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HIV Prevention Among Women Who Use Substances And Report Sex Work: Risk Groups Identified Among South African Women

Abstract

This cross-sectional study presents baseline data from women (n = 641) in a community-based randomized trial in Pretoria, South Africa. Women were eligible if they reported recent alcohol or other drug (AOD) use and condomless sex. Latent class analyses were conducted separately for those who reported sex work and those who did not. Among those who reported sex work, a Risky Sex class (n = 72, 28%) and Low Sexual Risk class (n = 190, 73%) emerged. Those in the Risky Sex class were more likely to report that their last episode of sexual intercourse was with their boyfriend (vs. a client/other partner) compared with the Low Sexual Risk class (p < 0.001). Among participants who did not report sex work, a Drug-Using, Violence-Exposed, and Impaired Sex class (n = 53; 14%) and Risky Sex and Moderate Drinking class (n = 326; 86%) emerged. The findings suggest that interventions for women who engage in sex work should promote safer sexual behavior and empowerment with main partners. Women who use AODs, experience physical or sexual violence, and have impaired sex may be a key population at risk for HIV and should be considered for tailored behavioral interventions in conjunction with South Africa’s plan to disseminate HIV prevention methods to vulnerable women. Trial Registration: ClinicalTrials.gov registration NCT01497405.

Resumen

Este estudio transversal presenta datos sobre referencia de mujeres (n = 641 basados) en un ensayo controlado aleatorio en la comunidad de Pretoria, Sudáfrica. Las mujeres fueron elegibles si reportaron el consumo reciente de alcohol o drogas y practicaron sexo sin condón. Se realizaron análisis de clase latente por separado para aquellas que reportaron ser trabajadoras sexuales y aquellas que no. Entre aquellas mujeres que reportaron ser trabajadoras sexuales, se encontró que (n = 72, 28%) tuvieron Prácticas Sexuales Riesgosas y (n = 190, 73%) Tuvieron Prácticas Sexuales de Bajo Riesgo. Aquellas mujeres que tuvieron Prácticas Sexuales Riesgosas, reportaron más frecuentemente que su último intercambio sexual fue con su novio y no con un cliente u otro compañero, comparado con las que tuvieron Prácticas Sexuales de Bajo Riesgo (p < 0.001). También se encontró consumo de drogas, violencia y algunos trastornos sexuales (n = 53, 14%) así como Prácticas Sexuales Riesgosas y consumo moderado de alcohol (n = 326; 86%), entre las participantes que no reportaron ser trabajadoras sexuales. Los hallazgos sugieren que las intervenciones en mujeres que están involucradas como trabajadoras sexuales podría promover las prácticas sexuales más seguras y el empoderamiento con su pareja principal. Las mujeres que usan sustancias alucinógenas, que están expuestas a violencia física y sexual, y que tienen trastornos sexuales podrían ser la población clave con riesgo de contagiarse de VIH, por lo tanto; deberían ser consideradas en las intervenciones de comportamiento adaptativo, en conjunto con el plan de Sudáfrica para diseminar los métodos de prevención de VIH entre mujeres vulnerables.

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References

  1. UNAIDS. AIDS by the numbers: 2015. 2015.

  2. Republic of South Africa Department of Health. The South African National Sex Worker HIV Plan. 2016.

  3. Dunkle K, Jewkes R, Brown H, Gray G, McIntryre J, Harlow S. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet. 2004;363(9419):1415–21.

    Article  PubMed  Google Scholar 

  4. Rodrigo C, Rajapakse S. HIV, poverty and women. Int Health. 2010;2(1):9–16.

    Article  PubMed  Google Scholar 

  5. Townsend L, Ragnarsson A, Mathews C, Johnston LG, Ekstrom AM, Thorson A, et al. “Taking care of business”: alcohol as currency in transactional sexual relationships among players in Cape Town, South Africa. Qual Health Res. 2011;21(1):41–50.

    Article  PubMed  Google Scholar 

  6. Devries KM, Child JC, Bacchus LJ, Mak J, Falder G, Graham K, et al. Intimate partner violence victimization and alcohol consumption in women: a systematic review and meta-analysis. Addiction. 2013;109(3):379–91.

    Article  PubMed  Google Scholar 

  7. Jewkes RK, Levin JB, Penn-Kekana LA. Gender inequalities, intimate partner violence and HIV preventive practices: findings of a South African cross-sectional study. Soc Sci Med. 2003;56(1):125–34.

    Article  PubMed  Google Scholar 

  8. Gilbert L, Walker L. Treading the path of least resistance: HIV/AIDS and social inequalities a South African case study. Soc Sci Med. 2002;54(7):1093–110.

    Article  PubMed  Google Scholar 

  9. Statistics South Africa. Quarterly Labour Force Survey. 2017.

  10. Wechsberg WM, Luseno WK, Lam WKK, Parry CDH, Morojele NK. Substance use, sexual risk, and violence: HIV prevention intervention with sex workers in Pretoria. AIDS Behav. 2006;10(2):131–7.

