The goal of this report was to assess current prevention strategies that attempt to reduce HIV prevalence among female sex workers (FSW) in Honduras. This analysis was based on the difference between behavioral change and structural approaches; that is, while behavioral change theories are based on risk reduction through promoting individuals’ change, the structural approach addresses the factors in the environment that make individuals vulnerable to HIV. In order to analyze prevention strategies in Honduras, I carried out an analysis of the structural conditions at the country level and, at the sex workers population level. The structural factors that make Honduras a country vulnerable to HIV are political instability, migrations, poverty and socio-economic conditions, and gender inequality. As a consequence of those macro-environmental conditions, sex workers face the following micro-environmental factors that increase their vulnerability to HIV: violence and male domination; large families and single parenthood; low income and poor education; and public policies against sex work, such as police abuse and closure of brothels. This report is based on an analysis of the Sonagachi Project in India, 100% Condom Use in Thailand, and the intervention in the Dominican Republic, programs that successfully address structural conditions and decrease women’s vulnerability to HIV. This report showed that in Honduras, the prevention strategies currently implemented are limited because they are based on behavioral change theories, failing to address environmental barriers that increase vulnerability to HIV among FSW. I give some specific recommendations about how to improve prevention strategies in this country reducing women’s vulnerability by addressing the structural factors they face. / text

archives@tulane.edu / Background: Although engagement and retention in HIV care and treatment is a critical issue across populations, it is of particular importance among female sex workers (FSWs) as they are disproportionately affected by HIV due to high rates of sexual risk behaviors and large sexual networks. Drug use is one of the most consistent and salient barriers to successful engagement in HIV care and treatment. For many FSWs, drug use is a common part of their daily lives. While individual-level factors likely explain a substantial portion of variability in drug use behavior, evidence demonstrates that differences in health behaviors and outcomes cannot be fully explained by individual-level factors alone. Previous explorations of drug-related harms have found that neighborhoods and social networks are two important environments that impact substance use behavior and associated health outcomes; yet, there has been little research on the interacting effects of networks and neighborhoods on drug use among FSWs living with HIV. Objective: Using innovative geospatial and social network methods, the purpose of this pilot study was 1) to characterize the physical and social risk environments of a small cohort of FSWs living with HIV in the Dominican Republic (DR), and 2) to examine the association between their daily activity patterns and social relationships on illicit drug use. Methods: A micro-longitudinal observational study design was employed. Data collection activities included: (1) semi-structured questionnaire, (2) daily activity space mapping, (3) daily behavior diary, (4) social network survey; and (5) secondary data. Statistical analysis included spatial mapping, social network analysis, univariate and bivariate means analysis, generalized estimating equations (GEE) with repeated measures, interaction and effect modification. Results: Findings suggest that social networks, specifically drug networks and sex and drug networks, and daily activity path and location-based risk exposures are independently associated with risk of daily drug use, and that network risk profile modifies the association between location-based risk exposure and daily drug use. Results from Paper 1 show that participants exposed to a higher number of risk outlets within 200 meters of their weekly activity paths weighted by time exposed had an increased risk of daily drug use (RRadj: 2.83, 95%CI: 1.14, 7.03). Similarly, per unit increase in risk outlet exposure within 200 meters of sex work locations was associated with an increased risk of daily drug use (RRadj: 1.03, 95%CI: 1.00, 1.05). Paper 2 results indicate that participants with more drug using members and sexual partners who were also drug users in their social networks were 8.89 (95%CI: 2.62, 30.33) and 6.08 (95 CI%: 1.20, 30.92) times more likely to use drugs compared to those with fewer drug using members and sexual partners who used drugs. Finally, paper 3 results suggest that the joint effects of networks and activity space are greater than individual effects alone and that drug network and sex and drug network modify the association between sex work location risk environment exposure and daily drug use. No differences were detected among individuals with large drug and sex and drug networks, but among individuals with small drug and sex and drug networks, per unit increase in risk outlet exposure within 200-meters of sex work locations was associated with an increased risk of daily drug use. Conclusions: This research provides significant information on the overlapping and diverging characteristics of the social factors and physical spaces that shape drug use in the broader context of sex work, HIV, and vulnerability in a low-and middle-income country (LMIC) setting. Findings may be used to inform integrated care interventions that are geographically targeted and address the social processes and structures that influence drug harms and HIV treatment in a highly stigmatized and vulnerable population. / 1 / Erica Ann Felker-Kantor

