Consenting adults who trade sex for money or other non-monetary items (sex workers) face a disproportionate burden of HIV around the globe. This is primarily due to structural factors that block access to prevention methods and care services -- such as stigma against the profession, fueled by ongoing criminalization of sex work and the pervasive physical and sexual violence experienced by sex workers. Increasing evidence shows a link between experiences of trauma and vulnerability to HIV acquisition, as well as worsened HIV health outcomes among women. However, HIV interventions for sex workers that also address violence are limited.
The needs and demands of people who trade sex received increased recognition at AIDS 2016 in Durban, South Africa. Contributing to this favorable development, a group of researchers from Johns Hopkins Bloomberg School of Public Health (JHBSPH) and School of Nursing, as well as the Baltimore City Health Department, worked with community-based advocates in that city to develop and pilot a brief, trauma-informed intervention in response to the dual burdens of violence and HIV vulnerability among female sex workers. The study was presented in an oral poster discussion at AIDS 2016 by Andrea Wirtz, Ph.D., assistant scientist in the department of epidemiology at JHBSPH.
According to the Substance Abuse and Mental Health Services Administration a trauma-informed approach adheres to a set of key principles, including safety, peer support and collaboration. In keeping with these values, INSPIRE (Integrating Safety Promotion With HIV Risk Reduction), a three-to-five-minute participatory intervention, was developed in collaboration with practitioners and clients from community-based organizations. The goal of the intervention was to integrate violence support with HIV outreach to address trauma-related barriers to HIV prevention.
Trained advocates implemented the intervention with female sex workers in Baltimore who engaged with a mobile support van for needle-exchange and related services. Sixty women participated in the intervention at baseline; 39 women, or 65% of the sample (non-differential by baseline measures), were retained for follow-up. Challenges to retention included participants being incarcerated or involved in drug treatment.
INSPIRE was evaluated for feasibility, acceptability and effect via a quasi-experimental, single group pre-test-post-test study design. The intervention included a semi-structured dialogue, reinforced with the provision of a safety card, as well as other resources and tips around staying safe at work drawn from the experiences of other women who trade sex. Implementers prioritized violence-related support, connection to services and countering the myth that sex workers cannot be raped.
The short-term outcomes of the study at 10-to-12-week follow-up reflected increased use of safety strategies, improved confidence in condom negotiation and reduced frequency of trading sex while under the influence of drugs and/or alcohol. INSPIRE was found to improve connection to violence-related support services (at follow-up, 68% of women knew of at least one place to get support in reporting violence to police and 29% had approached such a program) and to decrease women's own endorsement of myths that falsely blame sex workers for violence perpetrated against them -- both endpoints that were considered valuable to the community.
INSPIRE participants also emphasized the value of a safe, supportive space to talk about the violence they experience. "[Talking about violence] actually helps," one participant is quoted as saying. "[I]t's a real big burden off my chest because I've been holding it in so long, and it's been so much pain where I'm constantly having dreams. It's all I think about."
The feedback of participants and community partners indicated high feasibility and acceptability of this brief, trauma-informed, low-dose intervention. This small study indicates that impactful discussions about trauma and safety and providing connections to care are possible within the existing infrastructure of HIV outreach for women who trade sex. These early results ought to inform scalable interventions that address the impact of trauma on HIV acquisition and trajectories of care for female sex workers, thereby increasing awareness and response to the twinned epidemics of violence and HIV, and supporting the health and human rights of vulnerable communities.