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. Author manuscript; available in PMC: 2023 Apr 26.
Published in final edited form as: AIDS Behav. 2020 Mar;24(3):762–774. doi: 10.1007/s10461-019-02569-7

Inconsistent condom use among female sex workers: Partner-specific influences of substance use, violence, and condom coercion

Michele R Decker 1,2, Ju Nyeong Park 3,4, Sean T Allen 3, Bradley Silberzahn 3, Katherine Footer 3, Steven Huettner 3, Noya Galai 4, Susan G Sherman 3,4
PMCID: PMC10132468  NIHMSID: NIHMS1654144  PMID: 31254189

Abstract

Background:

Female sex workers (FSWs) are disproportionately affected by HIV. Inconsistent condom use (ICU) represents the most proximal risk for acquisition and transmission. We evaluate associations of partner-specific factors including physical and sexual violence, coercion, and substance use with ICU with clients and regular non-paying partners, respectively, among FSWs.

Methods.

Baseline survey data from a prospective cohort of 250 street-based FSW in Baltimore, Maryland, USA included partner-level drug and alcohol use, violence, condom coercion and ICU, in addition to individual and structural exposures. Logistic regression analyses were stratified by partner type, followed by path analysis where indicated.

Results:

Within client and regular non-paying partnerships, FSWs reported prevalent recent violence (34.8%, 16%, respectively), condom coercion (42.4%, 9.9%, respectively) and ICU (39.2%, 44.4%, respectively). Recent physical or sexual violence enabled coercive condom negotiation (AORclient 8.22, 95% CI 4.30, 15.73; AORnonpaying partner 3.01 95% CI 1.05, 8.63). ICU with clients was associated with client condom coercion (AOR 1.76, 95% CI 1.03, 3.02), and client intoxication during sex (AOR 2.25, 95% CI 1.13, 4.45). In path analysis of client-FSW partnerships, condom coercion fully mediated the influences of both sex worker intoxication and recent violence on ICU. ICU with non-paying partners was associated with FSW intoxication during sex (AOR 8.66, 95% CI 3.73, 20.10), and past-year police violence (AOR 2.92, 1.30, 6.57).

Discussion:

Partner-level substance use and gendered power differentials influenced FSWs’ ICU patterns differently by partner type. ICU with clients was rooted solely in partner factors, and coercive condom negotiation mediated the roles of violence and partner-level substance use on ICU. By contrast, ICU with non-paying partners was rooted in partner-level substance use and police violence as a structural determinant. Addressing HIV risk behavior for FSWs requires condom promotion efforts tailored to partner type that addresses power differentials.

Keywords: women, HIV, injection drug use, substance use, violence, condom

Background

Women comprise approximately 1 in 5 of the estimated 1.2 million people living with HIV in the US. Women’s HIV diagnoses are not randomly distributed, and average lifetime HIV risks (1 in 241 for heterosexual women)1 obscure high-risk sub-populations. Female sex workers (FSWs), are one critical at-risk population; globally, their HIV risk is an estimated 14 times that of women in the general population.2 Sex work is not well-characterized within the US HIV epidemic,3 but has been significantly associated with HIV in national surveillance.4 A recent meta-analysis estimated a pooled HIV prevalence of 17.3% for US-based FSWs,5 roughly comparable to the 1 in 6 estimated lifetime HIV risk for men who have sex with men (MSM).1 Condoms remain essential for preventing HIV acquisition and onward transmission as well as the STIs that can compromise health and exacerbate HIV risk.

FSWs’ risks for HIV acquisition and onward transmission are shaped by behavioral, interpersonal or dyadic, sexual network, and structural factors.6 Their structural risk environment includes criminalization, which fuels a cascade of social harms including impunity for violence and mistreatment at the hands of clients and non-paying partners, and exclusion from medical care, justice, safety and support.7–10 Gendered social and economic inequalities are exacerbated for FSWs, and male-dominated drug and street economies reinforce women’s dependence on men for drugs and relative safety.11–15

These structural features inform complex dynamics at the interpersonal partnership level, which represents the most proximal source of HIV risk and the level at which condom use or non-use occurs. The normative environment that tolerates coercion, violence, and male dominance in decision-making related to HIV risk reduction and other aspects of health can perpetuate gender-based power imbalances at the partnership level, and in turn condom use practices. For example, FSWs suffer violence disproportionately,7 with a homicide rate ~17 times that of general population women. As in general populations, among FSWs, violence is consistently associated with condom non-use,16–20 condom breakage,16,21,22 and condom failure.23,24 Gendered power dynamics enable male control over sexual decision-making, and limit women’s ability to negotiate risk reduction, ultimately undermining control over safe sex and injection practices.25–30

