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• W2056638645 abstract "THE SYNERGISTIC RELATIONSHIP BETWEEN sex work and drug use has propelled HIV epidemics in multiple settings.1–5 Both male sex workers (MSWs) and female sex workers (FSWs) who inject drugs are more likely to engage in injecting behaviors that increase risk for both acquiring and transmitting HIV infection.2,6 Many Central Asian Republics are experiencing concentrated HIV epidemics in at least 1 urban center, largely driven by injecting drug use.7–10 Uzbekistan, the most populous of the Central Asian Republics, has the largest HIV epidemic in the region.5 Samarkand, the second largest city in Uzbekistan, lies on major drug transportation routes and, as such, has been affected by the IDU epidemic, and the spread of HIV in the region.11,12 In late 2003, the AIDS Center in Samarkand had diagnosed 114 cases, with 6 (5.3%) among SWs.13 A rapid assessment conducted in 2003 estimated there to be between 1000 and 1200 SWs in Samarkand, with reported drug use varying by venue, but did not include a seroprevalence assessment.13 Our objective was to determine the prevalence and factors associated with HIV infection among SWs in Samarkand, Uzbekistan to inform relevant prevention programs for this marginalized group. This cross-sectional study was conducted between July, 2004 and July, 2005. Potential participants were: SW 18 years of age or older engaging in sex work in the last month able to provide informed consent. Participants were recruited by outreach workers and when presenting to Ayol Center, a nongovernment organization whose mission is to increase HIV awareness and provide legal counseling to marginalized groups and, through this work, has established rapport with the SW community. Participants received a small gift of vitamins (US$2), but no compensation was provided for referrals and nor were social networks mapped. This project was approved by the Investigational Review Boards of the U.S. Naval Medical Research Unit, No. 3, and the Ministry of Health of Uzbekistan. Participants completed an interviewer-administered questionnaire detailing demographic and socioeconomic characteristics, sexual risk behaviors and lifetime condom use in commercial and noncommercial settings, and drug use history. Awareness of HIV was queried; transmission and prevention knowledge were separately assessed through open-ended questions. Participants then completed pre and posttest counseling and HIV antibody testing using enzyme-linked immunoassay (ELISA) (Enzygnost Anti HIV 1/2 Plus, Dade Behring, Germany), with Western Blot (HIV BLOT 2.2, GeneLabs Diagnostics, Singapore) confirmation. Participants diagnosed with HIV were referred to the Samarkand Oblast Republican AIDS Center for further counseling and treatment. Differences between sex and descriptive variables were assessed with χ2 tests, while associations with HIV infection and, separately, correct HIV prevention knowledge were identified with logistic regression analysis. For HIV infection, demographic and risk behavior variables were considered, while for correct HIV prevention knowledge, select demographic and sex work associated variables were selected for analysis adjusted for sex. All variables with P ≤0.10 in univariable analysis were assessed with likelihood ratio test. Variables remaining significant (P ≤0.05) were retained in the multivariable model. All statistical analysis was performed using Stata Version 8.0 (Stata Corporation, College Station, TX). FSWs (n = 329) differed significantly from MSWs (n = 43) with regard to marital status, ethnic background, travel history, and educational level (Table 1). The mean age of sex work initiation was 24.6 years (range: 13–41 years). Most SW entered sex work due to financial hardship (93.3%), with only 1 participant engaging in sex work to earn money for drugs. SW reported a mean of 4.67 clients daily (IQR = 2–5). Sex work venue and sexual service fee varied significantly by sex, though daily client number did not (Table 1). Few SWs (5.7%) reported any condom use with nonclient partners, of whom all were female, and 57.1% (n = 12) reported always using condoms. Only 7.3% reported any illicit substance use and 6.1% reported prior injection drug use, which was equally likely for MSW and FSW.TABLE 1: Descriptive Characteristics and Differences Between Male and Female Sex Workers (SWs) in Samarkand, Uzbekistan (n = 372)HIV prevalence was 6.18% (n = 23; 95% CI: 3.96–9.13). Ever injecting drugs (OR = 6.49, 95% CI: 2.10–20.09) was the sole variable associated with HIV infection in analysis adjusted for sex. Approximately one-third stated they knew either how HIV was transmitted (38.4%) or how HIV could be prevented (41.4%). However, those aware of HIV were not always able to provide correct information. Of those reporting transmission knowledge, the most commonly identified routes were sexual (88.8%, n = 127), blood (66.2%, n = 94), and used needles/syringes (21.0%, n = 30); a few (4.9%, n = 7) provided incorrect answers. Most SWs with reported prevention knowledge identified using condoms (92.9%, n = 143) or new needles/syringes with each injection (52.0%, n = 80) as a means of prevention. In multivariable logistic regression analysis inclusive