Structural barriers to condom access in a community-based cohort of sex workers in Vancouver, Canada: influence of policing, violence and end-demand criminalisation

Abstract

ObjectivesSex workers (SWs) face a disproportionate burden of HIV/sexually transmitted infections (STIs), violence and other human rights violations. While recent HIV prevention research has largely focused on the HIV cascade, condoms remain a cornerstone of HIV prevention, requiring further research attention. Given serious concerns regarding barriers to condom use, including policing, violence and ‘end-demand’ sex work criminalisation, we evaluated structural correlates of difficulty accessing condoms among SWs in Vancouver over an 8-year period.MethodsBaseline and prospective data were drawn from a community-based cohort of women SWs (2010–2018). SWs completed semi-annual questionnaires administered by a team that included lived experience (SWs). Multivariable logistic regression using generalised estimating equations (GEE) modelled correlates of difficulty accessing condoms over time.ResultsAmong 884 participants, 19.1% reported difficulty accessing condoms during the study. In multivariable GEE analysis, exposure to end-demand legislation was not associated with improved condom access; identifying as a sexual/gender minority (adjusted odds ratio (aOR) 1.62, 95% CI 1.16 to 2.27), servicing outdoors (aOR 1.52, 95% CI 1.17 to 1.97), physical/sexual workplace violence (aOR 1.98, 95% CI 1.44 to 2.72), community violence (aOR 1.79, 95% CI 1.27 to 2.52) and police harassment (aOR 1.66, 95% CI 1.24 to 2.24) were associated with enhanced difficulty accessing condoms.ConclusionsOne-fifth of SWs faced challenges accessing condoms, suggesting the need to scale-up SW-tailored HIV/STI prevention. Despite the purported goal of ‘protecting communities’, end-demand criminalisation did not mitigate barriers to condom access, while sexual/gender minorities and those facing workplace violence, harassment or those who worked outdoors experienced poorest condom accessibility. Decriminalisation of sex work is needed to support SWs’ labour rights, including access to HIV/STI prevention supplies.

Latent Classes of Polysubstance Use and Associations with HIV Risk and Structural Vulnerabilities among Cisgender Women Who Engage in Street-Based Transactional Sex in Baltimore City

“…There is a myriad of structural and individual factors that drive elevated rates of HIV risk among women engaged in transactional sex. Structural determinants of heightened HIV risk include lack of access to economic opportunities, housing insecurity, food insecurity, violence, policing practices, and criminalization of sex work [ 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. These broader structural dynamics strongly influence individual-level HIV risk factors and behaviors, including patterns of substance use.…”

PrEP facilitators and barriers in substance use bridge clinics for women who engage in sex work and who use drugs

“…Structural factors, such as sex work and drug use criminalization and gendered-power imbalances, drive HIV risks among WSWUD and reduce their ability to prevent HIV through condom and/or sterile injection equipment use [6][7][8]. For example, among a cohort of sex workers from Baltimore, approximately 42% reported coercive condom negotiation, and 39% inconsistently used condoms [9].…”

Structural racism and violence: Routine healthcare access in a cohort of marginalized Indigenous women and Two-Spirit Peoples during the COVID-19 Pandemic

“…Previous studies describe high prevalence of violence perpetrated across community, intimate partner and community contexts among sex workers ( 31 , 53 , 54 ), with a disproportionate burden among Indigenous sex workers and Two-Spirit Peoples in Canada ( 31 , 53 , 55 ). Women living with HIV and sex workers also face several barriers to accessing healthcare services including violence ( 42 , 56 ). Sex workers face disproportionate health and social inequities, for example, high rates of HIV and STI’s, violence, and criminalization ( 56 ).…”

“…Women living with HIV and sex workers also face several barriers to accessing healthcare services including violence ( 42 , 56 ). Sex workers face disproportionate health and social inequities, for example, high rates of HIV and STI’s, violence, and criminalization ( 56 ). Sex workers and women living with HIV face several sources of structural violence, including lifetime exposure to violence, intimate partner violence, gender-based violence, and police harassment that impacts their access to healthcare services ( 22 , 31 , 57 ).…”