Power imbalances are manifested in part via coercive condom negotiation; FSWs describe client aggression and threats as specifically intended to undermine their negotiation power,31 the overt or implicit threat of violence can enable unprotected sex,21 FSWs describe client resistance and intimidation as key barriers to condom use, 32 and FSWs from a range of settings report client condom refusal,24,33 and pressure and insistence for unprotected sex.34,35 Gender-based power imbalances, including partner violence and provision of drugs and safety, have also been implicated in condom negotiation with non-paying partners.36,37

The roles of violence, coercion and other domains of gendered power imbalances are rarely considered at the interpersonal level, particularly as they relate to condom use within FSWs’ distinct sexual partnerships. FSWs’ sexual partners can include non-paying as well as clients; research demonstrates important differences across these relationship types.8,38 These differences can have implications for condom use and STI/HIV risk,39,40 as well as receptivity to intervention; one recent intervention was found to influence FSWs’ condom use with clients but not their steady partners.41 Existing research at the partner level has yet to disentangle the extent to which associations of violence and coercion with condom use are partner-specific vs. more general. Recent evidence from India reveals that both domestic violence and workplace violence (perpetrated by clients, police, coworkers or pimps) increase risk for recent STI symptoms, and that workplace violence, but not domestic violence, increases risk for condom non-use with regular and occasional clients.40 Among sex workers in Argentina, sexual violence history from any partner increased risk for unprotected sex with both clients and non-paying partners.42 Prospective analyses with FSWs in Cambodia link sexual violence with subsequent unprotected sex with non-paying partners. 43

Against this backdrop, the current study sought to: 1) describe individual, partner, and structural influences on physical and sexual violence, and coercive condom negotiation, with non-paying partners and clients, respectively; and 2) evaluate their impact on inconsistent condom use (ICU) with each respective partner type. Comparable data on clients and non-paying partners offers a unique opportunity to compare and contrast correlates of violence, condom coercion, and ICU with each respective partner type.

Methods

This study uses baseline data from the Sex workers And Police Promoting Health In Risky Environments (SAPPHIRE) study. The study is set in urban Baltimore, MD, whose HIV diagnosis rate per 100,000 (22.1 in 2015) consistently ranks among the nation’s top 10 major metropolitan areas.44 A prospective cohort of FSWs who were recruited between April 2016 and February 2017. Eligible participants were women who: (1) were age ≥ 15 years; (2) sold or traded oral, vaginal or anal sex “for money or things like food, drugs or favors”; (3) picked up clients on the street or at public places ≥ 3 times in the past 3 months; and (4) were willing to undergo HIV and STI testing. The cohort enrolled 250 cisgender FSWs and 63 transgender FSWs.45 This analysis is restricted to cisgender FSWs, as the cis and trans sub-cohorts diverged in demographics and HIV risk profiles.45 Participants were recruited from fifteen zones across Baltimore city with high concentrations of street-based sex work, with zone selection detailed elsewhere.46 Study staff approached potential participants within the designated zones for interest and eligibility. Recruitment, informed consent, and data collection were conducted on a mobile van. Self-reported data were collected via a 50-minute interviewer-administered computer assisted personal interview (CAPI) survey which covered domains including demographics, sex work history, police encounters, sexual and drug use behaviors, health service access, and health. All participants received referrals for a range of local health and social service organizations, and received a pre-paid $70 VISA gift card. Several design elements were designed to protect confidentiality for this vulnerable population, including a Certificate of Confidentiality, extensive and ongoing staff training specific to confidentiality, private location for data collection coupled with discretion in engagement with the study team and mobile van, and anonymization of data. All procedures were approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

Measures

The following partner-type-specific measures were asked for each respective partner type, specifically clients, defined as “people you’ve had oral, vaginal or anal sex with for money, food, drugs or favors,” and recent (past 3 months), regular, non-paying intimate partners, defined as “people you are in a romantic relationship with (like a boyfriend or girlfriend or spouse) who do not pay you for sex but that you have had sex with (vaginal, anal or oral) in the past 3 months,” consistent with similar research on regular/romantic non-paying partners of FSWs.38 Participants self-described their sexual orientation and the gender of their sex partners; the vast majority (98%) of participants reported that at least some of their recent non-paying partners were male; for five participants, past-3-month non-paying partners were exclusively female.

Violence.