Empirical research exploring the physical health of female sex workers and their risk of contracting and spreading sexually transmitted infections has been over-researched. There have also been numerous studies conducted on sex workers highlighting physical violence, rape and stigmatisation. There is, however, little empirical evidence exploring the personal lives of female sex workers especially with regards to their husbands and the impact that their wives choice in career may have on the constructions of their masculinity. Accordingly, this research aimed to qualitatively explore and understand, via a comparative in-depth case study with two married couples, how the masculinity of a man, who is married to a high-income female sex worker, may be constructed, as compared to a man who is married to a woman who is not involved in the sex industry. It was found, after conducting semi-structured, one-on-one interviews with each of the married couples, that the males constructed their masculinity in relation to their wives occupation, their income in comparison to that of their wives, their wives sexuality, familial and historical notions regarding infidelity, certainty regarding paternity, and issues of romantic jealousy (both sexual and emotional). It was found that, at least for the man from a non-traditional marriage (where his wife was a FSW), by constructing and reconstructing one’s masculinity (when faced with perceived threats regarding one's sense of masculinity), one is able to reclaim the typical patriarchal characteristics. This is done by strongly conforming (and potentially overcompensating by doing so) to traditional masculine and social patriarchal standards and/or by constructing one’s masculinity to align with a more liberal feminist perspective. Therefore one demonstrates a contemporary appreciation of gender equality and non-traditional gender roles for one’s female partner.

No description available.

Magister Public Health - MPH / HIV/AIDS remains a major public health issue that is affecting all population groups and communities in Zambia. Among the most affected groups are key populations (KPs) such as female sex workers. KPs are considered at high risk of contracting HIV but have limited access to HIV services and retention in care due to internalized stigma, discrimination, criminalization, and negative attitudes towards HIV treatment. Under the USAID Open Doors project in Zambia, KPs access comprehensive HIV prevention, care and treatment services. The test and treat strategy is implemented by the project in support of the UNAIDS 90-90-90 targets by 2020 to diagnose 90% of people living with HIV, put 90% of them on treatment, and for 90% of them to have suppressed viral load.

In this paper-based thesis, I describe the findings of my ethnographic research conducted among the intimate partners of female sex workers and adolescent boys in Northern Karnataka. By highlighting the contradictory and relational nature of masculinity, my study aims to contribute to the larger scholarship on masculinity in South Asia. In the first manuscript, I examine the intimate partners’ perceptions and practices to shed light on the common occurrence of intimate partner violence and how local ideologies of manhood—and the social and structural conditions that shape these ideologies—perpetuate intimate partner violence. In an attempt to destabilize hierarchical gender orders, the second manuscript builds on Connell’s theory of “hegemonic masculinity” by developing the notion of incipient masculinity. From a public health perspective, the findings of these studies are expected to inform the ongoing structural interventions in Northern Karnataka that aim to prevent violence against female sex workers. / October 2016

L’épidémie de VIH en Guyane est souvent présentée comme généralisée. Cependant, certains groupes semblent plus particulièrement touchés. Parmi ces groupes vulnérables, les travailleuses du sexe tiennent une place particulière compte tenu de la fréquence des rapports transactionnels dans la région. Ces échanges économico‐sexuels dépassent les frontières puisque de nombreux clients venant de Guyane rencontrent des travailleuses du sexe à Oiapoque, ville brésilienne frontalière. Malgré l'importance potentielle de la prostitution dans la dynamique de l'épidémie VIH, peu de données existent sur le sujet dans la région.L’objectif principal de cette étude était de répondre à ce manque de données et de décrire les connaissances, attitudes et pratiques des travailleuses du sexe en Guyane et à Oiapoque afin de pouvoir ajuster au mieux les actions de prévention.Les résultats des enquêtes menées en Guyane et à Oiapoque en 2010 et 2011 ont mis en lumière un certain nombre de faits favorisant la progression de l’épidémie au sein des travailleuses du sexe, mais également favorisant la diffusion de l’épidémie en population générale. Ainsi l’utilisation du préservatif n’était pas toujours adéquate et bien qu’elle était constante avec les clients, elle l’était beaucoup moins avec les partenaires intimes, dans un contexte de multipartenariat fréquent. Le taux de dépistage à Oiapoque était particulièrement faible également. Au‐delà de l’aspect individuel, le cadre structurel impactait clairement la vulnérabilité des travailleuses du sexe. Ainsi, la non‐disponibilité des traitements à Oiapoque, la précarité dans laquelle se trouvent les personnes et le cadre législatif des deux pays représentent des obstacles majeurs à la prise en charge destravailleuses du sexe.Différents niveaux de lecture sont nécessaires pour essayer de percevoir la complexité des comportements face au risque de transmission du VIH parmi les travailleuses du sexe. C’est à chacun de ces niveaux qu’il faut envisager la prévention, et non plus au seul niveau individuel, pour qu’elle puisse être efficace. Cette prévention doit, elle‐même, être envisagée plus globalement pour apporter une réponse efficace à l’épidémie de VIH en combinant des éléments de prévention comportementale, biomédicale et structurelle. / The HIV epidemic in French Guiana is often described as generalized. However, some vulnerable groups appear particularly affected. Among these groups, female sex workers hold a special place because of the frequency of transactional relationships in the region. These sexual‐economic exchanges go beyond the borders since many customers from French Guiana solicit female sex workers in Oiapoque, the Brazilian border town. Despite the potential importance of sex work in the HIV epidemic, there is scarce data on the subject in the area.The main objective of this study was to address this knowledge gap and to describe the knowledge, attitudes and practices among female sex workers in French Guiana and Oiapoque in order to optimize and subsequently evaluate prevention.The results of the survey conducted in French Guiana and Oiapoque in 2010 and 2011 highlighted a number of events promoting the spread of the epidemic among female sex workers, but also promoting the spread of the epidemic in the general population. Thus, condom use was not always adequate. Although it was consistent with the customers, it was much less with intimate partners, in a common multiple sexual partnerships context. The HIV screening rate was particularly low in Oiapoque as well. Beyond the individual aspect, the structural framework clearly impacted the vulnerability of female sex workers. Thus, the non‐availability of treatment in Oiapoque, the precariousness in which people live and the legislative framework of the two countries are major barriers to female sex workers’ support.Different levels of understanding are necessary to disentangle the complexity of behaviors facing the risk of transmission of HIV among female sex workers. Prevention must be considered at each level, not only at the individual level, to be effective. Furthermore, prevention must be considered more generally to provide an efficient response to the HIV epidemic by combining behavioral, biomedical and structural prevention elements.

