Skip to main content
PMC home page
Alcohol and Alcoholism (Oxford, Oxfordshire) logoLink to Alcohol and Alcoholism (Oxford, Oxfordshire)
. 2016 Jun 22;51(4):450–456. doi: 10.1093/alcalc/agv124

Prevalence and Correlates of Hazardous Drinking among Female Sex Workers in 13 Mexican Cities

Shirley J Semple 1, Eileen V Pitpitan 2, Claudia V Chavarin 1, Steffanie A Strathdee 2, Rosa Icela Zavala 3, Gregory A Aarons 1, Thomas L Patterson 1,*
PMCID: PMC4922383  PMID: 26546017

Abstract

Aims

To describe the prevalence and correlates of hazardous drinking among female sex workers (FSWs) at 13 sites throughout Mexico.

Methods

FSWs (N = 1089) who were enrolled in a brief sexual risk reduction intervention (Mujer Segura) were queried about their sexual risk and substance use practices and their work contexts. Participants were classified as hazardous or non-hazardous drinkers based on the Alcohol Use Disorders test (AUDIT-C). Logistic regression models were used to examine individual, contextual, and community-level factors as correlates of hazardous drinking.

Results

Ninety-two percent of participants reported alcohol consumption in the past month. Among drinkers (N = 1001), 83% met AUDIT-C criteria for hazardous drinking. Factors that were independently associated with hazardous drinking included: drug use in the past month (adjusted odds ratio (AOR) = 3.31; 95% CI 1.29—8.45), being a cigarette smoker (AOR = 1.71; 95% CI 1.13—2.58), being a barmaid or dance hostess (AOR = 3.40; 95% CI 1.95–5.91), alcohol use before or during sex with clients (AOR = 7.78; 95% CI 4.84–12.52), and working in a city with a higher marginalization index (AOR = 1.07; 95% CI 1.04–1.11).

Conclusions

Findings support the high prioritization by public health authorities of alcohol prevention and treatment programs for FSWs.

INTRODUCTION

Compared to the general population, female sex workers (FSWs) in Mexico have an elevated HIV prevalence, which has been estimated at 6% in cities along the USA–Mexico border (Patterson et al., 2008b). Studies with vulnerable populations in both developed and lower- to middle-income countries (LMIC) like Mexico have documented a link between alcohol consumption and HIV risk behaviors (Hendershot and George, 2007; Kalichman et al., 2007, 2008; Stein et al., 2009; Lambert et al., 2011; Hess et al., 2015), including among women who engage in transactional sex (Pitpitan et al., 2014).

High rates of alcohol use among FSWs have been reported in LMIC around the globe (e.g. Surratt, 2007; Verma et al., 2010; Witte et al., 2010; Chen et al., 2013; Odukoya et al., 2013; Alexander et al., 2014; Chersich et al., 2014; Fernandes et al., 2014). Worldwide, alcohol use among FSWs is significantly higher than in the general population (Samet et al., 2010; Odukoya et al., 2013). In several studies, 85% or more of FSWs reported using alcohol (Fernandes et al., 2014) or met criteria for harmful or hazardous drinking (Witte et al., 2010). A range of adverse health and social outcomes associated with drinking have also been documented in this population.

Studies in several countries have linked alcohol use by FSWs to higher levels of unprotected sex, including China (Chen et al., 2013), Kenya (Chersich et al., 2014) and India (Verma et al., 2010). However, the association of general alcohol consumption with condom use has been inconsistent (Li et al., 2010). The association of condom non-use with alcohol use appears to be more consistent in sexual contexts, most likely because in such contexts the alcohol use is closer in time to the FSW's deliberations about whether to use a condom (Kalichman et al., 2007). FSWs often use alcohol before and during sex with clients (Heravian et al., 2012; Saggurti et al., 2012; Urada et al., 2012; Chen et al., 2013). In one study, more than half of FSWs and their clients used alcohol in the context of their sexual encounters (Verma et al., 2010).

Besides potentially less condom use, other adverse outcomes associated with alcohol use among FSWs include higher incidence of HIV and STIs (Yadav et al., 2005; Chiao et al., 2006; Chersich et al., 2007), greater likelihood of exposure to sexual and physical violence (Chersich et al., 2007, 2014; Li et al., 2010; Go et al., 2011; Heravian et al., 2012), illicit drug use (Chiao et al., 2006; Surratt, 2007; Medhi et al., 2012), heavy tobacco use (Odukoya et al., 2013), and mental health problems (Hong et al., 2007).

Recent research on factors associated with alcohol use among FSWs has focused primarily on individual-level characteristics (e.g. age, education), with less attention paid to the work context and to conditions and practices in the broader community. However, in studies with non-FSW populations, both work context and community-level factors have yielded associations with heavy drinking and hazardous alcohol use (Scribner et al., 2008; Inder et al., 2012; Kuipers et al., 2012, 2013; Kissinger et al., 2013). Moreover, our work with male clients of Mexican FSWs (Pitpitan et al., 2013b) revealed that the context in which sex occurs is key to understanding the relationship between client intoxication and HIV risk behaviors.

