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Since there is no official job contract, in general FSW are merely removed from the workplace, without any social guarantee, such as unemployment insurance. In this regard, governments have an obligation to protect and fulfill the human rights of their vulnerable populations by promoting equitable access to health services and adopting appropriate legislative, administrative, budgetary, judicial, promotional and Prostitutes Guimaraes measures towards Prostitutes Guimaraes full realization of human rights [ 11 ].

In view of our current results showing that both awareness of PEP as well as its use are associated with non-disclosure of FSW Prostitutes Guimaraes to health care providers, and that pre-exposure prophylaxis PrEP has recently been introduced in Brazil, it is urgent to develop public health policies which enable disclosure of sex work status to health care providers.

At the same time, it is essential to combat stigmatization and discrimination against FSW from health care providers in order to guarantee the Prostitutes Guimaraes uptake of preventive methods and treatment already available in the Brazilian public health system. Prostitutes Guimaraes that foster inclusion of marginalized groups such as adolescent girls who engage in paid sex are also urgently needed.

This was Prostitutes Guimaraes cross-sectional RDS study. Although our analysis took into consideration the complex design of the study, potential homophily, size and duration of the recruitment chains may still hamper representativeness of the target population of interest.

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Potential correlations among some of our variables, Prostitutes Guimaraes. In addition, since we considered only a limited number of potential predictors, unknown confounding can still be present.

Despite universal access to health services in the Brazilian public health system, the results of this study show that Prostitutes Guimaraes work stigmatization and discrimination in health services may be major barriers to the maximal effectiveness of prevention and Prostitutes Guimaraes actions for FSW in Brazil. Interventions targeting stigma and discrimination against FSW in health care services are urgently needed to increase access to health services.

For a sustained HIV response, efforts must focus on building awareness of FSW health care rights and on addressing barriers to health care access and utilization, such as reducing sex work-related stigma, aiming at transforming health services into safe environments where FSW can disclose their status without fear of facing discrimination.

Moreover, Prostitutes Guimaraes empowerment-based HIV responses must enable sex workers to develop and implement public health actions themselves, and to encourage recognition of sex work as legitimate work in society. The authors would like to express their gratitude to the participants of the Prostitutes Guimaraes, to the local teams that Prostitutes Guimaraes out the fieldwork in the 12 cities, and all collaborating NGOs.

Ferreira Jr. All authors contributed to the concept of the paper and writing.

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ID and CL were responsible for writing the final version of the manuscript. CL and GD were responsible for data analysis. PRBSJ were Prostitutes Guimaraes for data management and helped with a draft version of the manuscript.

All authors have read and approved the paper, have met the criteria for authorship as established by the International Committee of Medical Journal Editors, believe that the paper represents Prostitutes Guimaraes work, and are able to verify the validity of the results reported.

All data are in aggregated form and no individual nor personal identification of participants are possible. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Giseli Nogueira Damacena, Email: moc. Laio Magno, Email: moc. Celia Landmann Szwarcwald, Email: moc. Ferreira, Jr. National Center for Prostitutes Guimaraes Information Prostitutes Guimaraes, U. Published online Mar 5. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Received Aug 31; Accepted Jan This Prostitutes Guimaraes has been cited by other articles in PMC.

Abstract Background Stigma in health services may be detrimental to health seeking attitudes and practices. Background Since the beginning of the AIDS epidemic, female sex workers FSW have Prostitutes Guimaraes recognized as a Prostitutes Guimaraes with high vulnerability to HIV infection stemming from individual and interpersonal factors, including biologic e.

Data Collection The questionnaire included modules on: sociodemographic characteristics and information related to professional Prostitutes Guimaraes, knowledge about HIV transmission, sexual behavior, previous HIV test - lifetime and in the last year, STI history, use of alcohol and illicit drugs, access to prevention activities and health services, discrimination and violence.

Study Variables For this analysis, we defined four Prostitutes Guimaraes groups of selected variables: socio-demographics, human rights violation indicators, access and uptake of health services indicators, disclosure of FSW status to health care providers and discrimination. Data analysis Statistical methods appropriate for RDS Prostitutes Guimaraes were used for data analysis, taking into account the dependence among observations resulting from the recruitment chains, and the unequal probabilities of selection resulting from the different sizes of networks of each participant.

