As shown in Table 1, a total of 209 SWs were recruited in Belgrade (Serbia), two in Podgorica (Montenegro) and 36 in Togliatti (Russian Federation).
Case 1: Serbia
RDS was conducted in the autumn of 2005 in Belgrade, Serbia’s capital, by a local fieldwork team with a limited access to SW networks. Estimates of the size of the SW population in the municipality, based on police records and anecdotal estimates, vary widely from 900 to 3,000 SWs.2,24,25
Sex work is illegal. Findings from in-depth interviews of SWs suggest that there are approximately ten areas located near the main transit routes in and out of Belgrade where street SWs operate in small groups. Qualitative data suggests that the majority of SWs operate independently, advertising their services in newspapers or through referrals via existing client networks, potentially making them harder to reach through RDS.
Formative interviews also found that there was little mixing of SWs across different sex work sectors (street, agency, and SWs working independently), among street SWs themselves (transvestite, Roma and Serbian/Montenegrin heterosexual SWs) and among SWs working independently. However, in addition to a lack of strong connection among SWs and their independent working situations, the study team undertaking formative qualitative research associated SWs’ reluctance to participate in the study to perceptions of inadequate incentive (10 euros for 1 hour of their time) and a general mistrust associated with coming into contact with ‘official’ agencies. However, the same interviews suggested that in principle SWs would be interested in participating in a survey involving the collection of both behavioural and biological data through HIV testing. Interviewees indicated that they knew approximately 20 other SWs, which again suggested that RDS would be feasible.
The RDS study had a target of 400 SWs, both male and female. The sample needed to be large enough for a statistically reliable analysis of risk factors and HIV prevalence, should RDS analysis show that the sample is reasonably representative. The interview site was on the premises of a non-governmental organisation (NGO) located in central Belgrade easily accessible by public transport. It was a part of a large apartment block with a separate entrance. The site was open everyday from 3 to 9 p.m. and could accommodate three to four participants an hour because of the computer administered questionnaire. After two months, the study ceased, having reached only 209 SWs. In total, 12 seeds were used during the study. Of the initial six seeds only three produced any subsequent waves. The rate of recruiting increased noticeably after an RDS study of IDUs being implemented at the same site had ceased. Due to the difficulties experienced by the research team in locating new seeds through other means, four participants with dense social networks were drawn from the seventh wave of two of the most productive recruitment chains and used as new seeds. This resulted in two more productive chains that ultimately reached seven waves.
The average SW network size reported during the study was 12. In response to the question, “where do you most often solicit your clients?,” the majority of SWs replied that they solicited on the street (43%), followed by referral from an agency, pimps, friends or other SWs (28.9%) and by telephone (25.2%). Importantly, the take-up of VCT provided as part of the RDS study was high (71.8%), and SWs indicated that they participated because of the HIV testing, rather than the monetary incentive.
Case 2: Montenegro
There are no estimates of the number of SWs in Podgorica, the Republic’s capital. Sex work is ostensibly illegal. Through formative rapid assessment no street-based SWs were identified and the majority of SWs were found to work independently from their homes. Key informant interviews (IDUs, ex-IDUs, taxi drivers, public health officials, NGO representatives and journalists) identified the only semi-public sex work sites as being approximately six illegal brothels, registered as lap dancing venues, in which most of the SWs also lived. At least one such brothel was found not to allow SWs to leave the premises. Indications were that local police also ‘moonlighted’ as security guards in these brothels. Other links between brothels and public services included taxi drivers, beauty salons and hotels. The intersection of the police and sex work networks, the small size of the city and the high number of implicated actors suggested that SWs could be easily monitored and controlled.
Previous attempts by the local NGOs to conduct research among SWs in Podgorica had failed. Key informants, interviewed during formative rapid assessment, reported knowing at least one SW or their pimps but in almost all cases introductions were denied or never materialized. Those conducting the formative rapid assessment received strong advice from local experts and key informants—including NGOs, police, and taxi drivers—against approaching brothel owners because of the highly controlled nature of SW venues in the city. After two weeks of trying to make a contact, four SWs were accessed via their drug user networks, the only entry points into SW networks available to researchers. These SWs were interviewed at their place of work (brothel and pimp’s flat). Each of the four interviewed SWs independently estimated that there were approximately 200 SWs in the city, many of them also drug injectors, most of whom worked independently, advertising their services via newspapers and television and via client recommendation but who were not open about their SW status. All four SWs interviewed indicated that they would participate in a RDS study and would invite others to do so, and each estimated they had personal regular contact with between five and ten SWs.