Like their counterparts in other LMIC, FSWs in Mexico solicit clients in a variety of settings, including bars, entertainment venues and massage parlors (Larios et al., 2009; Pitpitan et al., 2013a). The relationships that FSWs have with their clients also vary in kind, with some FSWs devoting most of their time to regular clients and friends, while others focus on one-time clients or other client types (Robertson et al., 2014). Also highly variable is FSWs' relative freedom to determine their working conditions, with some working independently and others answering to a pimp or manager (Bucardo et al., 2004).

On the community level, policing practices (e.g. arresting FSWs for having ‘track marks') have been linked to HIV infection among injection drug users (Strathdee et al., 2008). Another community-level factor is ‘marginalization,’ a term that encompasses an area's overall level of social, structural, and economic development and opportunity. Residents of communities that have fewer resources and a lower index of development may drink more (Ortiz-Hernandez et al., 2007), perhaps as a way to cope with the stress of poverty.

This study aims to describe the prevalence and correlates of hazardous drinking among FSWs in 13 cities located throughout Mexico. We explored individual-level factors (i.e. demographics, sexual risk behaviors and non-consensual sex, general health behaviors), work-related contextual factors (e.g. FSW has a pimp), and community-level variables that are relevant to commercial sex work (e.g. policing practices).

METHODS

Participants and setting

Participants were 1089 female sex workers recruited from 13 cities in diverse locations throughout Mexico for a randomized controlled trial of a brief, single-session intervention designed to reduce sexual risk behaviors (Patterson et al., 2012). To be eligible for the study, a woman had to be biologically female, at least 18 years of age, self-identify as a female sex worker, report having traded sex for drugs, money, shelter, or other material benefit in the previous 2 months, have had unprotected vaginal or anal sex with a client at least once during the previous 2 months, have no previous HIV-positive test result, and agree to be tested for HIV and STIs at baseline and 6-month follow-up. Our primary analysis compared hazardous and non-hazardous drinkers using baseline data from a subsample of 1001 FSWs who reported drinking alcohol in the past month; data from the 88 participants who reported no alcohol consumption in the past month were excluded. The baseline data were collected between June 2011 and December 2013.

Recruitment

Time-location sampling was used to recruit an average of 84 participants at each study site (range = 71–87). This sampling technique has demonstrated effectiveness in recruiting difficult-to-reach populations (Pawa et al., 2013; Yadav et al., 2014; Pitpitan et al., 2015), including FSWs and FSW-IDUs in Tijuana and Ciudad Juarez (Patterson et al., 2008a; Strathdee et al., 2013). Outreach workers at each site compiled a map of bars, brothels, hotels and motels, shooting galleries, alleys, and street corners, and they subsequently canvassed those venues to locate prospective participants. Interested women were referred to a local clinic operated by the Mexican Foundation for Family Planning (Mexfam) where they completed a screening interview. Women who were eligible were scheduled for a 2-h baseline visit, which included the consent procedure, a face-to-face interview, and a 30-min counseling session on reducing sexual transmission risk of HIV and STIs (either the theory-based Mujer Segura protocol or a time-equivalent, standard comparison condition) (Patterson et al., 2012). All procedures and measures were approved by ethical review boards at the University of California, San Diego and Mexfam. FSWs were reimbursed the equivalent of $30 USD for their baseline interview.

Procedure

The baseline interview, which was used with over 1000 Mexican FSWs in our previous studies, was conducted in Spanish and took 30 min to complete. Interviews were conducted by trained outreach workers using computer-assisted personal interviewing (CAPI, NOVA software, MD, USA).

Measures

AUDIT-C

This 3-item screening instrument, which is an abbreviation of the full (10-item) AUDIT but performs equally well (Kaarne et al., 2010), reliably identifies patients who are hazardous drinkers or at risk of becoming one (Bush et al., 1998; Bradley et al., 2003). The items query frequency of drinking, typical number of drinks per session, and frequency of excessive drinking (defined as six or more drinks on one occasion). Summary scores range from 0 to 12. Validation studies suggest that, for women, a score of 3 or more identifies risky or hazardous drinking (Bush et al., 1998; Bradley et al., 2003, 2007). AUDIT-C scores were used to create a dichotomized variable (hazardous vs. non-hazardous drinking), which was treated as the dependent variable in these analyses.

Individual-level factors

Demographics

Age, number of years of education, number of years employed as a sex worker, and number of financial dependents were entered into the analyses as continuous variables. Marital status (married or common law vs. other status) and whether FSWs had children were treated as dichotomous variables.

Sexual risk behaviors and non-consensual sex

(a) With reference to their commercial sex transactions, FSWs were asked to report how many times during the past month they had engaged in vaginal and anal sex and how many times they had used a condom for each type of act. The number of condom uses was subtracted from the number of acts to create a summary variable for unprotected sex. (b) Participants were asked to report how many male clients (regular and non-regular) they had during the past month. (c) Participants were distinguished into groups based on whether they reported both regular and non-regular clients (reference group) or only one of the two types of client (either regular or non-regular). (d) Participants were asked whether they had been forced or coerced into having sex with a client in the past year.