We measured recent (past 3 month) violence (sexual and physical) using an adapted version of the Revised Conflict Tactic Scale47 that has been previously used with this population.48 To measure exposure to physical violence we asked whether they had been hit, punched, slapped or otherwise physically hurt or threatened or hurt with a weapon by clients/intimate partners. Sexual violence was defined as being pressured or made to have vaginal or anal sex when they didn’t want to. Physical and sexual violence were often concurrent; to maximize statistical power and reflect the nature of violence in the population, a single violence exposure variable was created for each relationship type, reflecting experience of physical or sexual violence.

Condom coercion and consistency of use.

Recent condom coercion consisted of condom removal or refusal, consistent with past measures24 and based on extensive qualitative evidence of condom removal and refusal.8,24,33 In accordance with recommendations,49 condom use consistency frequency measures used a recent time period (past 3 months) and assessed separately for partnership type as well as type of sex, specifically vaginal sex and anal sex;inconsistent condom use was defined as answering never/rarely/sometimes/most of the time to either of the vaginal or anal sex items.

Drug or alcohol intoxication during sex.

We measured the recent frequency of personal and partner, respectively, intoxication during sexual encounters through “how often were [you/your partner] drunk or high during sex?”

We collected information on age, race, ethnicity, types and frequency of drug use, sex work characteristics including time in sex work, and the frequency of sex work, and structural factors representing economic instability (no monthly savings, food insecurity), police encounters (recent arrest, police extortion in the form of pressured sex in exchange for leniency, police violence, and behavior change in condom carrying, work locations, and client negotiations, respectively, in response to police practices).

Analysis

Descriptive analysis explored the prevalence of client-perpetrated violence and condom coercion, respectively, in the sample and by key demographic, substance use, sex work, police-related, partner, and structural factors. Analyses were stratified by partner type, specifically recent (past 3 months) regular non-paying partners and paying clients. Differences were evaluated via chi square analysis for binary and categorical independent variables and the Mann-Whitney U test for continuous independent variables. Significant associations in the bivariate logistic regressions (P < 0.05) were included in the six multivariable logistic models that separately examined the correlates of recent client violence, client condom coercion, intimate partner violence, intimate partner condom coercion, inconsistent condom use with clients, and inconsistent condom use with intimate partners, respectively. All analyses were conducted in Stata/SE 14.2 (College Station, Texas).

To further extend the study aims of evaluating the impact of violence and coercive condom negotiation on ICU, path analyses were conducted to model ICU with clients based on emergence of a potential mediating pathway, specifically violence incurred risk for condom coercion, and condom coercion incurred significant risk for ICU. using Mplus 8.0 (Muthén & Muthén, 1998–2017). The WLSV estimator with a logit link was used. Model fit was assessed using the goodness-of-fit chi-squared test of model fit, the RMSEA, the Comparative Fit Index (CFI), the Tucker-Lewis Index (TLI). RMSEA<0.1 reflects good fit and <0.05 indicates very good fit; 50CFI>0.9551 and TLI>0.9552 reflect excellent fit. Neither partner violence nor partner condom coercion were associated with NPP ICU in adjusted analyses, thus no path analyses were conducted for this partnership type.

Results

Client violence,condom coercion, and inconsistent condom use (ICU)

Recent client-perpetrated violence was reported by 34.8%, with violence more commonly reported for women under 35 years of age (43.2%, p=0.005), Hispanic women (51.9%, p=0.014), those engaged in receptive syringe sharing (56.3%, p=0.014), history of entering sex work through coercion, force or fraud (55.0%, p=0.048), ever had a pimp or manager (62.5%, p=0.003), identifying clients in indoor venues (41.7%, p=0.025), via referrals from non-intimate partners (41.8%, p=0.035), and online (47.8%, p=0.007; Table 1). At the partner level, recent client violence was more prevalent among those with recent intimate partner violence (62.5%, p<0.001). Structural factors that related bivariately to recent client violence included food insecurity (40.7%, p=0.033), recent police extortion for sex (63.6%, p<0.001), and rushed client negotiations due to policing (41.6%, p=0.013). In multivariate analyses, recent client violence remained significantly associated with recent intimate partner violence (Adjusted Odds Ratio [AOR] 2.88, 95% confidence interval [CI] 1.31, 6.34), and police extortion for sex (AOR 2.70, 95% CI 1.14, 6.40).

