Social and structural influences of condom negotiation among female sex workers FSWs remain understudied.
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This study assesses environmental and individual factors associated with condom negotiation among Sex site in philippines at high risk for acquiring HIV in a large urban setting of Metro Manila, Philippines. Data were collected from April January from 54 venues. Multiple logistic regressions were conducted to assess socio-behavioral factors e. Factors in the physical, economic, and policy environments, over individual excepting substance use and social level factors, were ificantly associated with these FSWs' condom negotiations in the Philippines.
Drawing upon Rhodes' risk environment framework, these highlight the need for policies that support safer sex negotiations among sex workers in the context of their risk environments. This is an open-access article distributed under the terms of the Creative Commons Attributionwhich permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
The funders had no role in study de, data collection and analysis, decision to publish, or preparation of the manuscript.
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Competing interests: The authors have declared that no competing interests exist. Many studies focus only on individual-level constructs, which assumes the FSW has control over her environment and is the main Sex site in philippines responsible for behavior change. However, other studies describe how FSWs' lack power in negotiating condoms with their clients  —  and that social and structural factors influence their behavior  — .
Morisky and his colleagues found that combined manager and peer interventions reduced STIs and risk behaviors among female bar entertainers in the southern Philippines . However, less known are factors in the physical, social, policy, and economic environment that may influence condom negotiations specifically. This paper focuses on whether FSWs working as entertainers term most commonly used to self-identify in this population negotiate condom use with their clients known as venue patronsand examines the social and structural factors associated with condom negotiation.
Rhodes and his colleagues'  developed a risk environment framework to address how harms in the physical, social, economic, and policy risk environments interact to influence the risk of HIV infection among substance users. This framework has been applied to FSWs  —  but not specifically to condom negotiation. Each physical, social, economic, and policy risk environment has a micro- and macro-level. Table 1 illustrates how this framework is defined and applied to the current study.
For the physical risk environment, Rhodes ased drug trafficking as a macro-physical risk and drug using location as a micro-physical factor. Likewise, sex trafficking in the current study is classified as macro-physical due to the organized nature of sex trafficking syndicates; recruiters usually target low income areas such as rural communities. Venue location or venue type is a micro-physical level variable. A study of injecting drug using FSWs, similar to this study, placed physical and sexual abuse as micro-physical risks .
Rhodes defines micro-social risks as social influences, such as peers, on substance use and HIV risk behaviors, while larger gender inequalities and stigmatization are classified as macro-social risks. Only micro-social level risks apply to the Sex site in philippines study and are expanded to include peer and manager influences, interactions with sexual partners, and overall social support.
Micro-economic risk level factors Sex site in philippines Rhodes' and colleagues framework entails cost of living and health treatments and in the present study only micro-level economic risks are used to include income, cost of condoms sold at the venue, locations where the FSW obtains condoms, and frequency carrying a condom. For policy-level influences on HIV risk behavior, Rhodes includes availability of clean needles and syringes at the micro-level and public health policy governing harm reduction at the macro-level. In this study, only micro-policy factors apply and were modified to include condom availability and condom rule at the venue and frequency of receiving an HIV and STI test.
Prostitution is estimated as the fourth largest source of gross national product GNP for the Philippines . Although illegal, many girls and women engage in sex work for lack of better options to support themselves and their families .
As many aswomen andchildren were forced or coerced into work annually within and across borders of the Philippines .
This paper addresses the role of trafficking, which has not yet been examined in relation to condom negotiation. Although the Philippines is a low prevalence country less than. However, condom distribution remains under debate because of the Catholic Church's strong position against artificial contraception. We sought to determine the extent to which social and structural factors were associated with condom negotiation among female sex workers at high risk of acquiring HIV in this large urban setting of Metro Manila, the Philippines.
All participants involved in the study provided both verbal and written informed consent, documented on two separate consent forms. To protect the confidentiality of the participants due to the sensitive nature of the substance use and sex work questions and the absence of government certificates of confidentiality in the Philippines, the consent form with the participant atures were only accessible for viewing by clinic staff for the purpose of matching names with clinic data. Only atures of the witnessing interviewers were written on the other consent form and copies were given to the participant.
The university ethics committees in both the U. The study identified venues in the community with workers registered at the two largest Social Hygiene Clinics in the city site within Metro Manila . After stratifying by size and type, we randomly selected 4—6 venues of each type per clinic site, e. All entertainers Sex site in philippines each venue were interviewed except for large Sex site in philippines where individuals were randomly sampled.
In the final regression model, had complete data and were included in the analysis. Non-government organization interviewers surveyed sex workers in private locations at the venue or SHC using structured questionnaires from April January Interviews, conducted in Filipino, lasted approximately 60 minutes. Interviewers surveyed participants on their sociodemographics, individual sexual risk and substance use behaviors, and experiences reflective of their physical, social, economic, and policy risk environments.
Questions included age, education, of children, marital status, income, length of employment, length of time involved in the sex trade, of sexual contacts in a typical week, of STIs in the past 6 months, alcohol use, and substance use frequency and type.
