of sex trade differ by biologic sex and whether length of homelessness is associated with sex trade. We conducted a cross-sectional study among a sample of 1,148 homeless and marginally housed individuals in San Francisco to assess correlates of exchanging sex for money or drugs. Key independent variables included length of homelessness; use of crack, heroin or methamphetamine; HIV status; and sexual orientation. Analyses were restricted by biologic sex. In total, 39% of women and 30% of men reported a lifetime history of sex exchange. Methamphetamine use and greater length of homelessness were positively associated with a history of sex trade among women while heroin use, recent mental health treatment, and homosexual or bisexual orientation were significantly associated with sex trade for men. Crack use was correlated with sex trade for both genders. Correlates of sex trade differ significantly according to biologic sex, and these differences should be considered in the design of effective HIV prevention programs. Our findings highlight the critical need to develop long-term services to improve housing status for homeless women, mental health services for homeless men, and drug treatment services for homeless adults involved in sex work.

Wood E; Schachar J; Li K; Stoltz JA; Shannon K; Miller C et al. Sex trade involvement is associated with elevated HIV incidence among injection drug users in Vancouver. Addiction Research & Theory 15(3): 321-325, 2007. (11 refs.)

Background: Canada's prostitution laws are under scrutiny, and there has been growing debate about the optimal strategies for reducing the harms associated with prostitution. Methods: We evaluated whether sex trade involvement was associated with elevated HIV incidence in a cohort of injection drug users. HIV incidence rates were calculated using Kaplan-Meier methods and Cox proportional hazards regression. Results: At 48 months after enrolment, the rate of HIV was 11.7% among those who did not report baseline sex trade involvement compared to 16.7% among those who did ( p = 0.049). The elevated HIV infection rate associated with sex trade involvement was also observed in a Cox model that considered sex trade involvement as a time-updated covariate ( relative hazard 1.51 [ 95% CI: 1.02-2.25]). Interpretation: These findings should be useful to those currently considering the optimal legal framework for addressing the community and health related harms associated with prostitution in Canada.