Longitudinal Associations between Recent Sex Work and Social and Health Outcomes in a National Cohort of Women Living with HIV in Canada: Implications for Stigma Informed and Sex Work Affirming HIV Care

Background: Sex workers experience stigma, criminalization, and violence that contribute to health inequities. These inequities may be exacerbated for sex working women living with HIV due to the intersection of sex work stigma with HIV-related stigma, racial discrimination, and gender discrimination. There are knowledge gaps regarding sex working women living with HIV’s wellbeing. Our study was informed by syndemics theory that explores the roles that social environments play in shaping interrelated health challenges. We explored social and health outcomes associated with recent sex work in a longitudinal cohort study with women living with HIV.

Methods: We conducted this three-wave survey with women living with HIV in three Canadian provinces (Ontario, British Columbia, Quebec) at 18-month intervals from 2013-2018. In bivariate analyses we examined associations between recent (past 6-month) sex work and: socio-demographic, health (CD4 count, viral load, physical health [SF-12], depression, post-traumatic stress disorder [PTSD], alcohol/drug use), and social (incarceration, violence, stigma [HIV-related stigma, racial discrimination, gender discrimination]) factors. We used generalized estimating equations (GEE) with an exchangeable correlation structure and robust standard errors to examine longitudinal associations between recent sex work with health and social outcomes. All equations were adjusted for socio-demographic factors associated with baseline sex work: gender identity, sexual orientation, education, ethnicity, and housing security.

Results: Among 1,422 participants (median age: 42.5, IQR: 35-50; ethnicity: 28.8% Black, 22.5% Indigenous, 41.6% White, 7.1% other ethnicities), 82 (5.8%) reported recent (past 6-month) sex work at baseline, while 73 and 37 reported recent sex work at the first and second follow-up, respectively. A total of 129 participants reported recent sex work during at least one of the three waves. At baseline, recent sex work was associated with sexual minority vs. heterosexual identity (32% vs. 12%), transgender vs. cisgender identity (22% vs. 2%), and housing insecurity (29% vs. 9%). Results of the GEE models revealed that, after adjusting for gender identity, sexual orientation, education, ethnicity, and housing security, participants reporting recent sex work were more likely to experience depression (AOR=1.75, 95% CI=1.24, 2.46) and PTSD (AOR=1.70, 95% CI=1.14, 2.54). They were also two and a half times more likely to have used injection drugs in the past six months (AOR=2.59, 95% CI=1.60, 4.20). Furthermore, they were more likely to have experienced racial discrimination (β=.21, 95% CI=.03, 0.38) and gender discrimination (β=.24, 95% CI=.01, 0.46).

Conclusions and Implications: Sex work trajectories among women living with HIV are dynamic. Recent sex work is associated with depression, injection drug use, racial discrimination, and gender discrimination over time. Findings suggest that sex working women living with HIV experience a syndemic of co-occurring social (racial and gender discrimination) and health (depression, PTSD, injection drug use) disparities. These findings signal the importance for intersectional stigma reduction interventions that tackle racial and gender bias at structural (e.g. health care and sex work venues), social (e.g. community norms), and individual (e.g. resilience, coping) levels. Trauma informed, sex work-affirming, and harm reduction strategies are needed to advance mental health and wellbeing among sex working women living with HIV in Canada.