Table 1:

Correlates of recent client violence, condom coercion and inconsistent condom use among female sex workers in Baltimore, Maryland (N=250)

Total N=250 n (col %) Recent violence n (row %) AOR (95% CI) Recent condom coercion n (row %) AOR (95% CI) Recent inconsistent condom n (row %) AOR (95% CI)
Total 250 (100.0) 87 (34.8) 106 (42.4) 98 (39.2)
Individual characteristics
Age
 <35 125 (50.0) 54 (43.2) 60 (48) 49 (39.2)
 ≥35 125 (50.0) 33 (26.4)** 0.54 (0.28, 1.04) 46 (36.8) 49 (39.2)
Race/ethnicity
 Non-Hispanic White 166 (66.4) 61 (36.8) REF: 1.00 69 (41.6) 65 (39.2)
 Non-Hispanic Black 57 (22.8) 12 (21.1) 0.56 (0.26, 1.22) 27 (47.4) 23 (40.4)
 Hispanic or Other 27 (10.8) 14 (51.9)* 1.86 (0.73, 4.73) 10 (37) 10 (37)
Substance use
Daily injection drug use (IDU) 146 (58.4) 55 (37.7) 62 (42.5) 59 (40.4)
Receptive syringe sharing, past 3 months; (n=177 IDU) 32 (18.1) 18 (56.3)* 15 (46.9) 17 (53.1)
Daily crack cocaine smoking 155 (62.0) 53 (34.2) 71 (45.8) 62 (40.0)
Daily/almost daily binge drinking 23 (9.2) 6 (26.1) 12 (52.2) 9 (39.1)
Sex work characteristics
Entered due to coercion, force, fraud 20 (8.0) 11 (55.0)* 1.07 (0.34, 3.38) 8 (40) 8 (40)** 0.95 (0.35–2.58)
Entered sex work as a minor 53 (21.2) 21 (39.6) 24 (45.3) 22 (41.5)
Ever had a pimp/manager 24 (9.6) 15 (62.5)** 1.82 (0.66, 5.03) 13 (54.2) 13 (54.2)
Length in street-based sex work
 <=1 year 44 (17.6) 12 (27.3) 12 (27.3) 13 (29.5)
 > 1 to 5 years 77 (30.8) 29 (37.7) 38 (49.4) 34 (44.2)
 > 5 years 129 (51.6) 46 (35.7) 56 (43.4) 51 (39.5)
Where met clients, ever
 Outdoors 250 (100.0) 87 (34.8) 106 (42.4) 98 (39.2)
 Indoor venues (e.g. bars, EDC) 120 (48.4) 50 (41.7)* 1.46 (0.74, 2.86) 58 (48.3) 56 (46.7)* 1.66 (0.97–2.84)
 Referrals from intimate partner 30 (12.1) 13 (43.3) 9 (30.0) 14 (46.7)
 Referrals from others 110 (44.4) 46 (41.8)* 1.23 (0.62, 2.42) 54 (49.1) 50 (45.5)
 Online 69 (27.8) 33 (47.8)** 1.33 (0.66, 2.68) 36 (52.2) 28 (40.6)
Partner factors
Recent client violence 87 (34.8) -- -- 64 (73.6)*** 8.22 (4.3, 15.73) 41 (47.1)
Recent client condom coercion 106 (42.4) -- -- -- -- 52 (49.1)** 1.76 (1.03, 3.02)
No. of male clients, past 3 months: median, (IQR) 30 (10–100) 50 (14–100) 43 (14–100) 40 (15–100)* 1.00 (1.00, 1.00)
Intoxication during sex with clients
 Self with client 230 (92.0) 79 (34.4) 102 (44.4)* 5.34 (1.42, 20.1) 91 (39.6)
 Client 190 (76.0) 71 (37.4) 87 (45.8) 1.44 (0.72, 2.89) 84 (44.2)** 2.25 (1.13, 4.45)
Client IDU (n=210 respondents) 50 (23.8) 26 (52.0)** 29 (58.0)** 23 (46.0)
Client injected them 0 (0.0) -- -- --
Recent IPV 40 (16.0) 25 (62.5)*** 2.88 (1.31, 6.34) 23 (57.5)* 0.92 (0.4, 2.14)
Structural factors
No monthly savings 224 (89.6) 78 (34.8) 93 (41.5) 7 (26.9)
Went to sleep hungry >once a week 135 (54.0) 55 (40.7)* 1.44 (0.78, 2.65) 63 (46.7) 53 (39.3)
Arrested, past 12 months 116 (46.6) 44 (37.9) 50 (43.1) 47 (40.5)
Police extortion: pressured respondent to have sex for no arrest/trouble, past 12 months 33 (13.2) 21 (63.6)*** 2.70 (1.14, 6.40) 21 (63.6)** 1.82 (0.76, 4.35) 16 (48.5)
Police violence, past 12 months^ 53 (21.2) 24 (45.3) 23 (43.4) 20 (37.7)
Behavioral change due to police practices, past 12 months
Avoided carrying condoms due to fear of trouble with police 35 (14.1) 16 (45.7) 19 (54.3) 12 (34.3)
Moved to an unfamiliar area to work to avoid police 55 (22.1) 24 (43.6) 25 (45.5) 25 (45.5)
Rushed negotiations with clients because of policing 137 (54.8) 57 (41.6)* 1.38 (0.75, 2.53) 63 (46.0) 55 (40.1)
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^

