Factors Associated with Engaging in Bystander Intervention Behavior Among College Students.

Sexual violence (SV) is a well-documented and highly prevalent issue on college campuses that disproportionately impacts women, students of color, and students who identify as lesbian, gay, bisexual, transgender, queer (LGBTQ). In recent years, bystander intervention programming has emerged as a promising prevention strategy for colleges due to its success in preventing SV before it occurs using community involvement; however, little consideration has been given to the power, status, or position that a bystander has when deciding whether to intervene and weighing the potential consequences of their actions. In order to inform university campus bystander intervention programming and increase its effectiveness, more work is needed to understand specific student characteristics (e.g., race/ethnicity, gender identity, sexual orientation, history of SV) that may be associated with engaging in bystander behavior in SV risk situations. Using cross-sectional data from a large west-coast university, 592 students were surveyed about their SV-related experiences. Poisson regression models were utilized to determine the relative risk of engaging in bystander behavior by sociodemographic identities and history of SV victimization. Our fully adjusted model indicated that experiencing attempted and completed sexual assault was associated with engaging in bystander behavior; belonging to specific minority groups was differentially associated with engaging in bystander behavior, as was belonging to a minority group and having a history of SV. Personal histories, identities, and power inequity matter when deciding to engage in bystander behavior. Additional research is needed to create more well-rounded and population-specific bystander intervention programs that are inclusive of diverse student voices and experiences.

Mental Health Service Needs of Commercially Sexually Exploited Youth: Voices of Survivors and Stakeholders.

Youth who experience commercial sexual exploitation (CSE) have complex mental health needs. This study describes what CSE survivors and stakeholders who work with them desire in mental health services. We conducted semi-structured interviews with 10 CSE survivors 16-20 years old, and 15 community experts on CSE (n = 25). Thematic analyses indicated CSE survivors value mental health services including individual therapy and coping skills, and they wanted providers who are nonjudgmental, and exhibit some level of understanding of CSE. Community stakeholders described skills important for CSE survivors to gain from mental health services including recognition of patterns of victimization, self-worth, and emotion regulation. Both stakeholders and CSE youth desired services that give survivors some control over their treatment and recovery utilizing a trauma-informed approach.

Intimate Partner Violence Among Female Sex Workers and Their Noncommercial Male Partners in Mexico: A Mixed-Methods Study.

Utilizing mixed methods, we examined intimate partner violence (IPV) behaviors among 428 female sex workers (FSWs) who use drugs and their noncommercial male partners in Tijuana and Ciudad Juarez, Mexico. Half of all participants reported perpetrating and experiencing at least one type of IPV behavior in the past year. In interviews, drug use emerged as an important theme associated with IPV behaviors, and we found men and women differed in their motivations for engaging in IPV behaviors. Findings highlight how gender and power are interlinked with and may exacerbate drug use and IPV behaviors among marginalized populations.

Changes in Condom Use Over Time Among Female Sex Workers and Their Male Noncommercial Partners and Clients.

Female sex workers (FSWs) often report inconsistent condom use with clients and noncommercial male partners, yet changes in condom use with various partner types during participation in observation studies remains underexplored. This longitudinal study of 214 FSWs and their male, noncommercial partners in the Mexico-U.S. border region, where HIV prevalence among FSWs continues to be high, utilized negative binomial regressions to examine changes in condom use with intimate partners and clients (regular and nonregular) over 24 months. Condom use decreased over time among couples in Ciudad Juarez, but there was no change in condom use among couples in Tijuana. FSWs' condom use with regular and nonregular clients significantly increased over time, which is consistent with previous research finding behavioral changes when participating in observational studies. Findings suggest the need for continued efforts to promote condom use among FSWs and their noncommercial male partners in addition to clients.

Intravaginal practices among HIV-negative female sex workers along the US-Mexico border and their implications for emerging HIV prevention interventions.