General health behaviors

(a) Participants were asked to report how often, on a six-point scale (never to every day), they had used each of 13 different drugs in the past month (e.g. marijuana, cocaine, crack, ecstasy, methamphetamine, heroin). The response for each drug was dichotomized (used vs. did not use). (b) FSWs were asked how often they smoked cigarettes in the past month. A dichotomous variable was created to identify cigarette smokers. (c) Participants were asked whether they had ever been tested for HIV/AIDS.

Contextual-level factors

Type of sex worker

Participants were asked which term from a list of nine types of sex worker (street worker, dance hostess, etc.) best described their work situation. For the analyses, type of sex worker was dichotomized based on whether the FSW worked in an alcohol-serving establishment.

Use of alcohol or drugs before or during sex

Participants were asked how often in the past month they had used alcohol or drugs before or during sex with a client. Response categories were recoded to create a dichotomous variable for each (did use vs. did not use).

Presence of a pimp

Participants were asked how much money they earned for each of a number of different sex acts and how much of that money went to someone else. In each case, the relationship of that person to the FSW was queried. The categories included ‘pimp.’ A dichotomous variable was created (FSW has vs. does not have a pimp).

Community-level factors

Marginalization index

This figure is calculated by Mexico's National Council of Population (CONAPO, 2010) for each municipality. It consolidates nine socioeconomic indicators: percentage of population over age 15 that is illiterate; percentage over age 15 that lacks an elementary school education; percentage living without a toilet, electricity, or access to water; overcrowding; and household income lower than that of two minimum wage earners. CONAPO uses the index to determine where basic public services are lacking and conditions of poverty prevail. The higher the marginalization index, the greater an area's degree of disadvantage. Based on CONAPO's most recent assessment (CONAPO, 2010), we assigned a marginalization score to each of the 13 different cities from which FSWs were recruited for this study.

Policing practices

Participants were asked how many times they had been arrested for prostitution in the community where they had been recruited for the study. The number of prostitution arrests was recoded as a dichotomous variable (ever arrested = 1, never arrested = 0).

Data analyses

FSWs who reported any alcohol consumption in the past month and who had a score on the AUDIT-C greater than or equal to 3 were classified as hazardous drinkers. We first examined variance in hazardous drinking to determine the extent to which the nested design of the study affected independence of the data. After determining that the assumption of independence was not violated, we examined individual-level traits and behaviors (i.e. demographics, sexual risk behaviors and non-consensual sex, general health behaviors) as well as contextual (work-related) and community-level factors among hazardous and non-hazardous drinkers using univariate regression analyses. We then conducted a multivariate logistic regression to identity factors that were uniquely associated with hazardous drinking. Variables that were independently associated with hazardous drinking in bivariate analyses (P < 0.05) were included in the multivariate logistic regression model. Two variables with skewed distributions (total unprotected vaginal and anal sex acts, total number of clients) were log 10 transformed. Data were analyzed using SPSS Statistics Version 22.0.

RESULTS

Sample characteristics

Ninety-two percent of FSWs reported alcohol consumption in the past month. The prevalence of hazardous drinking in the full sample of FSWs (N = 1089) was 76.7%. Among the subsample of FSWs who consumed alcohol in the past month (N = 1001), 83.4% (N = 835) met AUDIT-C criteria for hazardous drinking. The average AUDIT score was 8.8 (SD = 3.2) for hazardous and 1.1 (SD = 0.85) for non-hazardous drinkers. We computed the intraclass correlation (ICC) in hazardous drinking across the 13 cities. We found an ICC of 0.20, suggesting that a relatively low amount of variance is attributable to city and that, therefore, the assumption of independence was not violated.

The first two data columns of Table 1 show the characteristics of the study sample in terms of demographics, sexual risk behaviors and non-consensual sex, general health behaviors, contextual (work-related) factors, and community factors. A comparison of the FSWs who were included in the regression analyses with the non-drinking FSWs who were excluded (N = 88) revealed only one significant demographic difference: the FSWs who were excluded reported fewer financial dependents compared to their alcohol-consuming counterparts (2.2 vs. 2.7, t = 2.5, P = .012).

Table 1.

Individual, contextual and community factors by hazardous vs. non-hazardous drinking among FSWs in 13 Mexican cities (N = 1001)

