Objectives Female sex workers (FSWs) experience violence from a range of perpetrators, but little is known about how violence experience across multiple settings (workplace, community, domestic) impacts on HIV/sexually transmitted infection (STI) risk. We examined whether HIV/STI risk differs by the perpetrator of violence.
Methods An Integrated Biological and Behavioural Assessment survey was conducted among random samples of FSWs in two districts (Bangalore and Shimoga) in Karnataka state, south India, in 2011. Physical and sexual violence in the past six months, by workplace (client, police, coworker, pimp) or community (stranger, rowdy, neighbour, auto-driver) perpetrators was assessed, as was physical and sexual intimate partner violence in the past 12 months. Weighted, bivariate and multivariate analyses were used to examine associations between violence by perpetrator and HIV/STI risk.
Results 1111 FSWs were included (Bangalore=718, Shimoga=393). Overall, 34.9% reported recent physical and/or sexual violence. Violence was experienced from domestic (27.1%), workplace (11.1%) and community (4.2%) perpetrators, with 6.2% of participants reporting recent violence from both domestic and non-domestic (workplace/community) perpetrators. Adjusted analysis suggests that experience of violence by workplace/community perpetrators is more important in increasing HIV/STI risk during sex work (lower condom use with clients; client or FSW under the influence of alcohol at last sex) than domestic violence. However, women who reported recent violence by domestic and workplace/community perpetrators had the highest odds of high-titre syphilis infection, recent STI symptoms and condom breakage at last sex, and the lowest odds of condom use at last sex with regular clients compared with women who reported violence by domestic or workplace/community perpetrators only.
Conclusion HIV/STI risk differs by the perpetrator of violence and is highest among FSWs experiencing violence in the workplace/community and at home. Effective HIV/STI prevention programmes with FSWs need to include violence interventions that address violence across both their personal and working lives.
- female sex workers
- sexually transmitted infections
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Contributors AB conducted the analyses and wrote the first draft of the manuscript. RP supervised the analyses and reviewed the article. RP, SI, HLM, LP, JB and SM contributed to the study design and reviewed the article. TSB conceptualised the study, supervised the analyses and reviewed the article.
Funding This study was supported by the India AIDS Initiative (Avahan) of the Bill & Melinda Gates Foundation, grant no. OPP52138. TB, RP, LP and SI were supported by the UK Department for International Development (DFID) as part of STRIVE, a 6-year programme of research and action devoted to tackling the structural drivers of HIV (http://STRIVE.lshtm.ac.uk/). TB is supported by a British Academy Fellowship.
Disclaimer The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Bill and Melinda Gates Foundation, UK DFID or the British Academy.
Competing interests None declared.
Patient consent Not required.
Ethics approval This study was approved by the ethical review board of St Johns Medical College in Bangalore, India (IRB: 179/2010); the Research Ethics Board at the University of Manitoba, Canada (IRB: H2005:098); and the Research Ethics Committee at the London Schoolof Hygiene and Tropical Medicine (IRB: 11118).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.
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