OBJECTIVE: To describe intravaginal practices (IVPs) among female sex workers (FSWs) who inject drugs in two cities-Tijuana and Ciudad Juarez-on the border between the USA and Mexico. METHODS: Data for a secondary analysis were obtained from interviews conducted as part of a randomized controlled trial in FSWs who injected drugs between October 28, 2008, and May 31, 2010. Eligible individuals were aged at least 18years and reported sharing injection equipment and having unprotected sex with clients in the previous month. Descriptive statistics were used to assess frequency and type of IVPs. Logistic regression was used to assess correlates of IVPs. RESULTS: Among 529 FSWs who completed both surveys, 229 (43.3%) had performed IVPs in the previous 6months. Factors independently associated with IVPs were reporting any sexually transmitted infection in the previous 6months (adjusted odds ratio [aOR] 1.8, 95% confidence interval [CI] 1.1-3.1; P=0.03), three or more pregnancies (aOR 1.9, 95% CI 1.1-3.2; P=0.02), and having clients who became violent when proposing condom use (aOR 5.8, 95% CI 1.0-34.3; P=0.05), which are all factors related to inconsistent condom use. CONCLUSION: Screening for IVPs could help to identify FSW at increased risk of HIV, and facilitate conversations about specific risk-reduction methods.

Social and Structural Challenges to Drug Cessation Among Couples in Northern Mexico: Implications for Drug Treatment in Underserved Communities.

BACKGROUND: Available drug treatment modalities may inadequately address social and structural contexts surrounding recovery efforts. METHODS: This mixed methods analysis drew on (1) surveys with female sex workers and their intimate male partners and (2) semi-structured interviews with a subsample of 41 couples (n=82 individuals, 123 total interviews) in Northern Mexico. Descriptive and content analyses examined drug cessation and treatment experiences. RESULTS: Perceived need for drug treatment was high, yet only 35% had ever accessed services. Financial and institutional barriers (childcare needs, sex-segregated facilities) prevented partners from enrolling in residential programs together or simultaneously, leading to self-treatment attempts. Outpatient methadone was experienced more positively, yet financial constraints limited access and treatment duration. Relapse was common, particularly when one partner enrolled alone while the other continued using drugs. CONCLUSIONS: Affordable, accessible, evidence-based drug treatment and recovery services that acknowledge social and structural contexts surrounding recovery are urgently needed for drug-involved couples.

Measuring Current Drug Use in Female Sex Workers and Their Noncommercial Male Partners in Mexico: Concordance Between Data Collected From Surveys Versus Semi-Structured Interviews.

BACKGROUND: Self-reports are commonly used to assess prevalence and frequency of drug use, but it is unclear whether qualitative methods like semi-structured interviews are as useful at obtaining such information as quantitative surveys. OBJECTIVES: This study compared drug use occurrence and frequency using data collected from quantitative surveys and qualitative interviews. We also examined whether combining data from both sources could result in significant increases in percentages of current users and whether the concordance between the two sets of data was associated with the type of drug use, age, gender and socioeconomic status. METHODS: Self- reports of recent marijuana, heroin, crack, cocaine, crystal/methamphetamine, inhalant, and tranquilizer use were collected using both methods from a cohort of Mexican female sex workers and their non-commercial male partners (n = 82). RESULTS: Participants were significantly less likely to report marijuana, cocaine and tranquilizer use and frequency of use during the qualitative interviews than during the quantitative surveys. Agreement on frequency of drug use was excellent for crystal/methamphetamine, heroin and inhalant use, and weak for cocaine, tranquilizers and marijuana use. Older participants exhibited significantly higher concordance than younger participants in reports of marijuana and methamphetamine use. Higher monthly income was significantly associated with higher concordance in crack use but lower concordance with marijuana use. CONCLUSIONS: Although use of such data can result in an underreporting of drug use, qualitative data can be quantified in certain circumstances to triangulate and confirm the results from quantitative analyses and provide a more comprehensive view of drug use.