No hazardous drinkinga
(N = 166)		 Hazardous drinkinga
(N = 835)		 OR (95% CI) P
Demographics
 Age (mean, SD) 35.7 (10.4) 32.3 (9.1) 0.96 (0.95, 0.98) <0.001
 Years of education (mean, SD) 6.6 (3.9) 7.1 (3.2) 1.05 (1.01, 1.11) <0.05
 Married or common-law (N, %) 55 (33.1%) 214 (25.6%) 0.70 (0.49–0.99) <0.05
 Have children (N, %) 156 (94.0%) 729 (87.3%) 0.44 (0.23, 0.86) <0.05
 Number of financial dependents (mean, SD) 2.7 (1.6) 2.7 (1.8) 1.02 (0.93, 1.13)
 Number of years employed as a FSW (mean, SD) 6.9 (7.8) 6.1(6.3) 0.98 (0.96, 1.01)
Sexual risk behaviors and non-consensual sex
 Regular clients onlya (N, %) 7 (4.3%) 45 (5.6%) 1.34 (0.59, 3.03)
 Non-regular clients onlya (N, %) 2 (1.3%) 37 (4.7%) 3.86 (0.92, 16.2)
 Total number of clientsa (N, %) 57.7 (65.2) 39.7 (51.5) 0.52 (0.37, 0.74) <0.001
 Total number of unprotected vaginal and anal sex acts with clientsa (N, %) 16.9 (27.4) 15.7 (20.0) 1.04 (0.73, 1.49)
 Forced to have sex with client in past year (N, %) 27 (16.3%) 118 (14.1%) 0.85 (0.54, 1.34)
General health behaviors
 Used drugsb in the past month (N, %) 7 (4.2%) 99 (11.9%) 3.06 (1.39, 6.70) <0.01
 Cigarette smoker (N, %) 78 (47.0%) 522 (62.5%) 1.88 (1.34, 2.63) <0.001
 Ever been tested for HIV/AIDS (N, %) 113 (68.1%) 568 (68.0%) 0.99 (0.70, 1.43)
Contextual factors
 Bar worker or dance hostess (N, %) 21 (12.7%) 482 (57.7%) 9.43 (5.85, 15.20) <0.001
 Has a pimp or manager 28 (16.9%) 111 (13.3%) 0.76 (0.48, 1.19)
 Used alcohol before or during sex with client(s)a (N, %) 29 (17.5%) 632 (75.7%) 14.71 (9.56–22.63) <0.001
 Used drugsb before or during sex with client(s)a (N, %) 5 (3.0%) 68 (8.2%) 2.86 (1.14, 7.21) <0.05
Community factors
 Marginalization index for study site (mean, SD)c 10.5 (6.7) 16.5 (8.0) 1.13 (1.10, 1.17) <0.001
 Ever arrested by police (N, %) 39 (23.5%) 176 (21.1%) 0.87 (0.59, 1.29)
Open in a new tab

OR, odds ratio; CI, confidence interval.

aRefers to the last month.

bMexico's drug policy reform does not consider drug use illegal unless the amount possessed is above a certain threshold.

cThis association was tested to account for clustering using generalized estimating equations, and the results did not differ.

Univariate logistic regressions

A further column of Table 1 shows the results of univariate logistic regressions that examined associations between the dependent variable (hazardous drinking) and independent variables.

Individual-level factors

Compared to FSWs in the non-hazardous drinking group, FSWs who met AUDIT-C criteria for hazardous drinking had a lower odds of being older, of being married or in a common-law relationship, and of having children, along with a greater odds of having more years of education. Hazardous drinking was associated with a lower odds of having a large number of clients in the past month. FSWs who met AUDIT-C criteria for hazardous drinking also had a greater odds of having used drugs in the past month and of being a cigarette smoker.

Contextual-level factors

Hazardous drinkers had a greater odds of self-identifying as a bar maid or dance hostess (vs. working in a different type of venue), of having used alcohol before or during sex with clients in the past month, and of having used drugs with clients during this time frame.

Community-level factors

FSWs in the hazardous drinking group had a greater odds of conducting sex work in a location with a higher marginalization index compared to FSWs in the non-hazardous drinking group. No other variables at this level were significantly associated with hazardous drinking.

Factors independently associated with hazardous drinking

In a multivariate model, five factors were independently associated with hazardous drinking among the women in our sample. As shown in Table 2, participants who used drugs in the past month had over three times the odds of engaging in hazardous drinking, and cigarette smokers had almost twice the odds of hazardous drinking. FSWs who worked as barmaids or dance hostesses had almost three-and-one-half times the odds of meeting criteria for hazardous drinking compared to FSWs who self-identified as another type of sex worker. FSWs who used alcohol before or during sex with clients had almost eight times the odds of being in the hazardous drinking group compared to those who did not drink alcohol before or during sex with their clients. Hazardous drinking among FSWs was also associated with higher scores on Mexico's index of marginalization. For every unit increase in the marginalization index of the FSW's municipality of residence, the odds of engaging in hazardous drinking increased by 7%.

Table 2.

Multivariate logistic regression model examining correlates of hazardous drinkinga among FSWs in 13 Mexican cities (N = 1001)

Model AOR (95% CI) P
Age (years) 0.99 (0.97, 1.02)
Education (years) 1.04 (0.98, 1.11)
Marital status (married/cohabiting vs. other) 0.93 (0.60, 1.43)
Have at least one child 0.55 (0.25, 1.21)
Used drugsb 3.31 (1.29, 8.45) <0.01
Smoke cigarettes 1.71 (1.13, 2.58) <0.01
Number of clientsb 1.03 (0.66, 1.59)
Type of sex worker (bar worker vs. other) 3.40 (1.95, 5.91) <0.001
Used alcohol before or during sex with clientsb 7.78 (4.84, 12.52) <0.001
Used drugs before or during sex with clientsb 0.69 (0.23, 2.10)
Marginalization index 1.07 (1.04, 1.11) <0.001
Open in a new tab

Hazardous drinking: 1 = yes, no = 0. AOR, adjusted odds ratio; CI, confidence interval.

aAudit-C score greater than or equal to 3.

bIn the past month.

