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      Transactional Sex Risk across a Typology of Rural and Urban Female Sex Workers in Indonesia: A Mixed Methods Study

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          Context-specific typologies of female sex workers (FSWs) are essential for the design of HIV intervention programming. This study develops a novel FSW typology for the analysis of transactional sex risk in rural and urban settings in Indonesia. Mixed methods include a survey of rural and urban FSWs (n = 310), in-depth interviews (n = 11), key informant interviews (n = 5) and ethnographic assessments. Thematic analysis categorises FSWs into 5 distinct groups based on geographical location of their sex work settings, place of solicitation, and whether sex work is their primary occupation. Multiple regression analysis shows that the likelihood of consistent condom use was higher among urban venue-based FSWs for whom sex work is not the only source of income than for any of the other rural and urban FSW groups. This effect was explained by the significantly lower likelihood of consistent condom use by rural venue-based FSWs (adjusted OR: 0.34 95% CI 0.13–0.90, p = 0.029). The FSW typology and differences in organisational features and social dynamics are more closely related to the risk of unprotected transactional sex, than levels of condom awareness and availability. Interventions need context-specific strategies to reach the different FSWs identified by this study's typology.

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          Most cited references 21

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          Review of sampling hard-to-reach and hidden populations for HIV surveillance.

          Adequate surveillance of hard-to-reach and 'hidden' subpopulations is crucial to containing the HIV epidemic in low prevalence settings and in slowing the rate of transmission in high prevalence settings. For a variety of reasons, however, conventional facility and survey-based surveillance data collection strategies are ineffective for a number of key subpopulations, particularly those whose behaviors are illegal or illicit. This paper critically reviews alternative sampling strategies for undertaking behavioral or biological surveillance surveys of such groups. Non-probability sampling approaches such as facility-based sentinel surveillance and snowball sampling are the simplest to carry out, but are subject to a high risk of sampling/selection bias. Most of the probability sampling methods considered are limited in that they are adequate only under certain circumstances and for some groups. One relatively new method, respondent-driven sampling, an adaptation of chain-referral sampling, appears to be the most promising for general applications. However, as its applicability to HIV surveillance in resource-poor settings has yet to be established, further field trials are needed before a firm conclusion can be reached.
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            Social and structural violence and power relations in mitigating HIV risk of drug-using women in survival sex work.

            High rates of violence among street-level sex workers have been described across the globe, while in cities across Canada the disappearance and victimization of drug-using women in survival sex work is ongoing. Given the pervasive levels of violence faced by sex workers over the last decades, and extensive harm reduction and HIV prevention efforts operating in Vancouver, Canada, this research aimed to explore the role of social and structural violence and power relations in shaping the HIV risk environment and prevention practices of women in survival sex work. Through a participatory-action research project, a series of focus group discussions were conceptualized and co-facilitated by sex workers, community and research partners with a total of 46 women in early 2006. Based on thematic, content and theoretical analysis, the following key factors were seen to both directly and indirectly mediate women's agency and access to resources, and ability to practice HIV prevention and harm reduction: at the micro-level, boyfriends as pimps and the 'everyday violence' of bad dates; at the meso-level, a lack of safe places to take dates, and adverse impacts of local policing; and at the macro-level, dopesickness and the need to sell sex for drugs. Analysis of the narratives and daily lived experiences of women sex workers highlight the urgent need for a renewed HIV prevention strategy that moves beyond a solely individual-level focus to structural and environmental interventions, including legal reforms, that facilitate 'enabling environments' for HIV prevention.
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              Mapping violence and policing as an environmental-structural barrier to health service and syringe availability among substance-using women in street-level sex work.

              Within street-based sex work and substance-using populations, there is growing evidence to support the role of place, both physical setting and social meanings attached to place, in mediating the effectiveness and reach of health and harm reduction services. Social mapping was used to explore how health service and syringe availability may be impacted at the geographic level by avoidance of physical settings due to violence and policing among women in street-level sex work. Through a community-based research partnership and extensive peer-led outreach over a 6-month period, women were invited to participate in interview-questionnaires and mapping of their community, working conditions, and access to resources. Results were compiled used ArcGIS software and GIS street maps. In secondary analysis, logistic regression was used to model the geographic association (using likelihood ratio and significance at p<0.05) and stratified models were run to assess differential patterns of avoidance based on age, ethnicity and drug use. The findings reveal a significant geographic relationship between a heavily concentrated core area of health and syringe availability and avoidance of physical settings due to violence and policing by 198 women in street-level sex work in Vancouver, Canada. Of particular concern, this correlation is significantly elevated among younger and Aboriginal women, active injection drug users, and daily crack cocaine smokers, suggesting significant environmental-structural barriers to interventions among these vulnerable populations. The resultant displacement of sex work to primarily industrial settings and side streets pushes women further from health and social supports and reduces access to safer injection and drug use paraphernalia. This study offers important evidence for environmental-structural level prevention and safer environment interventions, supported by legal reforms, that facilitate safer sex work environments, including spatial programming, peer-based prevention, outreach and mobile resources, and peer-supervised safer sex work settings.

                Author and article information

                Role: Editor
                PLoS One
                PLoS ONE
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                28 December 2012
                : 7
                : 12
                [1 ]Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
                [2 ]Department of Social Policy, London School of Economics and Political Science, London, United Kingdom
                Indiana University and Moi University, United States of America
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: DIP EC. Performed the experiments: DIP. Analyzed the data: DIP. Contributed reagents/materials/analysis tools: DIP EC. Wrote the paper: DIP EC.


                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Pages: 12
                The work was supported by Economic and Social Science Research Council (ESRC) Grant ES.J004898.1 (; and Central Research Fund grants awarded in 2006 and 2007 respectively ( The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Research Article
                Clinical Research Design
                Qualitative Studies
                Infectious Diseases
                Viral Diseases
                HIV epidemiology
                HIV prevention
                Sexually Transmitted Diseases
                Mental Health
                Non-Clinical Medicine
                Health Care Policy
                Health Risk Analysis
                Sexual and Gender Issues
                Public Health
                Behavioral and Social Aspects of Health
                Women's Health
                Social and Behavioral Sciences
                Social Anthropology
                Sexual and Gender Issues



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