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Correlates of sex work stigma among female sex workers living with HIV in the Dominican Republic
Tahilin Sanchez Karver, MPH
PhD Student
Department of Health, Behavior and Society
Johns Hopkins Bloomberg School of Public Health
CCAS Expert Summit
27-31 August 2017
Barbados
Study Team
Tahilin S. Karver1, Yeycy Donastorg2, Martha Perez2, Clare Barrington3, and Deanna Kerrigan1
1. Johns Hopkins Bloomberg School of Public Health
2. Unidad de Vacunas e Investigación de República Dominicana, Instituto Dermatológico y Cirugía de Piel “Dr. Huberto Bogaert Díaz” (IDCP)
3. University of North Carolina- Chapel Hill
Background • Female Sex workers (FSW) experience a disproportionate risk of
HIV, STIs, violence, stigmatization and discrimination, among other human rights violations1-3
– Worldwide trends are reflected in the Dominican Republic, where FSW represent a disproportionally affected group with HIV rates being 6 times higher among this group compared to other adults (4.4% vs. 0.7%)4
• Recent studies have found that sex work related stigma could prevent FSW from accessing health services (e.g., inhibiting HIV care) and places women at increased vulnerability to violence5-7
• Among FSW living with HIV, research suggests that they are highly susceptible to intersectional stigma (sex work stigma and HIV stigma),5,8 which may exacerbate negative outcomes
What is sex work stigma?
• Stigma: “the symbolic ‘marking’ and discrimination of individuals with certain socially undesirable characteristics…” (Goffman 1963)
• Stigma as fundamental driver of health inequalities (Phelan and Link 2013)
• Sex work stigma: discreditation based on occupation
• “Social evils” (Liu et al., 2011).
• “Threat to society” (Bowen & Bungay, 2016).
• “Vectors of disease” (Pheterson 1993; Scambler 2007; Lazarus 2012).
Specific Aim
To examine the correlates between sex work stigma and socio-demographic and behavioral factors among FSWs living with HIV in the Dominican Republic.
Hypotheses
• H1: HIV stigma is positively associated with sex work stigma
• H2: Experience of physical abuse is positively associated with sex work stigma
• H3: Receiving HIV treatment and care (i.e., antiretroviral therapy (ART) or HIV care in the past 6 months) is negatively associated with sex work stigma
Parent Study: Abriendo Puertas
• Longitudinal cohort study in Santo Domingo, Dominican Republic – Study evaluated Abriendo Puertas (Opening Doors) intervention
aimed to improve HIV outcomes in FSWs living with HIV – Baseline data was collected between 2012-2013
• Recruitment and study population – Participants were recruited through a hybrid sampling approach
(referrals from clinics, other FSW, peer navigators) – All participants were at least 18 years of age, spoke Spanish,
were HIV infected, and reported exchanging sex for money in the past month
– A total of 268 participants conformed the baseline data collection
Stigma measures
HIV stigma (independent variable)
• Based on previously reliable 8 item scale11
• Score ranged between 8-32
• Reliability (alpha): 0.88
• Measures internalized stigma:
– "You feel like you are not as good as others because you have HIV”
– "You feel guilty because you have HIV"
Stigma measures
Sex work stigma (Outcome measure)
• Adapted from the HIV scale
• Based on a reliable 13 item scale9-10
• Score ranged between 13-49
• Reliability (alpha): 0.91
• Measures internalized stigma:
– “Working as a sex worker makes you feel like a bad person”
– "You feel ashamed of sex work"
Methods
• All analyses were conducted using Stata/IC 14.212
– Data was assessed for missing values • The data only had 5% missing values. • Variables were also assessed for collinearity
• Descriptive statistics were produced for variables of interest – Chi-squared tests and two sample t tests to explore sex work
stigma
• Simple linear regressions – Simple linear regression were conducted on all key covariates