DISCUSSION

FSWs in this study, like their counterparts in other LMIC (e.g. Surratt, 2007; Verma et al., 2010; Odukoya et al., 2013; Alexander et al., 2014; Chersich et al., 2014; Fernandes et al., 2014), had a high prevalence of alcohol use. Ninety-two percent of the FSWs in our sample reported alcohol consumption in the past month, and an alarming 83% of the drinkers met AUDIT-C criteria for hazardous drinking. These findings suggest that interventions targeting alcohol use among FSWs in Mexico are urgently needed. Although hazardous drinking in general showed no association with rates of FSWs' condom use with clients, alcohol use in sexual contexts was so associated. This finding is consistent with results from our study of male clients of FSWs in Tijuana (Pitpitan et al., 2013b; Goodman-Meza et al., 2014), in that it highlights the importance of examining context-specific alcohol consumption in relation to high-risk unprotected sex. Overall, our findings support an increased emphasis upon programs for alcohol prevention and treatment among FSWs.

Our findings also indicate that it is important that harm-reduction interventions for alcohol be multi-level (Chersich et al., 2014). We found that hazardous drinking among FSWs in Mexico is influenced by a combination of individual-, contextual- and community-level factors, all of which should be taken into account when developing interventions for FSWs. At the individual level, we found an association between hazardous drinking and general negative health behaviors, including the use of drugs and cigarette smoking. This suggests that health consciousness among Mexican FSWs may be low and that holistic intervention approaches are needed to address multiple risky health habits simultaneously (Allamani et al., 2011). Prevention programs for high-risk drinking should take into account these other health habits, which are known contributors to lifestyle diseases (Gracey and King, 2009).

At the contextual level, we found hazardous alcohol consumption to be associated with type of sex worker and with use of alcohol before or during sex with clients. The strong association between hazardous drinking and type of sex worker (employment in venues where alcohol is served) suggests that interventions directed at alcohol-serving establishments could be useful. Kalichman et al. (2007) advocated the implementation of HIV prevention interventions in alcohol-serving establishments as a form of structural intervention. Interventions that integrate brief alcohol prevention counseling with HIV prevention messages could reach large numbers of FSWs who work in these venues. Such interventions may also be more acceptable to alcohol-serving businesses than alcohol prevention counseling alone. Educating owners about the benefits of such programs and obtaining their support and approval remains a challenge for researchers.

Another potentially fruitful point of intervention on the contextual level is FSWs' alcohol use during sexual encounters with their clients. The Mujer Segura intervention did not specifically target alcohol use; however, counselors addressed alcohol use if the participant identified it as a barrier to her use of condoms with clients. Counselors applied motivational interviewing (Miller and Rollnick, 1991) to elicit the participant's reasons for drinking with her clients and to increase her insight into how alcohol use affected her personal values and behavior, with the goal of increasing her motivation and willingness to reduce or stop using alcohol with clients. Social cognitive strategies (Bandura, 1986) were also used to increase the FSW's knowledge, self-efficacy, and positive outcome expectancies in relation to changing alcohol use behaviors with clients and negotiating condom use in the context of alcohol use. Cognitive behavioral therapy strategies (e.g. leaving high risk situations, delaying the decision to drink) were also offered for avoiding alcohol consumption or overconsumption with clients (Beck et al., 1979). Other studies have suggested that workplace-based policies of promoting ‘ladies’ drinks' (which are lower in alcohol) may be effective in reducing alcohol consumption and related risk behaviors among FSWs (Urada et al., 2012, 2013). Another approach that has been found effective in other risk groups and may be useful for FSWs is the promotion of strategies for self-management of alcohol cravings (e.g. Bowen et al., 2014).

FSWs who resided in Mexican cities with higher marginalization index scores had a greater odds of engaging in hazardous drinking. This finding is consistent with the situation described by the World Health Organization's framework of social determinants of health (World Health Organization, 2012). Research on the social determinants of substance abuse have linked a number of factors (low socioeconomic status, low income, low educational attainment, prevailing poverty, and social exclusion or discrimination) to increased vulnerability to substance abuse (Galea and Vlahov, 2002; Galea et al., 2004). Although Mexico has experienced overall economic growth over the past 20 years (Trading Economics, 2014), the benefits are unequally distributed. Underprivileged and stigmatized groups such as FSWs are often at the highest risk for hazardous drinking, particularly in developing countries where alcohol consumption levels are increasing (World Health Organization (WHO), 2004). High rates of hazardous drinking are of major concern to governments because of the associated social, financial, and health burdens (Poznyak et al., 2005). Addressing the social determinants of hazardous drinking among FSWs in Mexico will require multiple strategies, which may include some or all of the following: providing effective alcohol prevention and treatment programs, examining the role of alcohol availability, assessing extant alcohol policies, reducing stigma, and increasing opportunities for education and employment (Poznyak et al., 2005).