Table 1 Socio-demographics, social rights, human rights violations, and health care indicators among FSW. Open in a separate window. Table Prostitutes Guimaraes Disclosure of FSW status and perception of discrimination in health services. Table 3 Factors associated to non-disclosure of FSW status to health care staff. Table 4 Association Prostitutes Guimaraes non-disclosure of FSW status to health care staff with preventive health care, PEP awareness and use after controlling for selected variables.

Limitations This was a cross-sectional RDS study. Conclusions Despite universal access to health services in the Brazilian public health system, the results of this study show that sex work stigmatization and discrimination in health services may be major barriers to the maximal effectiveness of prevention and care actions for FSW in Brazil.

Acknowledgements The authors would like to express their gratitude to the participants of the study, to Prostitutes Guimaraes local teams that carried out the fieldwork in the 12 cities, and all collaborating NGOs.

Consent for publication All data are in aggregated form and Prostitutes Guimaraes individual nor personal identification of participants are possible. Competing interests The authors declare that they have no competing interests. References 1. Prevalence of Human Immunodeficiency Virus and sexually transmitted infections and associated risk factors among female sex workers in Guangdong Province, China. J Acquir Immune Defic Syndr. HIV risk practices Prostitutes Guimaraes female sex workers according to workplace.

Rev Saude Publica. AIDS Care.

Factors associated with violence against female sex workers in ten Brazilian cities. Cad Saude Publica. Global Prostitutes Guimaraes of HIV among female Prostitutes Guimaraes workers: influence of structural determinants.

Petersburg, Russia. AIDS Behav. BMC Womens Health. Utilisation of sexual health services by female sex workers in Nepal. Tarantola D. Global justice and Human Rights in practice.

Global Justice: Theory Practice Rhetoric. Health reform in Brazil: lessons to consider. Am J Public Health. The Brazilian Health System: history, advances, and challenges. Brazilian Prostitutes Guimaraes Code. Sexual and reproductive health needs of sex workers: two feminist projects in Brazil. Reprod Health Matters.

Factors associated with perceived discrimination in health services of Brazil: Results of the Brazilian National Health Survey, Prostitutes Guimaraes Saude Colet.

Perceived discrimination and health: a meta-analytic review. Psychol Bull. Stigma as a fundamental cause of population health inequalities.

Sex worker health: San Francisco style. Sex Transm Infect. Prostitutes Guimaraes to health and social services for street-based sex workers. J Health Care Poor Underserved. Scambler G, Paoli F. Soc Sci Med. Occupational stigma as a primary barrier to health Prostitutes Guimaraes for street-based sex workers in Canada.

Cult Health Sex. Female sex workers and access to social and health services in Catalonia: Influence of region of origin and place of work.

Personal, interpersonal and structural challenges to accessing HIV Prostitutes Guimaraes, treatment and care services among female sex workers, men who have Prostitutes Guimaraes with men and transgenders in Karnataka state, South India.

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J Epidemiol Community Health. Ham J, Gerard A. Criminol Crim Just. Engagement with HIV prevention treatment and care among female sex workers in Zimbabwe: a respondent driven sampling survey.

PLoS One. Where do female sex workers seek HIV and reproductive health care and what motivates Prostitutes Guimaraes choices? Tropical Med Int Health. Sampling and estimation in hidden populations using respondent-driven sampling. Sociol Methodol. Escorel S, Giovanella L. The sample size was set at FSW in each city. Women were eligible to participate in the study if they met the following inclusion criteria: age 18 years old or over; to report working as a sex worker in one of the cities of the study; to have had at least one sexual intercourse in Prostitutes Guimaraes for money in the past Prostitutes Guimaraes months; and to present a valid coupon to participate.

Fieldwork Prostitutes Guimaraes conducted in health services located in the 12 cities.

Seeds were well-connected FSW in their community who reported large social networks. Each seed received 3 coupons to distribute to other sex workers from Prostitutes Guimaraes social network.

Recruits of the seeds in the survey were considered the first wave of the study. After participating in the interview, each participant received 3 additional coupons to distribute Prostitutes Guimaraes their peers and this process was repeated until the sample size was achieved in each city. The RDS method also draws on the strategy of giving incentives to the participants.

A 1st incentive, that is, primary Prostitutes Guimaraes, is given to participants when they Prostitutes Guimaraes their participation in the study. Thereafter, a 2nd incentive, that is, secondary incentive, is given to participants for each peer successfully recruited into the study. The choice of sites, in general a health service, for data collection and the level of incentives were established according to the formative research carried out in each city before the RDS survey.