Inappropriately touched, forced sexual intercourse (vaginal or anal), threatened or used a weapon, or physically hurt (“hit, punched, slapped or otherwise physically hurt you”)

*

p<0.05

**

p<0.01

***

p<0.001

Recent client-perpetrated condom coercion was similarly prevalent at 42.4%; significantly more prevalent for those with recent client violence (73.6%, p<0.001), recent IPV (57.5%, p=0.035), intoxication before sex with clients (44.4%, p=0.035), client injection drug use (58.0%, p=<0.01) and police extortion for sex (63.6%, p=0.008). In multivariate analysis, recent client condom coercion remained significantly associated with recent client violence (AOR 8.22, 95% CI 4.30, 15.73), and intoxication at sex with clients (AOR 7.06, 1.61, 30.94).

Overall, 39.2% reported recent ICU with clients. Client ICU was bivariately associated with client condom coercion (49.1%, p=0.006), number of recent clients (p=0.037), and client intoxication at sex (44.2%, p=0.006). In the final multivariate model, client intoxication emerged as the sole factor significantly associated with client ICU (AOR 2.28, 95% CI 1.08, 4.82).

Path model results: ICU with clients

Based on these results, we conducted path analyses to further extend the study aims of evaluating the impact of violence and coercive condom negotiation on ICU (Figure 1). In path model results of pathways to ICU with clients, recent client violence (AOR 8.70, 95% CI 4.69, 16.16; p<0.001) and FSW self-intoxication during sex (AOR 4.66, 95% CI 1.32, 16.42; p=0.017) were significantly associated with recent client condom coercion. In turn, recent client condom coercion was significantly associated with ICU with clients (AOR 1.86, 95% CI 1.03, 3.35; p=0.039), whereas recent client violence (AOR 1.24, 95% CI 0.68, 2.27; p=0.482) and FSW self-intoxication during sex were not significantly associated (AOR 1.06, 95% CI 0.40, 2.83; p=0.910). No significant associations between client intoxication during sex and client condom coercion (AOR 1.45, 95% CI 0.72, 2.89; p=0.298) or recent client violence (AOR 1.64, 95% CI: 0.86, 3.12; p=0.131) were observed.

Figure 1:

Figure 1:

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Path model for inconsistent condom use with clients

Non-paying partner (NPP) violence,condom coercion, and inconsistent condom use (ICU)

Recent NPP violence was reported by 16% of the sample, with violence more commonly reported by those engaged in receptive syringe sharing (34.4%, p=0.002), partner-level risk correlates included recent client violence (28.7%, p<0.001), intoxication at sex with partner (23.0%, p=0.001), partner intoxication at sex (29.3%, p<0.001), and injection by an intimate partner (50%, p=0.001; Table 2). Structural risk correlates included food insecurity (23.7%, p<0.001), police extortion (30.3%, p=0.016), and rushed client negotiations due to policing (20.4%, p=0.035). In multivariate analysis, recent NPP violence remained significantly associated with recent client violence (AOR 2.81, 95% CI 1.30, 6.07), partner intoxication at sex (AOR 4.01, 95% CI 1.28, 12.55), and food insecurity (AOR 3.47, 95% CI 1.45, 8.29).

Table 2:

Correlates of recent intimate partner violence, condom coercion and inconsistent condom use among female sex workers in Baltimore, Maryland (N=250)