This study has a number of limitations. (a) The FSWs in our sample were volunteers in a sexual risk reduction intervention and thus may not be representative of the overall population of FSWs in Mexico. (b) Our findings are based on cross-sectional data, which provide no basis for inferring causal relationships. (c) The findings are limited by the retrospective and self-report nature of the behavioral data. In particular, both alcohol use and behaviors that occur in the context of alcohol use are subject to inaccurate recall and reporting biases. (d) We did not use event-level analysis, which is desirable in studies of alcohol use and behavior. (e) Our baseline survey was brief, and as a consequence, a limited number of contextual and community-level factors were examined. Future studies should examine a wide range of individual, contextual, and community-level factors as correlates of hazardous drinking among FSWs in Mexico and other LMIC. In addition, the potential risks associated with hazardous drinking (e.g. STIs, HIV infection) should be examined prospectively.

FUNDING

This work was supported by the National Institutes of Health (R01 MH087054-01A1 to T.L.P. and K01 DA036447-01 to E.V.P.).

CONFLICT OF INTEREST STATEMENT

No financial disclosures were reported by the authors of this paper. The authors declare that they have no conflict of interest. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the National Institutes of Health.

REFERENCES

  1. Alexander M, Mainkar M, Deshpande S et al. (2014) Heterosexual anal sex among female sex workers in high HIV prevalence states of India: need for comprehensive intervention. PLoS One 9:e88858. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Allamani A, Voller F, Decarli A et al. (2011) Contextual determinants of alcohol consumption changes and preventive alcohol policies: a 12-country European study in progress. Subst Use Misuse 46:1288–303. [DOI] [PubMed] [Google Scholar]
  3. Bandura A. (1986) Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall. [Google Scholar]
  4. Beck AT, Rush AJ, Shaw BF et al. (1979) Cognitive Therapy of Depression. New York: Guilford Press. [Google Scholar]
  5. Bowen S, Witkiewitz K, Clifasefi SL et al. (2014) Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: a randomized clinical trial. JAMA Psychiatry 71:547–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Bradley KA, Bush KR, Epler AJ et al. (2003) Two brief alcohol-screening tests from the Alcohol Use Disorders Identification Test (AUDIT): validation in a female Veterans Affairs patient population. Arch Intern Med 163:821–9. [DOI] [PubMed] [Google Scholar]
  7. Bradley KA, DeBenedetti AF, Volk RJ et al. (2007) AUDIT-C as a brief screen for alcohol misuse in primary care. Alcohol Clin Exp Res 31:1208–17. [DOI] [PubMed] [Google Scholar]
  8. Bucardo J, Semple SJ, Fraga-Vallejo M et al. (2004) A qualitative exploration of female sex work in Tijuana, Mexico. Arch Sex Behav 33:343–51. [DOI] [PubMed] [Google Scholar]
  9. Bush K, Kivlahan DR, McDonell MB et al. (1998) The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med 158:1789–95. [DOI] [PubMed] [Google Scholar]
  10. Chen Y, Li X, Shen Z et al. (2013) Alcohol and sexual risk: an event-level analysis in commercial sex setting. Addict Behav 38:2888–92. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Chersich MF, Luchters SM, Malonza IM et al. (2007) Heavy episodic drinking among Kenyan female sex workers is associated with unsafe sex, sexual violence and sexually transmitted infections. Int J STD AIDS 18:764–9. [DOI] [PubMed] [Google Scholar]
  12. Chersich MF, Bosire W, King'ola N et al. (2014) Effects of hazardous and harmful alcohol use on HIV incidence and sexual behaviour: a cohort study of Kenyan female sex workers. Global Health 10:22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Chiao C, Morisky DE, Rosenberg R et al. (2006) 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. Subst Use Misuse 41:1509–33. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. CONAPO. (2010) Índices de marginación [Marginalization indices]. Secretaría de Gobernación, Mexico City: http://conapo.gob.mx/es/CONAPO/Indices_de_Marginacion (21 February 2015, date last accessed). [Google Scholar]
  15. Fernandes FR, Mousquer GJ, Castro LS et al. (2014) HIV seroprevalence and high-risk sexual behavior among female sex workers in central Brazil. AIDS Care 26:1095–9. [DOI] [PubMed] [Google Scholar]
  16. Galea S, Vlahov D (2002) Social determinants and the health of drug users: socioeconomic status, homelessness, and incarceration. Public Health Rep 117(Suppl 1):S135–45. [PMC free article] [PubMed] [Google Scholar]
  17. Galea S, Nandi A, Vlahov D (2004) The social epidemiology of substance use. Epidemiol Rev 26:36–52. [DOI] [PubMed] [Google Scholar]
  18. Go VF, Srikrishnan AK, Parker CB et al. (2011) High prevalence of forced sex among non-brothel based, wine shop centered sex workers in Chennai, India. AIDS Behav 15:163–71. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Goodman-Meza D, Pitpitan EV, Semple SJ et al. (2014) Hazardous drinking and HIV-risk-related behavior among male clients of female sex workers in Tijuana, Mexico. Am J Addict 23:502–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Gracey M, King M (2009) Indigenous health part 1: determinants and disease patterns. Lancet 374:65–75. [DOI] [PubMed] [Google Scholar]