The questionnaire included modules on: socio-demographic characteristics and information related to commercial sex activity, knowledge about HIV and other STI transmission, sexual behavior, history of HIV Prostitutes Guimaraes syphilis testing, STI history, use of alcohol and illicit drugs, access to Prostitutes Guimaraes activities, access to and utilization of health services, discrimination, and violence.

The questionnaire was designed for tablets and could be self-administered according to the participant's desire and readiness. Tests for HIV, syphilis, and hepatitis B and C were Prostitutes Guimaraes by standard rapid tests using peripheral venous blood collection, according to protocols recommended by the Brazilian Ministry of Health.

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All tests occurred before the interview and Prostitutes Guimaraes participants received pre- and posttest counseling. Participants Prostitutes Guimaraes tested positive for any of the rapid tests had their blood samples taken for confirmatory laboratory testing and received additional posttest counseling, both for psychological impact and to encourage partner notification, and were referred to public health systems for follow-up.

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A Prostitutes Guimaraes result on the initial HIV rapid test was followed by a 2nd HIV rapid test, from a different manufacturer and samples reactive on Prostitutes Guimaraes tests were further submitted Prostitutes Guimaraes confirmatory assays. The proposed weighting for data collected by RDS is proportional to the inverse of network size of each participant. The tendency of a participant to recruit peers with similar characteristics is usually referred to as homophily. Additionally, the logistic regression models were performed by taking into account the complex sample design, by considering each city as a stratum and Prostitutes Guimaraes participants recruited by the same FSW as a cluster.

Taking into account the homophily effect and the dependence between recruiters and their recruited participants, the design effect was estimated at 1. Analysis of the association between socio-demographic variables, characteristics related to sex work, prevention activities and HIV infection adjusted by the recruiter's HIV test results among FSW, Brazil, Regarding commercial sex characteristics, HIV infection was associated with time in commercial sex work: HIV prevalence ranged from 1.

Additionally, an inverse association was found for the Prostitutes Guimaraes of each sexual encounter, the higher the price the smaller the odds of HIV infection.

In relation to participation in prevention activities, women who were affiliated to or participated in an FSW-NGO in the past 6 months had 1.

STI counseling in the last 6 months prior to the survey was not statistically significant. On the other hand, the use of illicit drugs at least once a week was highly significant: HIV prevalence varied from 4. Although HIV prevalence was smaller for consistent condom use with clients, the OR was not statistically significant. Regarding the occurrence of STI signs over the 12 months prior to the survey, presence of blisters on the vagina or anus indicated a chance 2.

Educational level remained statistically significant, highlighting the stronger effect of illiteracy or very low level of education, as well as price per sexual encounter, time of exposure to sex work, and the workplace street vs others after controlling for all other variables that also showed significant effects on HIV infection.

Syphilis reactive treponemal test was the most important predictor of HIV infection, with corresponding adjusted OR of 2. A large and significant homophily effect was found as well. The recruitment of a large number of FSWs in 12 Brazilian cities, in a short time period, at a relatively low cost compared to studies conducted in high-income countries, and the use of appropriate statistical procedures in data analysis, indicate that RDS is a feasible methodology for Prostitutes Guimaraes study of FSW in Brazil.

The experience of the previous RDS study enabled us to improve the techniques for data analysis and all the logistic regression models used in the present Prostitutes Guimaraes took into account the Prostitutes Guimaraes infection homophily effect and the intraclass correlation between recruited FSW by the same participant. In relation to socio-demographic and commercial sex characteristics, low educational level, street as the main work venue, low price per sexual Prostitutes Guimaraes, and longer exposure time as a sex worker were found to be the main predictors of HIV infection.

As Prostitutes Guimaraes the use of alcohol Prostitutes Guimaraes illicit drug use, our findings reiterate the effects of a greater HIV vulnerability associated to unprotected sex.

The possibility of not using condoms in some specific situations, such as not having condom available at the time of the sexual encounter, showed a significant effect on HIV infection as well. Data from previous surveys in Brazil evidenced a tendency for FSW to report consistent condom use with clients, especially when interviewed by health staff. However, when questions are asked indirectly, they reveal not using condoms in several circumstances.

Regarding participation in prevention activities, the results Prostitutes Guimaraes a higher chance of HIV infection among women who reported being affiliated to or participating in FSW-oriented NGOs. Unfortunately, in the current situation of weakening of NGOs in Brazil, the role of these institutions has been less and less focused on prevention and health promotion, as had historically occurred in Brazil.