Total N=250 n (col %) Recent violence n (row %) AOR (95% CI) Recent condom coercion n (row %) AOR (95% CI) Recent inconsistent condom use n (row %) AOR 95% CI
Total 250 (100.0) 40 (16.0) 24 (9.9) 111 (44.4)
Individual characteristics
Age
 <35 125 (50.0) 25 (20.0) 13 (10.7) 57 (45.6)
 ≥35 125 (50.0) 15 (12.0) 11 (8.9) 54 (43.2)
Race/ethnicity
 Non-Hispanic White 166 (66.4) 28 (16.9) 10 (6.2) 81 (48.8)
 Non-Hispanic Black 57 (22.8) 7 (12.3) 11 (19.3) 22 (38.6)
 Hispanic or Other 27 (10.8) 5 (18.5) 3 (11.1)* 8 (29.6)
Substance use
Daily injection drug use (IDU) 146 (58.4) 25 (17.1) 12 (8.4) 67 (45.9)
Receptive syringe sharing, past 3 months (n=177 IDU) 32 (18.1) 11 (34.4)** 5 (16.1) 16 (50.0)
Daily crack cocaine smoking 155 (62.0) 21 (13.6) 12 (7.9) 63 (40.7)
Daily/almost daily binge drinking 23 (9.2) 5 (21.7) 4 (17.4) 13 (56.5)
Sex work characteristics
Entered due to coercion, force, fraud 20 (8.0) 6 (30.0) 3 (15.8) 9 (45)
Entered sex work as a minor 53 (21.2) 9 (17.0) 6 (11.5) 17 (32.1)* 0.31 (0.13–0.70)
Ever had a pimp/manager 24 (9.6) 7 (29.2) 5 (21.7)* 2.28 (0.63, 8.28) 11 (45.8)
Length in street-based sex work
 <=1 year 44 (17.6) 10 (22.7) 1 (2.3) 23 (52.3)
 > 1 to 5 years 77 (30.8) 11 (14.3) 8 (10.7) 31 (40.3)
 > 5 years 129 (51.6) 19 (14.7) 15 (11.9) 57 (44.2)
Where met clients, ever
 Outdoors 250 (100.0) 40 (16.0) 24 (9.8) 111 (44.4)
 Indoor venues (e.g. bars, EDC) 120 (48.4) 22 (18.3) 15 (12.8) 57 (47.5)
 Referrals from intimate partner 30 (12.1) 7 (23.3) 5 (16.7) 17 (56.7)
 Referrals from others 110 (44.4) 21 (19.1) 14 (13) 58 (52.7)* 1.54 (0.68–3.50)
 Online 69 (27.8) 11 (15.9) 6 (8.8) 25 (36.2)
Partner factors
Recent IPV 40 (16.0) -- -- 11(28.2)*** 3.01 (1.05, 8.63) 24 (60.0)* 1.18 (0.49–2.88)
Recent intimate partner condom coercion 24 (9.9) -- -- -- -- 11 (45.8)
Relationship status
 Single 165 (66.3) 27 (16.4) 17 (10.4) 51 (30.9) REF: 1.00
 In a relationship/Married 84 (33.7) 13 (15.5) 7 (8.8) 60 (71.4)*** 3.97 (1.98–7.94)
Intimate partner role in sex work+ 53 (21.2) 11 (20.8) 6 (12.2) 29 (54.7)
Intoxication during sex
 Self with intimate partner 135 (54.0) 31 (23.0)** 1.08 (0.32, 3.61) 21 (16.0)*** 4.09 (0.86, 19.47) 93 (68.9)*** 8.66 (3.73–20.10)
 Intimate partner 99 (39.6) 29 (29.3)*** 4.01 (1.28, 12.55) 17 (17.7)** 1.25 (0.35, 4.37) 70 (70.7)*** 1.54 (0.68–3.50)
Partner injected (N=158 respondents) 49 (31.0) 16 (32.7)* 8 (16.3) 38 (77.6)
Intimate partner has injected them, past 3 months (N=177 IDU)# 12 (17.7) 6 (50.0)** 1 (8.3) 10 (83.3)**
Received money from intimate partner, past 3 months 65 (26.1) 14 (21.5) 7 (11.5)
No. of male clients, past 3 months: median, (IQR) 30 (10–100) 30 (8–134) 32 (12–100) 30 (10–85)
Recent client violence 87 (34.8) 25 (28.7)*** 2.81 (1.30, 6.07) 13 (15.5)* 1.37 (0.50, 3.77)
Structural factors
No monthly savings 224 (89.6) 34 (15.2) 18 (8.2)* 0.26 (0.08, 0.87) 100 (44.6)
Went to sleep hungry >once a week 135 (54.0) 32 (23.7)*** 3.47 (1.45, 8.29) 11 (8.3) 60 (44.4)
Arrested, past 12 months 116 (46.6) 22 (19.0) 16 (14.2)* 2.28 (0.84, 6.19) 48 (41.4)
Police extortion: pressured respondent to have sex for no arrest/trouble, past 12 months 33 (13.2) 10 (30.3)* 1.78 (0.67, 4.69) 7 (21.9)* 1.54 (0.50, 4.68) 16 (48.5)
Police violence, past 12 months^ 53 (21.2) 10 (18.9) 0 (0.0) 31 (58.5)* 2.92 (1.30–6.57)
Behavioral change due to police practices, past 12 months
Avoided carrying condoms due to fear of trouble with police 35 (14.1) 9 (25.7) 7 (20.6)* 2.2 (0.72, 6.76) 21 (60)* 1.13 (0.47–2.73)
Moved to an unfamiliar area to work to avoid police 55 (22.1) 13 (23.6) 8 (14.8) 24 (43.6)
Rushed negotiations with clients because of policing 137 (54.8) 28 (20.4)* 1.39 (0.61, 3.15) 15 (11.2) 66 (48.2)
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^