Love, Trust, and HIV Risk Among Female Sex Workers and Their Intimate Male Partners.

OBJECTIVES: We examined correlates of love and trust among female sex workers and their noncommercial male partners along the Mexico-US border. METHODS: From 2011 to 2012, 322 partners in Tijuana and Ciudad Juárez, Mexico, completed assessments of love and trust. Cross-sectional dyadic regression analyses identified associations of relationship characteristics and HIV risk behaviors with love and trust. RESULTS: Within 161 couples, love and trust scores were moderately high (median 70/95 and 29/40 points, respectively) and correlated with relationship satisfaction. In regression analyses of HIV risk factors, men and women who used methamphetamine reported lower love scores, whereas women who used heroin reported slightly higher love. In an alternate model, men with concurrent sexual partners had lower love scores. For both partners, relationship conflict was associated with lower trust. CONCLUSIONS: Love and trust are associated with relationship quality, sexual risk, and drug use patterns that shape intimate partners' HIV risk. HIV interventions should consider the emotional quality of sex workers' intimate relationships.

Incidence and Predictors of HIV and Sexually Transmitted Infections Among Female Sex Workers and Their Intimate Male Partners in Northern Mexico: A Longitudinal, Multilevel Study.

Preventing human immunodeficiency virus (HIV) infection and other sexually transmitted infections (STIs) requires an understanding of sexual relationship factors beyond the individual level. We estimated HIV/STI incidence and identified time-varying predictors of STI acquisition in a prospective cohort study of female sex workers and their intimate (noncommercial) male partners in northern Mexico. From 2010 to 2013, couples underwent behavioral and biological assessments biannually for 24 months. Among 413 initially HIV-uninfected participants, 8 seroconverted during follow-up. Incidence of HIV (1.12 cases/100 person-years (PY)), chlamydia (9.47 cases/100 PY), active syphilis (4.01 cases/100 PY), and gonorrhea (1.78 cases/100 PY) was higher among women than among men (HIV: P = 0.069; all STIs combined: P < 0.001). In multivariable conditional logistic regression with individual fixed effects and correlated error terms within couples, risk of STI acquisition was significantly higher among women who had recently used cocaine, crack, or methamphetamine (adjusted odds ratio (OR) = 2.13, 95% confidence interval (CI): 1.07, 4.28). STI risk was lower among women who reported physically assaulting their male partners (adjusted OR = 0.44, 95% CI: 0.22, 0.86) and among men whose female partners had regular sex-work clients (adjusted OR = 0.38, 95% CI: 0.14, 1.03). Improving vulnerable couples' sexual health will require addressing the contexts in which drug use, interpersonal conflict, and economic vulnerability converge.

Associations between mental health, substance use, and sexual abuse experiences among Latinas.

This study examined self-reported sexually abusive experiences in childhood and adulthood as correlates of current drug use, alcohol abuse, and depression and posttraumatic stress disorder (PTSD) symptoms. Participants were 204 Latina women 18-34 years old. Results indicated significant relationships between history of sexual abuse (regardless of age of occurrence), depression symptoms, PTSD symptoms, alcohol abuse, and drug use. When examined separately, childhood sexual abuse was associated with symptoms of depression, PTSD, and substance use but not alcohol abuse behaviors. Experiencing sexual abuse in adulthood was associated with symptoms of depression, alcohol abuse behaviors, and substance use but not PTSD symptoms. Structural equation modeling showed that substance use partially mediated the relationship between sexual abuse and mental health outcomes. These findings suggest mental health and substance use services should incorporate treatment for trauma, which may be the root of comorbid mental health and substance use issues.

Correlates of unprotected sex by client type among female sex workers that inject drugs in Tijuana and Ciudad Juarez, Mexico.