Frequency of HIV testing represents the individual concern with preventive health care but also self-perception of risk. The occurrence of other STI indicated by the presence of blisters on the vagina or anus and syphilis were the most significant determinants of HIV infection. History of sexual violence was shown to be a relevant factor associated with HIV infection. Although prostitution in Brazil is not considered a crime under the National Constitution, FSW constantly experience human rights violations Prostitutes Guimaraes as physical and sexual violence usually perpetrated by partners, family members, and clients.

Engagement in violent and unprotected sexual practices, even against their will, Prostitutes Guimaraes the stigma and discrimination suffered by these Prostitutes Guimaraes, factors that have been shown to be strongly associated with adverse health outcomes.

The results of the multivariate analysis showed that the association of some variables with HIV infection persisted, such as effect of lower education Prostitutes Guimaraes cheaper fee for services, working at street spots, longer exposure time of sex work, syphilis, and crack use at least once a week.

It is important to note that Prostitutes Guimaraes use of multivariate models on the data collected by RDS Prostitutes Guimaraes renders variables that lose statistical significance due to Prostitutes Guimaraes complex sampling design with Prostitutes Guimaraes of the homophily effect, or to adjustments for confounding.

Other limitations are related to the cross-sectional design, for which the analysis of causality is restricted since temporality is not addressed in this type of study.

In conclusion, the main factors associated with HIV infection identified in this multivariate analysis characterize a specific type of street-based commercial sex work in Brazil: older women with none or very low degree of instruction, who charge less for the sexual encounter and frequently engage Prostitutes Guimaraes higher risk sexual behavior.

The small fee per sexual encounter is a determinant of the type of client, in general of low socioeconomic status and who are more likely to request unprotected sex. Ultimately, although the statistical analyses provide valuable information for developing targeted interventions, there is a further need to address other contextual factors. FSWs are exposed to multiple harms including illicit drug use, violence and Prostitutes Guimaraes, exploitation, as well as stigma and discrimination.

The authors thank the participants of the study and to the local teams that carried out the fieldwork in the 12 cities. Consent for publication: see institutional consent. Authorship: Prostitutes Guimaraes manuscript has not been submitted or accepted for publication elsewhere.

All authors contributed to the concept of the paper and data analysis. All authors have read and approved the paper, have met the criteria for authorship as established by the International Committee Prostitutes Guimaraes Medical Journal Editors, believe Prostitutes Guimaraes the paper represents honest work, and are able to verify the validity of the results reported.

No funding bodies had any role in study design, data collection and analysis, decision to publish, or Prostitutes Guimaraes of the manuscript. The authors have no Prostitutes Guimaraes of interest to disclose. National Center for Biotechnology InformationU. Journal List Medicine Baltimore v. Medicine Baltimore.

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Published online May Author information Article notes Copyright and License information Disclaimer. Published by Wolters Kluwer Health, Inc. Prostitutes Guimaraes is an open access article distributed under the Creative Commons Attribution License 4. This article has been cited by other articles in PMC. Results: HIV prevalence was estimated as 5. Conclusions: The main factors Prostitutes Guimaraes with HIV infection identified in our study characterize a specific type of street-based sex work in Brazil and provided valuable information for developing interventions.

Keywords: Brazil, female sex workers, HIV infection, homophily, respondent-driven sampling, risk factors. Introduction Since the beginning of the acquired immune deficiency syndrome AIDS epidemic, female sex workers FSWs Prostitutes Guimaraes been nationally and internationally recognized as a population at high risk for acquiring human immunodeficiency virus HIV infection. Open in a separate window.

Figure 1. Data analysis The proposed weighting for data collected by RDS is proportional to the inverse of network size of each participant. Results HIV prevalence was estimated as 5. Acknowledgments The Prostitutes Guimaraes thank the participants of the study and to the local teams that carried out the fieldwork in the 12 cities.

HIV risk perception, risk behavior, and seroprevalence among female commercial sex workers in Georgetown, Guyana. Lancet ; — Int J Drug Prostitutes Guimaraes ; 9 — Priority interventions to Prostitutes Guimaraes HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services. Sex workers in HIV prevention: from social change agents to peer educators. Glob Public Health ; 10 — High burden of HIV infection and risk behaviors among female sex workers in three main urban areas of Mozambique.

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Support Center Support Center. Washington, DC: World Bank; The choice of sites, in general a health service, for data collection and the level of incentives were established according to the formative research carried out in each city before the RDS survey.