Inappropriately touched, forced sexual intercourse (vaginal or anal), threatened or used a weapon, or physically hurt (“hit, punched, slapped or otherwise physically hurt you”)

+

introduced to sex work, referred clients, took a cut or entered sex work to support them

#

Excluded from multivariate analysis due to being only applicable to injectors

*

p<0.05

**

p<0.01

***

p<0.001

Recent NPP condom coercion was reported by 9.9% and significantly more prevalent for non-Hispanic Black women (19.3%, p=0.016), history of having had a pimp or manager (21.7%, p=0.043), recent client violence (15.5%, p=0.031), recent IPV (28.2%, p<0.001), intoxication with NPP at sex (16.0%, p<0.001), NPP intoxication at sex (17.7%, p=0.001), arrest history (14.2%, p=0.035), police extortion (21.9%, p=0.014), and condom avoidance to avoid police (20.6%, p=0.023). In the multivariate model, recent IPV remained a significant driver of condom coercion by NPPs (AOR 3.01, 95% CI 1.05, 8.63), while no monthly savings was significantly protective (AOR 0.26, 95% CI 0.08, 0.87).

ICU with NPPs was reported by 44.4%; NPP ICU was bivariately associated with IPV (60.0%, p=0.03), being in a relationship (71.4%, p<0.001), intoxication with NPP at sex (68.9%, p<0.001), NPP intoxication at sex (70.7%, p<0.001), partner-facilitated injection (83.3%, p=0.004), police violence (58.5%, p=0.02), and avoidance of condom carrying to avoid police harassment (60.0%, p=0.048). In the multivariate model, ICU with NPPs was significantly associated with being in a relationship (AOR 3.97, 95% CI 2.00, 7.85), intoxication at sex with non-paying partners (AOR 8.66, 95% CI 3.73, 20.10), and police violence (AOR 2.92, 95% CI 1.30, 6.57).

Discussion

In this sample of US-based FSWs in an HIV-prevalent setting, distinct differences emerged by partner type in factors associated with inconsistent condom use. In client relationships, only partner-level factors were associated with ICU. These included client condom coercion, and client intoxication before sex. By contrast, with non-paying partners, ICU was associated with partner factors of being in an established relationship, intoxication near the time of sex, and the structural influence of police violence. The similarities across ICU determinants in these respective partnerships included relationship power imbalances as expressed via violence, condom coercion, and, with intimate partners, receptive syringe exchange, and the partner context of substance use in affecting ICU as a primary HIV risk behavior in this population. Results demonstrate needs for partner-specific interventions.

Results also speak to partnership-type-specific mechanisms by which substance use relates to ICU. Whether with alcohol or illicit drugs, FSWs’ substance use intensity as assessed globally over the risk period did not enhance risk for violence, coercion or ICU. By contrast, episodic intoxication, specifically at the time of sex, was significantly associated with ICU; client intoxication drove client ICU while FSW intoxication drove non-paying partner ICU. FSWs’ substance use intensity itself was not as important as the context of substance use within a given partner type, in incurring risk for violence, coercion and ICU within those partnerships. Receptive syringe sharing was bivariately associated with violence from both clients and non-paying partners. Moreover, receptive syringe sharing with an intimate partner increased risk for both violence and ICU with this partner type. These results, considered in light of the HIV transmission efficiency of injecting, and evidence of heightened sexual HIV risk within injecting networks, 53–55 demonstrate the clear HIV risk pathways resulting from gendered power differentials in access to and use of drugs, echoing past work.11–15 The links of substance use, violence, and HIV risk are recognized as complex;56,57 substance use serves as a trauma coping mechanism, 48,58–61 and can also enable abuse.56,57,60,62 Current results demonstrate the need for a partner-level lens in responding to patterns of violence and substance use, particularly for injection drug use and the unique risk of receptive syringe sharing.63