and the continuous measure of sex work stigma – Robust variance estimation used given the sampling strategy
Methods
• Multiple linear regression with robust variance estimation
• Model building – Model selection was conducted a priori, informed by the
literature
– Akaike's information criterion was used to aid selection of final model
– Interactions were explored, but ultimately removed from final model
– Collinearity assessed through multivariable regression analysis (Mean variance inflation factor 2.21)
Socio-demographic characteristics Table 1. Participants' socio-demographic characteristics by experiencing high sex work stigma
Characteristics Total
Experiences High Sex Work Stigma
No Yes
n Percentage n Percentage n Percentage p-value
Marital Status
Single 50 18.66 33 24.26 16 12.31 0.04
Married or Cohabitating 105 39.18 52 38.24 53 40.77
Has partner 113 42.16 51 37.5 61 46.92
Educational Attainment
Primary or less 173 65.04 92 67.65 79 61.72 0.31
Secondary or more 93 34.96 44 32.35 49 38.28
Number of children
No children 17 6.34 9 6.62 8 6.15 0.21
1 child 50 18.66 23 16.91 27 20.77
2 children 54 20.15 30 22.06 23 17.69
3 children 73 27.24 43 31.62 29 22.31
4 children or more 74 27.61 31 22.79 43 33.08
Homeownership
No 173 64.55 91 66.91 80 61.54 0.36
Yes 95 35.45 45 33.09 50 38.46
Participant has insurance
No 118 44.36 66 48.89 52 40.31 0.16
Yes 148 55.64 69 51.11 77 59.69
n Mean
(Standard Deviation)
n Mean
(Standard Deviation)
n Mean
(Standard Deviation)
p-value
Age (in years) 268 35.89 ( 9.02) 136 35.61 (8.83) 130 36.13 ( 9.31) 0.64
Characteristics related to sex work and violence
Table 2. Key characteristics related to sex work, experience with substance use and violence by experiencing high sex work stigma
Characteristics Total
Experiences High Sex Work Stigma
No Yes
n Percentag
e n Percentage n Percentage p-value
Sex work disclosure
No 144 53.73 71 52.21 72 55.38 0.60
Yes 124 46.27 65 47.79 58 44.62
Average payment receive for services
Below the median of 800 DRP 129 48.13 59 43.38 68 52.31 0.15
At or Above the median 800 DRP 139 51.87 77 56.62 62 47.69
Street-based sex work
No 121 45.15 61 44.85 59 45.38 0.93
Yes 147 54.85 75 55.15 71 54.62
Number of clients in the past month
<11 121 45.15 64 47.06 56 43.08 0.51
≥11 147 54.85 72 52.94 74 56.92
Experience of physical abuse in the past 6 months
No 230 85.82 120 88.24 108 83.08 0.23
Yes 38 14.18 16 11.76 22 16.92
n Mean
(Standard Deviation)
n Mean
(Standard Deviation)
n Mean
(Standard Deviation)
p-value
Years working as a sex worker 265
15.44 (9.24)
134 15.67 (9.47) 134 15.67 (9.47)
0.35
Characteristics related to HIV
Table 3. Key HIV characteristics by experiencing high sex work stigma
Characteristics Total
Experiences High Sex Work Stigma
No Yes
n Percentage n Percentage n Percentage p-value
Received HIV care in the past 6 months
No 40 14.93 16 11.76 24 18.46 0.13
Yes 228 85.07 120 88.24 106 81.54
Currently on Antiretroviral Therapy (ART)
No 72 27.48 34 25.76 38 29.69 0.48
Yes 190 72.52 98 74.24 90 70.31
Participated in a HIV support group in the last 6 months
No 173 64.55 83 61.03 89 68.46 0.21
Yes 95 35.45 53 38.97 41 31.54
Experience high level of HIV stigma
No 152 56.93 107 78.68 45 34.62 <0.001
Yes 115 43.07 29 21.32 85 65.38
Model selection: Exploring the correlates of sex work stigma
Table 4. Akaike's information criterion and Bayesian information criterion for select models
Model Obs ll(null) ll(model) df AIC BIC
Base model + HIV stigma 261 -180.82 -147.78 12 319.55 362.33
Base model + HIV stigma + Physical violence 261 -180.82 -147.69 13 321.37 367.71
Base model + HIV stigma + Physical violence + Current use of ART + Received HIV care in the past 6 months
255 -176.70 -142.29 15 314.59 367.71
Base model + HIV stigma + Physical violence + Current use of ART
255 -176.70 -143.13 14 314.26 363.84
Base model + HIV stigma + Physical violence + Received HIV care in the past 6 months
261 -180.82 -146.86 14 321.71 371.62
Table 5. OLS regression exploring the correlates of sex work stigma
Covariates
Unadjusted Adjusteda
β Robust Std.
