Evaluating the role of structural inequities, gender-based violence, and power in shaping STI/HIV transmission dynamics in public place-based sex work

Street-involved women who exchange sex for money, drugs, shelter, food or other commodities across Canadian cities remain highly vulnerable to violence, exploitation, homelessness, substance use, mental health issues, suicide, and premature mortality. Of particular concern, increasing evidence suggests this population is at elevated risk for acquiring HIV and other sexually transmitted infections (STIs), with preliminary findings in Vancouver suggesting an HIV prevalence of 25% among female sex workers (FSWs). Importantly, emerging theoretical paradigms and global environmental-structural HIV/STI prevention research highlight the need to re-conceptualize women's HIV/STI risk as negotiated interactions, embedded in gendered power dynamics and access to resources, and the broader social, physical, and policy environment. While previous research has identified the individual risk factors for STI/HIV acquisition among FSWs, data has been largely drawn from studies among injection drug users and street involved youth, and there remains a dearth of longitudinal research evaluating the impact of the broader risk environment on HIV/STI transmission among street involved women who exchange sex. The proposed study aims to prospectively investigate how structural inequities (eg. housing insecurity, enforcement), gender-based violence, and power may shape the negotiation of risk reduction with clients and STI/HIV incidence among FSWS in public place-based sex work settings (e.g. bars, streets). As the first prospective study of FSWs and HIV/STI incidence in Canada, this research has a strong potential to contribute to innovative public health and HIV prevention strategies for some of the most vulnerable women in Canadian society. This research is also particularly timely and has the potential to inform ongoing legal proceedings and public policy discussions, as well as serve to help monitor the health and social impacts of major international events (e.g., 2010 Olympics).