In client relationships, ICU was driven by coercive condom negotiation, which in turn was influenced by both client violence and client intoxication during sex with ICU. The context of violence and substance use appears to be uniquely risky in client-related condom negotiation. Findings extend past evidence that FSWs’ STI/HIV infection, sexual risk behavior, and substance use are often rooted in trauma, violence, and broader social environments that threaten and perpetuate sustained abuse.7,8,24,48,64,65

With non-paying partners, both partner factors (relationship status and FSW alcohol use at the time of sex) and structural factors (police violence) remained associated with ICU. The enduring independent effect of recent police violence on ICU with nonpaying partners in multivariate analysis suggests that the partner-level factors were insufficient in explaining this elevated risk. Findings build on past research in this cohort demonstrating the links of police interference with client violence,66 to illustrate the ways in which police abuse may similarly affect interactions with nonpaying partners. Further qualitative research is needed to identify the most salient mediating pathways. Notably, receptive injection by an intimate partner increased risk for ICU with this partner type, however small cell sizes prohibited multivariate analysis. Intimate partner violence incurred a 3-fold increased risk for client condom coercion; while no monthly savings was a protective factor, this finding should be considered with caution given the wide confidence interval for the estimate, driven by the relatively small cell sizes that resulted from the relative distributions of both exposure (89.6% no monthly savings) and outcome (9.9% NPP condom coercion).

Several important dimensions of relationship power inequity with clients and non-paying partners should be noted. The bivariate associations of recent client violence with forced, coerced or fraudulent entry to sex work and history of a pimp/manager both suggest enduring impact of early disempowerment within sex work on subsequent risk for abuse. Approximately one in 5 (21.2%) FSWs indicated that an intimate partner was involved in sex work. In contrast with past qualitative evidence,8 intimate partner involvement in sex work was not significantly related to violence, condom coercion or ICU with intimate partners. Approximately one quarter (26%) reported recent receipt of money from an intimate partner. Key structural risk sources provided a backdrop for the interpersonal negotiations described herein. Police extortion for sex (13%) gave rise to client violence. Significant proportions of women reported working in unfamiliar areas to avoid police (22%), and rushing negotiations with clients due to police (54.8%).

Findings should be considered in light of several limitations, including the cross-sectional design. Partner influences were assessed at the partner type level, which may have masked heterogeneity within partner types. This limitation is likely particularly salient for client relationships given women reported a median of 30 clients in the 3 months prior to the survey. We lacked data on factors previously related to ICU including relationship intimacy and duration. Diary techniques and exploration of specific partnerships or incidents would enable further precision and clarity on partner-specific factors leading to inconsistent condom use in individual sexual encounters. Statistical power for multivariate analysis was somewhat constrained; small cell sizes limited multivariate analysis for several exposures specific to injection drug use in particular.

Taken together, demonstrate the need for a partner-specific lens to address gendered power differentials and substance use as drivers of HIV risk behavior, particularly coital-specific methods such as condom use. Results echo evidence from other populations that male dominance in sexual and drug-related decision-making, and women’s dependence on male partners for drugs and safety undermines women’s control over safe sex and injection practices.25–30 Despite calls for interventions to address the dual epidemics of violence and HIV,67–69 interventions are in their earliest stages. Recent evidence from Kenya shows that a brief alcohol intervention can reduce some forms of violence for FSWs.70 Finally, the high levels of condom nonuse and coercive condom dynamics illustrate the need for FSW-controlled methods of preventing HIV acquisition and onward transmission. HIV pre-exposure prophylaxis (PReP) represents a female-controlled, pharmacologic method of prevention that holds the promise of overcoming the partnership-specific barriers to coital dependent methods, and is ever more relevant for FSWs in light of the gendered power differentials identified in this study and their impact on condom use. While both commercial sex and injection drug use are indicators for PrEP in the US,71 PrEP knowledge and uptake among US-based FSWs in this72 and other73 cohorts has been found limited to date, consistent with overall trends for women. Yet, even with widespread PReP uptake, condoms will remain valuable for STI prevention, rendering results informative for overall sexual health promotion for FSWs in the changing landscape of HIV prevention. Attending to partner-level power dynamics and substance use patterns that shape HIV risk and onward transmission is critical for FSWs, as is addressing the underlying social and structural risk environment that gives rise to harmful interpersonal dynamics.

Acknowledgements:

This study was supported by NIDA R01DA038499 and NIAID P30AI094189.

Footnotes

Compliance with Ethical Standards

Disclosure of potential conflicts of interest.

The authors report research grants from funding agencies NIDA R01DA038499 NIAID P30AI094189. Dr. Sherman is an expert witness for plaintiffs in opioid litigation.

Research involving Human Participants and/or Animals

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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