    Article  PubMed  Google Scholar 

  11. Wechsberg WM, Luseno WK, Lam WK. Violence against substance-abusing South African sex workers: intersection with culture and HIV risk. AIDS Care. 2005;17(Suppl 1):S55–64.

    Article  PubMed  Google Scholar 

  12. Wechsberg WM, Wu LT, Zule WA, Parry CD, Browne FA, Luseno WK, et al. Substance abuse, treatment needs and access among female sex workers and non-sex workers in Pretoria, South Africa. Subst Abuse Treat Prev Policy. 2009;4:11.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Dunkle KL, Decker MR. Gender-based violence and HIV: reviewing the evidence for links and causal pathways in the general population and high-risk groups. Am J Reprod Immunol. 2013;69(Suppl 1):20–6.

    Article  PubMed  Google Scholar 

  14. Dunkle KL, Jewkes RK, Brown HC, Yoshihama M, Gray GE, McIntyre JA, et al. Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa. Am J Epidemiol. 2004;160(3):230–9.

    Article  PubMed  Google Scholar 

  15. Groves AK, Moodley D, McNaughton-Reyes L, Martin SL, Foshee V, Maman S. Prevalence, rates and correlates of intimate partner violence among South African women during pregnancy and the postpartum period. Matern Child Health J. 2015;19(3):487–95.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Wechsberg W, Parry C, Jewkes R. Drugs, sex and gender-based violence: the intersection of the HIV/AIDS epidemic with vulnerable women in South Africa—forging a multilevel collaborative response. Policy Brief 2008.

  17. Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet. 2010;376(9734):41–8.

    Article  PubMed  Google Scholar 

  18. Wechsberg WM, Parry CDH, Jewkes RK. Drugs, sex, gender-based violence, and the intersection of the HIV/AIDS epidemic with vulnerable women in South Africa. RTI Press Publication PB-0001-1005. Research Triangle Park: RTI International; 2010.

  19. Sullivan TP, McPartland TS, Armeli S, Jaquier V, Tennen H. Is it the exception or the rule? Daily co-occurrence of physical, sexual, and psychological partner violence in a 90-day study of substance-using, community women. Psychol Violence. 2012;2(2):154.

    Article  Google Scholar 

  20. Pitpitan EV, Kalichman SC, Eaton LA, Cain D, Sikkema KJ, Skinner D, et al. Gender-based violence, alcohol use, and sexual risk among female patrons of drinking venues in Cape Town, South Africa. J Behav Med. 2013;36(3):295–304.

    Article  PubMed  Google Scholar 

  21. Gilbert L, Raj A, Hien D, Stockman J, Terlikbayeva A, Wyatt G. Targeting the SAVA (substance abuse, violence, and AIDS) syndemic among women and girls: a global review of epidemiology and integrated interventions. J Acquir Immune Defic Syndr. 2015;69(2):S118–27.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Wechsberg WM, Zule WA, Ndirangu J, Kline TL, Rodman NF, Doherty IA, et al. The biobehavioral Women’s Health CoOp in Pretoria, South Africa: study protocol for a cluster-randomized design. BMC Public Health. 2014;14:1074.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Wechsberg WM. Revised risk behavior assessment, part I and part II. Research Triangle Park: Research Triangle Institute; 1998.

    Google Scholar 

  24. Chandler RK, Kahana SY, Fletcher B, Jones D, Finger MS, Aklin WM, et al. Data collection and harmonization in HIV research: the seek, test, treat, and retain initiative at the National Institute on Drug Abuse. Am J Public Health. 2015;105(12):2416–22.

    Article  PubMed  Google Scholar 

  25. Wechsberg WM, Myers B, Kline TL, Carney T, Browne FA, Novak SP. The relationship of alcohol and other drug use typologies to sex risk behaviors among vulnerable women in Cape Town, South Africa. J AIDS Clin Res. 2012. doi:10.4172/2155-6113.S1-015.

    PubMed  PubMed Central  Google Scholar 

  26. Morojele NK, Kachieng’a MA, Mokoko E, Nkoko MA, Parry CD, Nkowane AM, et al. Alcohol use and sexual behaviour among risky drinkers and bar and shebeen patrons in Gauteng province, South Africa. Soc Sci Med. 2006;62(1):217–27.

    Article  PubMed  Google Scholar 

  27. Dokubo EK, Shiraishi RW, Young PW, Neal JJ, Aberle-Grasse J, Honwana N, et al. Awareness of HIV status, prevention knowledge and condom use among people living with HIV in Mozambique. PLoS ONE. 2014;9(9):e106760.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Babor TF, Biddle-Higgins JC, Saunders JB, Monteiro MG. AUDIT: The Alcohol Use Disorders Identification Test: guidelines for use in primary health care. Geneva: World Health Organization; 2001.