AIMS: Risk environment factors may influence unprotected sex between female sex workers who are also injection drug users (FSW-IDUs) and their regular and non-regular clients differently. Our objective is to identify correlates of unprotected vaginal sex in the context of client type. METHODS: A cross-sectional survey of 583 FSW-IDUs in Tijuana and Ciudad Juarez, Mexico, was analyzed using negative binomial regression to determine physical, social, economic, and policy risk-environment factors that affect the frequency of unprotected sex with regular and non-regular clients. RESULTS: Median number of unprotected vaginal sex acts in the past month among FSW-IDUs and their regular and non-regular clients was 11 (IQR 3-30) and 13 (IQR 5-30), respectively. Correlates differed by site and client type and were most closely associated with the risk environment. In Tijuana, social factors (e.g., injecting drugs with clients) were independently associated with more unprotected sex. Factors independently associated with less unprotected sex across client type and site included social and economic risk environment factors (e.g., receiving more money for unprotected sex). In the policy risk environment, always having free access to condoms was independently associated with less unprotected sex among non-regular clients in Tijuana (Risk rate ratio = 0.64; 95% confidence interval 0.43-0.97). CONCLUSIONS: Primarily physical, social, and economic risk-environment factors were associated with unprotected vaginal sex between FSW-IDUs and both client types, suggesting potential avenues for intervention.

STI/HIV test result disclosure between female sex workers and their primary, non-commercial male partners in two Mexico-US border cities: a prospective study.

OBJECTIVES: Disclosure of sexually transmitted infections (STI)/HIV diagnoses to sexual partners is not mandated by public health guidelines in Mexico. To assess the feasibility of couples-based STI/HIV testing with facilitated disclosure as a risk-reduction strategy within female sex workers' (FSW) primary partnerships, we examined STI/HIV test result disclosure patterns between FSWs and their primary, non-commercial male partners in two Mexico-US border cities. METHODS: From 2010 to 2013, 335 participants (181 FSWs and 154 primary male partners) were followed for 24 months. At semiannual visits, participants were tested for STIs/HIV and reported on their disclosure of test results from the previous visit. Multilevel logistic regression was used to identify individual-level and partnership-level predictors of cumulative (1) non-disclosure of ≥1 STI test result and (2) non-disclosure of ≥1 HIV test result within couples during follow-up. RESULTS: Eighty-seven percent of participants reported disclosing all STI/HIV test results to their primary partners. Non-disclosure of ≥1 STI test result was more common among participants who reported an STI diagnosis as part of the study (adjusted OR=3.05, 95% CI 1.13 to 8.25), while non-disclosure of ≥1 HIV test result was more common among participants in longer-duration partnerships (AOR=1.15 per year, 95% CI 1.03 to 1.28). Drug use before/during sex within partnerships was associated with non-disclosure of both STI (AOR=5.06, 95% CI 1.64 to 15.62) and HIV (AOR=4.51, 95% CI: 1.32 to 15.39) test results. CONCLUSIONS: STI/HIV test result disclosure was highly prevalent within FSWs' primary partnerships, suggesting couples-based STI/HIV testing with facilitated disclosure may be feasible for these and potentially other high-risk, socially marginalised couples.

"Amar te Duele" ("love hurts"): sexual relationship power, intimate partner violence, depression symptoms and HIV risk among female sex workers who use drugs and their non-commercial, steady partners in Mexico.

A significant body of research among female sex workers (FSWs) has focused on individual-level HIV risk factors. Comparatively little is known about their non-commercial, steady partners who may heavily influence their behavior and HIV risk. This cross-sectional study of 214 FSWs who use drugs and their male steady partners aged ≥18 in two Mexico-U.S. border cities utilized a path-analytic model for dyadic data based upon the Actor-Partner Interdependence Model to examine relationships between sexual relationship power, intimate partner violence (IPV), depression symptoms, and unprotected sex. FSWs' relationship power, IPV perpetration and victimization were significantly associated with unprotected sex within the relationship. Male partners' depression symptoms were significantly associated with unprotected sex within the relationship. Future HIV prevention interventions for FSWs and their male partners should address issues of sexual relationship power, IPV, and mental health both individually and in the context of their relationship.