of employment outside sex work, gender, and educational level, only lack of employment outside of sex work (AOR = 12.56, 95% CI: 4.43–35.57) and higher level of education (AOR = 2.89, 95% CI: 1.05–7.93) were independently associated with correct prevention knowledge. A lower HIV prevalence was detected among SWs in Samarkand than among FSWs in Tashkent.14 History of injection drug use was the only high risk behavior associated with HIV infection, similar to Tashkent, where it was the most strongly associated variable.14 Risky injection practices among SWs were equally prevalent in Samarkand and Tashkent. However, no sexual risk behaviors were associated with HIV infection in Samarkand. It is possible that there was not sufficient power to detect this difference due to the lower prevalence of HIV among Samarkand SW. Reported consistent condom use with clients was similar between FSWs in Tashkent and Samarkand, which was surprising given that most Samarkand FSWs were brothel-based. We received anecdotal reports that brothel managers (mama rosas) charged higher prices for services performed without a condom. Further investigation of the role of mama rosas in condom use should be conducted to determine whether their influence may contribute to greater support for or actual use of condoms as seen in Thailand and India.15,16 Although sex work venue was not associated with HIV infection or knowledge, venue may impact access to outreach and education services for this population. It is interesting that outreach workers were able to access brothel-based FSWs; our understanding is that mama rosas allow their SWs to access the program services for free examinations and sexually-transmitted infection treatment. To our knowledge, Ayol was the only outreach service for SWs operating in Samarkand at the time of the study. MSWs were more likely to engage in high-risk sexual behavior (lack of condom use) despite being more likely to have correct prevention knowledge. However, HIV infection was lower, though not significantly so, among MSWs in this population, possibly due to either sharing of injecting equipment or higher-risk sexual partners among FSWs. MSWs have been noted to engage disproportionately in higher risk sexual behaviors compared with FSWs in settings where this difference could explain disproportionate HIV infection among MSWs.17,18 However, given the findings, disparate injecting behaviors between the sexes seem to have greater impact on HIV prevalence than sexual behaviors. At the time of the study, there was 1 needle exchange program operating in Samarkand; subsequently, trust points have been established at government HIV clinics, including the clinic in Samarkand, where vulnerable groups may access condoms and clean needles.19 However, as noted in Tashkent, sex work and drug use are both illegal in Uzbekistan and these groups tend to avoid government facilities. An assessment of the efficacy of government trust points would be beneficial to ensure programs are reaching the target population.19 Both awareness and correct knowledge of HIV transmission and prevention was much lower among Samarkand than Tashkent SWs.14 This difference may be due to less dissemination of public service messages or more conservative social structures outside of Tashkent. Although venue was not associated with prevention knowledge, peer education programs in various settings have been shown to improve both HIV prevention knowledge and practice among SWs.20,21 Limitations include cross-sectional design preventing demonstration of causal relationships and lack of proportional sampling resulting in a potentially nonrepresentative sample. Low prevalence of HIV infection and of history of injecting drugs diminishes the certainty with which some associations may be made. Further, some terms were based on perception, such as “financial hardship” as a reason for entering sex work; the meaning may be variable and cannot be uniformly applied. Sexual partnerships were not assessed beyond the basic divisions of client and nonclient regular partner. Other studies indicate that condom use varies based on degree of familiarity between client and partner, and between spouses/regular partners, and casual nonclient partners.22,23 Last, condom use and prior drug use are based on self-report in interview and may not be accurate due to socially-desirable response. In this first assessment of HIV among SW in Samarkand, the association of HIV infection with injection drug use and the inconsistent use of condoms with clients emphasize a pressing need for prevention programs accessible to these marginalized populations. Drug treatment and harm reduction programs aimed at decreasing risky injecting behaviors, interventions targeted to SWs and their clients on sexual risk reduction, and development of confidential, accessible reproductive health services for SWs are urgently needed." @default.
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• W2056638645 date "2009-02-01" @default.
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• W2056638645 title "Prevalence and Factors Associated With Human Immunodeficiency Virus Infection Among Sex Workers in Samarkand, Uzbekistan" @default.
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