    Google Scholar 

  29. Johnson JA, Lee A, Vinson D, Seale JP. Use of AUDIT-based measures to identify unhealthy alcohol use and alcohol dependence in primary care: a validation study. Alcohol Clin Exp Res. 2013;37(Suppl 1):E253–9.

    Article  PubMed  Google Scholar 

  30. London L. The ‘dop’ system, alcohol abuse and social control amongst farm workers in South Africa: a public health challenge. Soc Sci Med. 1999;48(10):1407–14.

    CAS  Article  PubMed  Google Scholar 

  31. Parry CD. South Africa: alcohol today. Addiction. 2005;100(4):426–9.

    Article  PubMed  Google Scholar 

  32. Seth P, Glenshaw M, Sabatier JH, Adams R, Du Preez V, DeLuca N, et al. AUDIT, AUDIT-C, and AUDIT-3: drinking patterns and screening for harmful, hazardous and dependent drinking in Katutura, Namibia. PLoS ONE. 2015;10(3):e0120850.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Lanza ST, Tan X, Bray BC. Latent class analysis with distal outcomes: a flexible model-based approach. Struct Equ Model. 2013;20(1):1–26.

    Article  Google Scholar 

  34. DiStefano C, Kamphaus R. Investigating subtypes of child development a comparison of cluster analysis and latent class cluster analysis in typology creation. Educ Psychol Meas. 2006;66(5):778–94.

    Article  Google Scholar 

  35. Muthén LK, Muthén BO. Mplus user’s guide: statistical analysis with latent variables: user’s guide. Los Angeles: Muthén & Muthén; 2010.

    Google Scholar 

  36. Berlin KS, Williams NA, Parra GR. An introduction to latent variable mixture modeling (part 1): overview and cross-sectional latent class and latent profile analyses. J Pediatr Psychol. 2014;39(2):174–87.

    Article  PubMed  Google Scholar 

  37. Varga CA. The condom conundrum: barriers to condom use among commercial sex workers in Durban, South Africa. Afr J Reprod Health. 1997;1(1):74–88.

    CAS  Article  PubMed  Google Scholar 

  38. Republic of South Africa Department of Health National Policy on HIV Pre-exposure Prophylaxis (PrEP) and Test and Treat (T&T). 2016.

  39. Napierala Mavedzenge S, et al. HIV testing among key populations, adolescent girls and men in Eastern and Southern Africa: a review of research, policy and programming. RTI International; 2016.

  40. Bekker L-G, Johnson L, Cowan F, Overs C, Besada D, Hillier S, et al. Combination HIV prevention for female sex workers: what is the evidence? Lancet. 2015;385(9962):72–87.

    Article  PubMed  Google Scholar 

  41. Wechsberg WM, Peasant C, Browne FA, Ndirangu J, Kline T, Zule WA. Opiate use a new crisis in South Africa after a decade of reaching substance-using women at risk for HIV. Denver, CO: American Public Health Association; 2016.

  42. Carrasco MA, Esser MB, Sparks A, Kaufman MR. HIV-alcohol risk reduction interventions in Sub-Saharan Africa: a systematic review of the literature and recommendations for a way forward. AIDS Behav. 2016;20(3):484–503.

    Article  PubMed  Google Scholar 

  43. Wechsberg WM, Zule WA, Luseno WK, Kline TL, Browne FA, Novak SP, et al. Effectiveness of an adapted evidence-based woman-focused intervention for sex workers and non-sex workers: the Women’s Health Coop in South Africa. J Drug Issues. 2011;41(2):233–52.

    Article  Google Scholar 

  44. Green MJ. Latent class analysis was accurate but sensitive in data simulations. J Clin Epidemiol. 2014;67(10):1157–62.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

This research was supported by the U.S. National Institutes of Health, National Institute on Drug Abuse (NIDA) Grant R01DA032061 PI: Wechsberg. The views and conclusions are those of the authors and do not necessarily reflect the views of NIDA. The funding agency had no role in the research design; in the collection, analysis, and interpretation of the data; in the writing of this article, or in the decision to submit the article for publication. We wish to thank all of our project staff, the women participants, and our editor, Mr. Jeffrey Novey, for their contribution to this project and Dr. Sreelatha Meleth for her statistical review.

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Correspondence to Wendee M. Wechsberg.

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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. This includes obtaining informed consent from all participants.

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Wechsberg, W.M., Peasant, C., Kline, T. et al. HIV Prevention Among Women Who Use Substances And Report Sex Work: Risk Groups Identified Among South African Women. AIDS Behav 21 (Suppl 2), 155–166 (2017). https://doi.org/10.1007/s10461-017-1889-0

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Keywords

  • Women
  • Alcohol use
  • Drug use
  • Physical or sexual violence
  • Sex work
  • HIV prevention

Palabras claves

  • Mujeres
  • consumo de alcohol
  • Consumo de drogas
  • violencia física y sexual
  • Trabajadora sexual
  • prevención del VIH