HIV in Karnataka, south India disproportionately burdens female sex workers (FSWs) and men who have sex with men (MSM). The best long-term strategy for managing the global HIV epidemic might involve a preventive vaccine; however, vaccine availability cannot guarantee its acceptability. An exploratory, cross-sectional study was conducted among frontline health service providers (HSPs) working with MSM/FSWs in relation to HIV-related health services in Karnataka. Face-to-face structured interviews were performed to better understand potential barriers/facilitators to acceptability/uptake of a future HIV vaccine among MSM/FSW communities. Descriptive analyses explored HSPs’ perceptions of vaccine acceptability/uptake and likelihood to recommend an HIV vaccine. Although HSPs mentioned numerous potential barriers to future HIV vaccine acceptability/uptake, most believed that MSM/FSWs would be willing to receive the vaccine to protect their health and avoid HIV. HSPs reported being very likely to recommend the vaccine, however young age of potential vaccine recipients negatively affected likelihood to recommend.

HIV in Karnataka, south India disproportionately burdens female sex workers (FSWs) and men who have sex with men (MSM). The best long-term strategy for managing the global HIV epidemic might involve a preventive vaccine; however, vaccine availability cannot guarantee its acceptability. An exploratory, cross-sectional study was conducted among frontline health service providers (HSPs) working with MSM/FSWs in relation to HIV-related health services in Karnataka. Face-to-face structured interviews were performed to better understand potential barriers/facilitators to acceptability/uptake of a future HIV vaccine among MSM/FSW communities. Descriptive analyses explored HSPs’ perceptions of vaccine acceptability/uptake and likelihood to recommend an HIV vaccine. Although HSPs mentioned numerous potential barriers to future HIV vaccine acceptability/uptake, most believed that MSM/FSWs would be willing to receive the vaccine to protect their health and avoid HIV. HSPs reported being very likely to recommend the vaccine, however young age of potential vaccine recipients negatively affected likelihood to recommend.

While female sex workers (FSWs) are often the focus of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and other sexually transmitted infections (STIs) research in Kenya, little else is known about their lives, including their intimate relationships. This thesis explores the relationships between FSWs and their intimate partners in Kibera, an urban informal settlement in Nairobi, Kenya. As part of the Kenya Free of AIDS (KeFA) project, previous field research found that FSWs with an intimate partner saw over 50% fewer clients per week and were statistically more likely to use a condom with clients. These findings suggested that FSWs' intimate relationships might act as a form of harm and/or use reduction. Sex work harm reduction aims to diminish the occupational harms associated with sex work, such as discrimination, violence and disease, through strategies such as empowerment and education. Use reduction aims to reduce FSWs' frequency of exposure to these occupational risks through a reduction in clients. Specifically, it is proposed that FSW intimate relationships promote harm and/or use reduction in three ways: 1) by reducing the number of clients on a weekly basis, 2) by reducing harm from the virus through adherence to antiretroviral drugs (ARV), and 3) by offering a supportive environment financially, emotionally, and in terms of health and/or childcare. To test these theories this thesis analyzed interviews with 27 HIV positive FSWs from Kibera. Results showed that HIV was normalized in intimate relationships, whereas sex work was stigmatized. As a result, FSWs in this study were more likely to tell their partners that they were HIV positive than disclose their involvement in sex work. Therefore, rather than genuine use reduction, client reduction was unintentional and, in reality associated with sex work stigmatization that prevents women from disclosing their occupation. Some intimate partnerships were found to be a source of emotional and health-related support for Kibera FSWs. Intimate partners provided support for participants' HIV status and adherence to ARV. They also provided emotional support in the form of advice and comfort. Overall, this study suggested it would be difficult to include intimate partners in interventions with HIV positive Kibera FSWs because of the considerable, continued stigma surrounding sex work but that intimate partners can have a positive and/or protective role to play in HIV positive Kibera FSWs’ lives. / Graduate / 0573 / 0327 / 0626 / kimberly.m.sharpe@gmail.com