A item Center for Epidemiologic Studies Depression Scale C-ESD was used with a cutoff of 23 used in substance use research to indicate higher depressive symptoms  ; Cronbach's alpha was. Factors at the micro-social environment included peer and manager support using dichotomous measures ly validated in the southern Philippines  e.
Social support measured emotional, tangible, and functional support adapted from the Norbeck Social Support Scale . Cronbach's alpha for all items in the scale was. The C-ESD was also ly validated with similar high risk groups in other countries while the Norbeck Social Support scale had not been widely used in FSW populations, but were tested in other high risk populations, e.
HIV-positive substance users  and female-to-male transgender men . Micro-economic items, ly used by Morisky and colleagues in the southern Philippines included weekly income, price of condoms sold at the venue, and where entertainers obtained condoms. Micro-policy factors, also ly validated in the Philippines  included condom rule at the venue, workplace provision of condoms, frequency of HIV and STI tests, and how often entertainers carried a condom. Originally, this item was developed by Sex site in philippines an open-ended question in Morisky Sex site in philippines his colleagues' study of a southern Philippines population of FSWs.
They found that intervention group participants identified more effective behaviors compared to a standard treatment group. The items were collapsed into a single closed ended question and tested in subsequent southern Philippines surveys .
Statistical analyses were conducted on FSWs who traded sex over the past six months, comparing those who usually negotiated condom use with those who did not, using t-tests for continuous and Pearson's Chi-square for non-continuous variables. Univariate and multivariate logistic regressions were performed to identify factors associated with condom negotiation, considering aforementioned factors at the micro and macro-level of the risk environment. Multi-level modeling controlled for individuals nested within venues.
As shown in Table 2median age and duration in sex work were 23 and 12 months, respectively.
Three-quarters had CES-D depression scores of 23 or higher. Also, those who usually negotiated worried ificantly more about getting HIV and had more perceived knowledge of STIs. In Table 3those who usually negotiated Sex site in philippines use vs. The groups did not differ ificantly on manager and peer support, social support, or whether venue patrons were high while having sex Table 3.
Women who usually negotiated condom use did not differ ificantly with respect to condom prices at their venue or income Table 4. Women who usually negotiated condom use and those who did not were similar in their frequency of taking an HIV test and venue condom policies Table 4. Similarly, studies of FSWs in Vietnam found that only half Sex site in philippines clients consistently complied with their requests to use condoms  and successful condom use negotiation had a protective effect . Substance use was also a factor contributing to not negotiating condom use among the FSWs.
These findings highlight the need for macro- and micro-policy level Sex site in philippines, such as a stronger enforcement of the Anti-Trafficking in Persons Act of increasing availability of condoms in venues and in the community, considering the impact of economics on an FSW's ability to negotiate condom use, and addressing substance use among the FSWs. Except for a few studies the relationship between trafficking and condom use negotiation has not been studied.
Women may not feel empowered to negotiate safer sex because they experienced less control over their work environments . The UN defines trafficking as those forced or coerced into sex, including minors under 18 years old engaged in the sex trade . Only 3 women in this study revealed being underage when they first traded sex, but others identified being tricked or coerced into sex work. Trafficking legislation is critical at international and national levels, and more importantly, local government adherence to these laws, while being sensitive to the complexities of FSWs in the entertainment industry .
Philippine laws support anti-trafficking prosecution, but the Philippines remains on the U. Our findings imply a need for stronger enforcement of the law and primary prevention of trafficking. At the policy level, having sex without a condom because none was available was associated with not negotiating condoms.
Other studies have found that having access to condoms was associated with safer sex practices among women who worked in bars in Tijuana, Mexico  and decreased unprotected sex among bathhouse patrons in Taiwan . Studies underscore the importance of a supportive social environment for FSWs in China and India, such as a venue's condom availability, managerial support of condom availability, and clinic visitations .
We therefore recommend policies requiring sex work venues in the Philippines to make condoms available to their workers. Likewise, efforts must be exerted to engage the Catholic Church to be more realistic and flexible in its stance on the use of artificial contraceptives, including condoms, similar to actions taken by civil society groups in the campaign to have the Reproductive Health Bill passed into Philippine law .
The church's interference of HIV prevention efforts continues to be a center of debate in the Philippines and other settings, despite the Vatican Sex site in philippines more recent approval of condom use to fight AIDS . The fact that the women had sex without a condom to make more money illustrates continued economic environment risks that impact condom negotiation.
Likewise, sex workers in other countries like India and Mexico feared losing income if they negotiated . Making condoms free, not just available, may help in situations where condoms are already difficult to negotiate due to economic pressures. DKT International, a non-government organization has sold condoms in the country at 5 Pesos through its social marketing campaigns, compared to the average cost sold at the venue of 33 Pesos .
Also, developing options such as involving FSWs in community participatory research methods and grant-writing may lead to additional income. Besides the cost of condoms, condom availability, and income differences, other factors may influence the women's decisions to have sex without a condom to make more money and needs further study.