Prevalence and correlates of client-perpetrated abuse among female sex workers in two Mexico-U.S. border cities.

History of abuse has been associated with greater HIV risk among women. This study examined client-perpetrated abuse among female sex workers (FSWs) in two Mexico-U.S. border cities where HIV prevalence is rising. Among 924 FSWs, prevalence of client-perpetrated abuse was 31%. In multivariate logistic regression models, intimate partner violence (IPV), psychological distress, and having drug-using clients were associated with experiencing client-perpetrated abuse. FSWs along the Mexico-U.S. border report frequently experiencing abuse from both clients and intimate partners, which may have serious mental health consequences. Our findings suggest the need for screening and gender-based violence prevention services for Mexican FSWs.

Prevalence and correlates of HIV and sexually transmitted infections among female sex workers and their non-commercial male partners in two Mexico-USA border cities.

Female sex workers (FSWs) acquire HIV and other sexually transmitted infections (STIs) through unprotected sex with commercial and non-commercial (intimate) male partners. Little research has focused on FSWs' intimate relationships, within which condom use is rare. We sought to determine the prevalence and correlates of HIV/STIs within FSWs' intimate relationships in Northern Mexico. From 2010 to 2011, we conducted a cross-sectional survey of FSWs and their non-commercial male partners in Tijuana and Ciudad Juárez, Mexico. Eligible FSWs and their verified male partners were aged ≥18 years; FSWs reported lifetime use of heroin, cocaine, crack, or methamphetamine and recently exchanged sex (past month). Participants completed baseline questionnaires and testing for HIV, chlamydia, gonorrhea, and syphilis. We determined the prevalence and correlates of individuals' HIV/STI positivity using bivariate probit regression. Among 212 couples (n = 424), prevalence of HIV was 2.6 % (n = 11). Forty-two (9.9 %) tested positive for any HIV/STIs, which was more prevalent among women than men (12.7 % vs. 7.1 %, p < 0.05). FSWs with regular sex work clients were less likely to test positive for HIV/STIs than those without regular clients. Similarly, male partners of FSWs who had regular clients were 9 % less likely to have HIV/STIs. Higher sexual decision-making power was protective against HIV/STIs for women. Men who recently used methamphetamine or reported perpetrating any conflict within steady relationships were more likely to test positive for HIV/STIs. Within FSWs' intimate relationships in two Mexican-US border cities, nearly one in ten partners tested positive for HIV/STIs. Couple-based prevention interventions should recognize how intimate relationship factors and social contexts influence HIV/STI vulnerability.

Client perspectives on design and implementation of a couples-based intervention to reduce sexual and drug risk behaviors among female sex workers and their noncommercial partners in Tijuana and Ciudad Juárez, México.

This mixed-methods study examined the acceptability of a hypothetical couples-based HIV prevention program for female sex workers and their intimate (non-commercial) male partners in Mexico. Among 320 participants, 67 % preferred couples-based over individual programs, particularly among men. Reasons cited for preferring couples-based programs included convenience and health benefits for both partners. Participants reported that they would benefit from general health information and services, HIV counseling and testing, job training (particularly for men) and other services. However, qualitative interviews revealed that barriers relating to the environment (i.e., poor access to services), providers (i.e., lack of a therapeutic alliance), and intimate relationships (i.e., mistrust or instability) would need to be addressed before such a program could be successfully implemented. Despite women's concerns about privacy and men's preferences for gender-specific services, couples-based HIV prevention programs were largely acceptable to female sex workers and their intimate male partners.

Adverse pregnancy outcomes and sexual violence among female sex workers who inject drugs on the United States-Mexico border.