  21. Hendershot CS, George WH (2007) Alcohol and sexuality research in the AIDS era: trends in publication activity, target populations and research design. AIDS Behav 11:217–26. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Heravian A, Solomon R, Krishnan G et al. (2012) Alcohol consumption patterns and sexual risk behavior among female sex workers in two South Indian communities. Int J Drug Policy 23:498–504. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Hess KL, Chavez PR, Kanny D et al. (2015) Binge drinking and risky sexual behavior among HIV-negative and unknown HIV status men who have sex with men, 20 US cities. Drug Alcohol Depend 147:46–52. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Hong Y, Li X, Fang X et al. (2007) Correlates of suicidal ideation and attempt among female sex workers in China. Health Care Women Int 28:490–505. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Inder KJ, Handley TE, Fitzgerald M et al. (2012) Individual and district-level predictors of alcohol use: cross sectional findings from a rural mental health survey in Australia. BMC Public Health 12:586. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Kaarne T, Aalto M, Kuokkanen M et al. (2010) AUDIT-C, AUDIT-3 and AUDIT-QF in screening risky drinking among Finnish occupational health-care patients. Drug Alcohol Rev 29:563–7. [DOI] [PubMed] [Google Scholar]
  27. Kalichman SC, Simbayi LC, Kaufman M et al. (2007) Alcohol use and sexual risks for HIV/AIDS in sub-Saharan Africa: systematic review of empirical findings. Prev Sci 8:141–51. [DOI] [PubMed] [Google Scholar]
  28. Kalichman SC, Simbayi LC, Vermaak R et al. (2008) HIV/AIDS risks among men and women who drink at informal alcohol serving establishments (Shebeens) in Cape Town, South Africa. Prev Sci 9:55–62. [DOI] [PubMed] [Google Scholar]
  29. Kissinger P, Althoff M, Burton N et al. (2013) Prevalence, patterns and predictors of substance use among Latino migrant men in a new receiving community. Drug Alcohol Depend 133:814–24. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Kuipers MA, van Poppel MN, van den Brink W et al. (2012) The association between neighborhood disorder, social cohesion and hazardous alcohol use: a national multilevel study. Drug Alcohol Depend 126:27–34. [DOI] [PubMed] [Google Scholar]
  31. Kuipers MA, Jongeneel-Grimen B, Droomers M et al. (2013) Why residents of Dutch deprived neighbourhoods are less likely to be heavy drinkers: the role of individual and contextual characteristics. J Epidemiol Community Health 67:587–94. [DOI] [PubMed] [Google Scholar]
  32. Lambert G, Cox J, Hottes TS et al. (2011) Correlates of unprotected anal sex at last sexual episode: analysis from a surveillance study of men who have sex with men in Montreal. AIDS Behav 15:584–95. [DOI] [PubMed] [Google Scholar]
  33. Larios SE, Lozada R, Strathdee SA et al. (2009) An exploration of contextual factors that influence HIV risk in female sex workers in Mexico: the social ecological model applied to HIV risk behaviors. AIDS Care 21:1335–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Li Q, Li XM, Stanton B (2010) Alcohol use among female sex workers and male clients: an integrative review of global literature. Alcohol Alcohol 45:188–99. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Medhi GK, Mahanta J, Kermode M et al. (2012) Factors associated with history of drug use among female sex workers (FSW) in a high HIV prevalence state of India. BMC Public Health 12:273. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Miller WR, Rollnick S (1991) Motivational Interviewing: Preparing People to Change Addictive Behavior. New York, NY: Guilford Press. [Google Scholar]
  37. Odukoya OO, Sekoni AO, Onajole AT et al. (2013) Alcohol consumption and cigarette smoking pattern among brothel-based female sex workers in two local government areas in Lagos State, Nigeria. Afr Health Sci 13:490–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Ortiz-Hernandez L, Lopez-Moreno S, Borges G (2007) Socioeconomic inequality and mental health: a Latin American literature review. Cad Saude Publica 23:1255–72. [DOI] [PubMed] [Google Scholar]
  39. Patterson TL, Mausbach B, Lozada R et al. (2008a) Efficacy of a brief behavioral intervention to promote condom use among female sex workers in Tijuana and Ciudad Juarez, Mexico. Am J Public Health 98:2051–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Patterson TL, Semple SJ, Staines H et al. (2008b) Prevalence and correlates of HIV infection among female sex workers in 2 Mexico-US border cities. J Infect Dis 197:728–32. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Patterson TL, Semple SJ, Chavarin CV et al. (2012) Implementation of an efficacious intervention for high risk women in Mexico: protocol for a multi-site randomized trial with a parallel study of organizational factors. Implement Sci 7:105. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Pawa D, Firestone R, Ratchasi S et al. (2013) Reducing HIV risk among transgender women in Thailand: a quasi-experimental evaluation of the Sisters Program. PLoS One 8:e77113. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Pitpitan EV, Kalichman SC, Eaton LA et al. (2013a) HIV/STI risk among venue-based female sex workers across the globe: a look back and the way forward. Curr HIV/AIDS Rep 10:65–78. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Pitpitan EV, Wagner KD, Goodman-Meza D et al. (2013b) Context matters: the moderating role of bar context in the association between substance use during sex and condom use among male clients of female sex workers in Tijuana, Mexico. AIDS Behav 17:2577–87. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Pitpitan EV, Kalichman SC, Eaton LA et al. (2014) Men (and women) as ‘sellers’ of sex in alcohol-serving venues in Cape Town, South Africa. Prev Sci 15:296–308. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Pitpitan EV, Strathdee SA, Semple SJ et al. (2015) Perceived stigma of purchasing sex among Latino and non-Latino male clients of female sex workers in Tijuana, Mexico. J Immigr Minor Health 17:172–80. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Poznyak V, Saraceno B, Obot IS (2005) Breaking the vicious circle of determinants and consequences of harmful alcohol use. Bull World Health Organ 83:803. [PMC free article] [PubMed] [Google Scholar]
  48. Robertson AM, Syvertsen JL, Amaro H et al. (2014) Can't buy my love: a typology of female sex workers’ commercial relationships in the Mexico-U.S. border region. J Sex Res 51:711–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Saggurti N, Jain AK, Sebastian MP et al. (2012) Indicators of mobility, socio-economic vulnerabilities and HIV risk behaviours among mobile female sex workers in India. AIDS Behav 16:952–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Samet JH, Pace CA, Cheng DM et al. (2010) Alcohol use and sex risk behaviors among HIV-infected female sex workers (FSWs) and HIV-infected male clients of FSWs in India. AIDS Behav 14(Suppl 1):S74–83. [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Scribner R, Mason K, Theall K et al. (2008) The contextual role of alcohol outlet density in college drinking. J Stud Alcohol Drugs 69:112–20. [DOI] [PubMed] [Google Scholar]
  52. Stein MD, Anderson BJ, Caviness CM et al. (2009) Relationship of alcohol use and sexual risk taking among hazardously drinking incarcerated women: an event-level analysis. J Stud Alcohol Drugs 70:508–15. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Strathdee SA, Lozada R, Pollini RA et al. (2008) Individual, social, and environmental influences associated with HIV infection among injection drug users in Tijuana, Mexico. J Acquir Immune Defic Syndr 47:369–76. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Strathdee SA, Abramovitz D, Lozada R et al. (2013) Reductions in HIV/STI incidence and sharing of injection equipment among female sex workers who inject drugs: results from a randomized controlled trial. PLoS ONE 8:e65812. [DOI] [PMC free article] [PubMed] [Google Scholar]
  55. Surratt H. (2007) Sex work in the Caribbean basin: patterns of substance use and HIV risk among migrant sex workers in the US Virgin Islands. AIDS Care 19:1274–82. [DOI] [PubMed] [Google Scholar]
  56. Trading Economics. (2014) Mexico GDP Growth Rate http://www.tradingeconomics.com/mexico/gdp-growth (16 June 2014, date last accessed).
  57. Urada LA, Morisky DE, Pimentel-Simbulan N et al. (2012) Condom negotiations among female sex workers in the Philippines: environmental influences. PLoS One 7:e33282. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Urada LA, Morisky DE, Hernandez LI et al. (2013) Social and structural factors associated with consistent condom use among female entertainment workers trading sex in the Philippines. AIDS Behav 17:523–35. [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Verma RK, Saggurti N, Singh AK et al. (2010) Alcohol and sexual risk behavior among migrant female sex workers and male workers in districts with high in-migration from four high HIV prevalence states in India. AIDS Behav 14(Suppl 1):S31–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Witte SS, Batsukh A, Chang M (2010) Sexual risk behaviors, alcohol abuse, and intimate partner violence among sex workers in Mongolia: implications for HIV prevention intervention development. J Prev Interv Community 38:89–103. [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. World Health Organization. (2004) Global Status Report on Alcohol 2004. Geneva, Switzerland: http://www.who.int/substance_abuse/publications/global_status_report_2004_overview.pdf (5 March 2015, date last accessed). [Google Scholar]
  62. World Health Organization. (2012) Social Determinants of Health Geneva, Switzerland: http://www.who.int/social_determinants/B_132_14-en.pdf?ua=1 (5 March 2015, date last accessed). [Google Scholar]
  63. Yadav G, Saskin R, Ngugi E et al. (2005) Associations of sexual risk taking among Kenyan female sex workers after enrollment in an HIV-1 prevention trial. J Acquir Immune Defic Syndr 38:329–34. [PubMed] [Google Scholar]
  64. Yadav D, Chakrapani V, Goswami P et al. (2014) Association between alcohol use and HIV-related sexual risk behaviors among men who have sex with men (MSM): findings from a multi-site bio-behavioral survey in India. AIDS Behav 18:1330–8. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Alcohol and Alcoholism (Oxford, Oxfordshire) are provided here courtesy of Oxford University Press

RESOURCES