Programme planning must take into account diversity of sex worker populations - Pakistan

Heterogeneity among sex workers in overlapping HIV risk interactions with people who inject drugs: a cross-sectional study from 8 major cities in Pakistan. 

Melesse DY, Shafer LA, Shaw SY, Thompson LH, Achakzai BK, Furqan S, Reza T, Emmanuel F, Blanchard JF. Medicine (Baltimore). 2016 Mar;95(12):e3085. doi: 10.1097/MD.0000000000003085.

Concerns remain regarding the heterogeneity in overlapping human immunodeficiency virus (HIV) risk behaviors among sex workers (SWs) in Pakistan; specifically, the degree to which SWs interact with people who inject drugs (PWID) through sex and/or needle sharing. Following an in-depth mapping performed in 2011 to determine the size and distribution of key populations at highest risk of HIV acquisition in Pakistan, a cross-sectional biological and behavioral survey was conducted among PWID, female (FSWs), male (MSWs), and hijra/transgender (HSWs) sex workers, and data from 8 major cities were used for analyses. Logistic regression was used to identify factors, including city of residence and mode of SW-client solicitation, contributing to the overlapping risks of drug injection and sexual interaction with PWID. The study comprised 8483 SWs (34.5% FSWs, 32.4% HSWs, and 33.1% MSWs). Among SWs who had sex with PWID, HSWs were 2.61 (95% confidence interval [CI], 1.19-5.74) and 1.99 (95% CI, 0.94-4.22) times more likely to inject drugs than MSWs and FSWs, respectively. There was up to a 3-fold difference in drug injecting probability, dependent on where and/or how the SW solicited clients. Compared with SWs in Larkana, the highest likelihood of drug injection use was among SWs in Multan (OR = 4.52; 95% CI: 3.27-6.26), followed by those in Lahore, Quetta, and Faisalabad. Heterogeneity exists in the overlapping patterns of HIV risk behaviors of SWs. The risk of drug injection among SWs also varies by city. Some means of sexual client solicitation may be along the pathway to overlapping HIV risk vulnerability due to increased likelihood of drug injection among SWs. There is a need to closely monitor the mixing patterns between SWs and PWID and underlying structural factors, such as means of sexual client solicitation, that mediate HIV risk, and implement prevention programs customized to local sub-epidemics.

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Editor’s notes: This is an important paper reporting findings of an HIV prevalence and risk behaviour survey among sex workers and people who inject drugs. The paper describes the diversity of sex work, including male and transgender sex workers that are often neglected in research and service planning. It also examines injecting drug use among sex workers, a behaviour that can increase sex workers’ vulnerability to HIV, violence and other health harms. The finding that among sex workers who had a sex partner who also injected drugs, transgender sex workers had higher odds of injecting than male or female sex workers is important. This finding highlights the differences in vulnerability among the three sex worker populations, whose diversity is often not taken into account in programme planning. Other international evidence suggests increased stigma experienced by transgender sex workers on account of their gender. For example, with increased arrest and harassment administered by police and higher levels of poor emotional health. These are factors that might explain use of injecting drugs as a coping strategy. The study illustrates a clear need to target harm reduction services among this population, to ensure they have access to needle-syringe programmes.  Advice on safe injecting practices and how to manage injecting drug use alongside sex work are also necessary. Findings also clearly illustrate the need to understand better the underlying determinants of drug use and address those. Understanding why prevalence of drug use varies by city is vital. So too, is understanding how the way in which clients are engaged increases risk of injecting, in order to create enabling environments to minimise harms associated with injecting. 

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