This study examines the prevalence of miscarriage/stillbirth among female sex workers who inject drugs (FSW-IDUs) and measures its associations with physical and sexual violence. Baseline data from 582 FSW-IDUs enrolled in an HIV intervention study in Tijuana and Ciudad Juárez, Mexico were used for current analyses. 30% of participants had experienced at least one miscarriage/stillbirth, 51% had experienced sexual violence, and 49% had experienced physical violence. History of miscarriage/stillbirth was associated with sexual violence (adjusted odds ratio [aOR] = 1.7, p = .02) but not physical violence. Additional reproductive risks associated with miscarriage/stillbirth included high numbers of male clients in the previous month (aOR = 1.1 per 30 clients, p = 0.04), history of abortion (aOR = 3.7, p < .001), and higher number of pregnancies (aOR = 1.4 per additional pregnancy, p < .001). Programs and research with this population should integrate reproductive health and consider gender-based violence.

Prevalence and characteristics of abuse experiences and depression symptoms among injection drug-using female sex workers in Mexico.

This mixed methods study examined the prevalence and characteristics of physical and sexual abuse and depression symptoms among 624 injection drug-using female sex workers (FSW-IDUs) in Tijuana and Ciudad Juarez, Mexico; a subset of 47 from Tijuana also underwent qualitative interviews. Linear regressions identified correlates of current depression symptoms. In the interviews, FSW-IDUs identified drug use as a method of coping with the trauma they experienced from abuse that occurred before and after age 18 and during the course of sex work. In a multivariate linear regression model, two factors-ever experiencing forced sex and forced sex in the context of sex work-were significantly associated with higher levels of depression symptoms. Our findings suggest the need for integrated mental health and drug abuse services for FSW-IDUs addressing history of trauma as well as for further research on violence revictimization in the context of sex work in Mexico.

Acceptability of vaginal microbicides among female sex workers and their intimate male partners in two Mexico-US border cities: a mixed methods analysis.

Female sex workers (FSWs) may benefit from pre-exposure prophylaxis (PrEP) including microbicides for HIV prevention. Since adherence is a key factor in PrEP efficacy, we explored microbicide acceptability and potential barriers to use within FSWs' intimate relationships in Tijuana and Ciudad Juárez, Mexico, where HIV prevalence is increasing. FSWs and their verified intimate (non-commercial) male partners completed quantitative and qualitative interviews from 2010 to 2012. Our complementary mixed methods design followed an iterative process to assess microbicide acceptability, explore related relationship dynamics and identify factors associated with concern about male partners' anger regarding microbicide use. Among 185 couples (n=370 individuals), interest in microbicides was high. In qualitative interviews with 28 couples, most participants were enthusiastic about microbicides for sex work contexts but some explained that microbicides could imply mistrust/infidelity within their intimate relationships. In the overall sample, nearly one in six participants (16%) worried that male partners would become angry about microbicides, which was associated with higher self-esteem among FSWs and lower self-esteem and past year conflicts causing injury within relationships among men. HIV prevention interventions should consider intimate relationship dynamics posing potential barriers to PrEP acceptability and adherence, involve male partners and promote risk communication skills.

The influence of having children on HIV-related risk behaviors of female sex workers and their intimate male partners in two Mexico-US border cities.

Among female sex workers who use drugs, the experience of having children and its effect on HIV risk behaviors remains underexplored. We draw from a study of 214 female sex workers and their intimate non-commercial partners in Tijuana and Ciudad Juárez, México (n = 428), approximately 30% of whom have children living with them. During qualitative interviews with 41 of these couples, having children emerged as an important topic. Children influenced partners' lives and HIV-related risk behaviors in positive and negative ways. Couples perceived that children strengthened their relationships. Concern for children's well-being motivated couples to contemplate healthier lifestyle changes. However, childrearing costs motivated sex work and structural constraints prevented couples from enacting lifestyle changes. Case studies illustrate these themes and highlight implications for couple- and family-based harm reduction interventions. Specifically, our results suggest a need for economic alternatives to sex work while working with families to develop risk reduction skills.