Error 95% C.I. β
Robust Std. Error
95% C.I.
Age (years) 0.014 0.053 -0.090 - 0.119 0.093 0.072 -0.049 - 0.235
Marital status
Single (ref) -- -- -- -- -- --
Married or Cohabitating 0.948 1.297 -1.605 - 3.501 -0.584 1.150 -2.849 - 1.682
Has Partner 1.726 1.207 -0.651 - 4.103 -1.265 1.167 -3.563 - 1.033
Education
Primary or less (ref) -- -- -- -- -- --
Secondary or more 1.430 1.031 -0.599 - 3.459 2.016** 0.995 0.056 - 3.976
Children
No children (ref) -- -- -- -- -- --
1 child 0.876 2.113 -3.285 - 5.038 1.44 1.772 -2.048 - 4.934
2 children 0.672 2.211 -3.681 - 5.026 1.28 1.943 -2.545 - 5.110
3 children -1.415 2.077 -5.505 - 2.674 0.07 1.740 -3.355 - 3.501
4 children or more 2.675 2.094 -1.447 - 6.797 3.217* 1.823 -0.375 - 6.809
Years in sex work -0.024 0.051 -0.124 - 0.077 -0.061 0.057 -0.174 - 0.052
Participant is street-based
No (ref) -- -- -- -- -- --
Yes 0.428 0.983 -1.508 - 2.364 1.06 0.925 -0.758 - 2.887
Experience of physical abuse in last 6 months
No (ref) -- -- -- -- -- --
Yes 2.465 1.465 -0.420 - 5.350 0.88 1.440 -1.958 - 3.717
Currently on ART
No (ref) -- -- -- -- -- --
Yes -2.992*** 1.079 -5.116 - -0.868 -2.691*** 1.032 -4.724 - -0.658
Experience high level of HIV stigma
No (ref) -- -- -- -- -- --
Yes 7.345*** 0.873 5.626 - 9.063 7.309*** 0.892 5.551 - 9.067
Constant 24.061*** 2.755 18.633 - 29.489
Observations 255 aAdjusted for all covariates
*** p<0.01, ** p<0.05, * p<0.1
Summary of Results • Sex work stigma is significantly correlated with HIV stigma
– FSWs who experience high levels of HIV stigma are associated with a 7.31 point increase on the sex work stigma scale compared to FSWs who do not report high levels of HIV stigma, after controlling for other covariates (95% CI: 5.55, 9.10; p<0.001).
• Sex work stigma is highly correlated with currently on ART
– FSWs currently on ART are associated with a 2.70 point decrease on the sex work stigma scale compared to FSWs not on ART, after controlling for other covariates (95% CI: -4.72, -0.66; p<0.001).
Summary of Results • Sex work stigma is highly correlated with education
– FSWs with a secondary education or more are associated with a 2.02 point increase on the sex work stigma scale compared to FSWs with a primary education or less, after controlling for other covariates (95% CI: 0.06, 3.98; p<0.05).
• Though marginally significant, results also indicate that FSWs with 4 children or more are associated with a 3.22 point increase on the sex work stigma scale compared to FSWs with no children, after controlling for other covariates (95% CI: -0.38, 6.81; p<0.10).
• No significant associations were found between experiences of physical abuse and sex work stigma.
Discussion
• Findings offer important insight of the intersectional nature of HIV and sex work stigma
• Future work should explore the impact of intersectional stigma on health inequalities
• Findings reflect the literature on the associations of sex work stigma and HIV treatment and adherence
Limitations
• Not a randomly selected sample
• Baseline data cross-sectional study design
• HIV treatment and care variables rely on self-reported data
Conclusion
• Future studies should seek to further explore sex work stigma across diverse FSW, including HIV-negative FSWs
• Need for a more robust measure of sex work stigma that identifies the different layers of stigma manifestation, including:
• Internalized, perceived, enacted sex work stigma, and stigma management strategies
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