The four SWs participating in the formative rapid assessment were invited to participate in the RDS study as seeds. Only one of the four participated but failed to recruit anyone else. She reported having had contact with ten SWs in 4 weeks, but no additional seeds were secured. Despite recruiting an additional SW (who required complete anonymity fearing being identified as a SW by others to his family and who had not seen other SWs in the past month), the RDS study failed to identify a sufficient pool of seeds willing to participate.
Case 3: Russia
The RDS study of IDUs and IDU/SWs was conducted in May 2004 in Togliatti City. Togliatti City is the second city of Samara Region situated approximately 1,000 km south of Moscow. Togliatti was selected as a study site because evidence suggests a recent increase in the number of IDUs and SWs and an explosive spread of HIV associated with injecting drug use.6,11
Approximately 2,000 SWs are estimated to operate in Togliatti, half of whom work from the street.6 Despite ambiguous Russian legislation towards sex work, it is not tolerated by the wider community or the police. The city has been noted for its intense street policing of drug users and SWs, often involving fines levied under administrative codes, such as possession of drugs, causing a public nuisance, or lack of official residency permit, rather than criminal codes.26,27 Street-based SWs in Togliatti operate openly along the main roads and highways. Two popular locations are Moskovsky Prospect where approximately 70 women are working at any one time, and Pobeda Street where about 100 women work.
In a study conducted in Togliatti City in 2001, 50% of female IDUs (n=155) reported ever exchanging sex for goods or money, of whom 86% (n=66) were currently SWs.6 Although no stand-alone RDS studies of SWs have been conducted in Russia, attempts have been made to boost participation of IDU/SWs in RDS studies of IDUs motivated by the evidence of high proportion of SWs who also inject drugs in other cities.28–30
A cross-sectional survey of IDUs and female IDU/SWs was undertaken in Togliatti in 2004 as a follow up to the 2001 baseline survey. A total of 476 IDUs were sampled during a 5-week period in May 2004 using RDS. Among these, 55 (11%) reported ever exchanging sex for money, drugs or goods, and of these, 36 in the past month, which was lower than expected. At the start of the field work, seven seeds were selected, of which one seed was female who had exchanged sex in the past month. SWs were explicitly asked to recruit other SWs, and non-SWs were encouraged to recruit either SWs or non-SWs (Table 1, column 4). This first SW seed produced no recruits and was lost to follow up. Another female non-SW started a chain that recruited a total of 22 female IDUs who had ever exchanged sex, of whom 13 had exchanged sex in the past month. This female non-SW seed produced a total of 135 recruits by the end of the study equivalent to 28% of the total sample, of which 15% (20) were SWs and who reported working on the street. Among the other seeds, only a handful of current SWs were recruited (n=4). Towards the end of the project more coupons were distributed to female SWs in an attempt to increase the SW sample (n=5), none of which produced any recruits. In order to increase the sample of SWs in the survey, 21 SWs were subsequently identified and interviewed without coupons.
Data on the number of female SWs within an individual’s IDU network were unfortunately not provided. The mean IDU network size among SWs was 19.5 (SD 14.2) and among non-SWs 27.1 (SD 33.0). Only one SW recruited through RDS reported working from an apartment; all others were street-based SWs. We expected that RDS would enable us to recruit more hidden populations of SWs such as those working from apartments or hotels. The fact that SW seeds failed to produce any waves of SWs or were lost to follow up, indicates that SW networks may not be as well connected.
Field notes show that initial attempts to access street SWs at Moskovsky Prospect and Pobeda Street had failed primary because of intensified police action in the area. A local officer of the Federal Security Service believed he had been recently infected with HIV by a SW from the area, and, in revenge, he and his colleagues enforced a repressive policy of fines and arrests among SWs. Recruiting SWs towards the end of the survey was more successful when policing practices returned to normal. Meanwhile, the sample target was reached for non-SW IDUs.