Exploring associations between place of sex work and HIV vulnerabilities among sex workers in Jamaica

Abstract

Sex workers’ work environment shapes HIV transmission dynamics. We applied the Structural HIV Determinants Framework to examine associations between the work environment of public spaces and HIV infection risks among sex workers in Jamaica, considering macro-structural (police harassment) and intrapersonal (depression) pathways. We implemented a cross-sectional survey with sex workers in Kingston, Ocho Rios, Montego Bay, and nearby towns in Jamaica. We conducted structural equation modeling to examine direct and indirect associations between place of sex work on HIV serostatus via mediators of police harassment and depression. Results indicate that public place of sex work had a significant indirect effect on self-reported HIV-positive serostatus; depression and police harassment mediated this relationship. Findings suggest that in contexts of criminalization, the sex work environment can elevate exposure to police violence and depression, in turn increasing HIV vulnerabilities.

Keywords

Sex work Jamaica violence HIV depression work environment

Introduction

Sex workers across global contexts experience criminalization, rights violations and violence that elevate HIV vulnerabilities.¹,² In 2018 sex workers had a 21-fold higher relative risk of HIV acquisition compared with the general population.³ Other populations particularly impacted in the global HIV epidemic include gay, bisexual and other men who have sex with men (MSM) who have a 22 times higher relative risk, and transgender women who have 12-fold increased relative risk, of HIV acquisition when compared to general populations.³ Less research has studied HIV vulnerabilities among cisgender men and transgender sex workers, yet they may have increased HIV exposure in comparison with the general population⁴,⁵ and with non-sex-working cisgender men and transgender (trans) women.⁴,⁶,⁷ The social environments in which sex workers live and work shape their exposure to HIV in complex ways, particularly where sex work is criminalized.⁸

Criminalization elevates sex workers’ exposure to violence from police, clients and community members, while simultaneously reducing opportunities to access justice from police when victimized.¹,⁹ In Jamaica, sex work and same-sex sexual practices are both criminalized. Sex workers’ HIV prevalence is estimated at 2%.¹⁰ Gay, bisexual and other men who have sex with men’s (MSM) HIV prevalence in Jamaica is estimated at 30% while trans women’s prevalence is estimated at 51%.¹ Sexually and gender diverse people in Jamaica frequently report sex work; for instance, one-third of MSM in a study in three Jamaican cities reported transactional sex.⁶ Sex-working MSM reported increased HIV vulnerabilities in comparison with non-sex-working MSM, including lower safer sex efficacy and social support and increased sexual stigma, food and housing insecurity.⁶ In a community-based study with trans women in Jamaica, approximately half reported sex work.⁷ Sex work-engaged trans women reported increased intimate partner violence and incarceration compared to their non-sex work involved counterparts. These findings signal the need to understand HIV risk environments among sex workers in Jamaica.

Shannon et al. conceptualized the Structural HIV Determinants Framework to guide research on HIV vulnerabilities among sex workers within macrostructural (e.g. stigma, criminal law), community, and work (e.g. policing, violence) environments.⁸ This model unpacks the ways in which structural determinants interact with sex workers’ physical and social work environments. Within this framework, the work environment’s physical, social and policy features include policing and access to the HIV prevention cascades, and in turn is linked with sexual patterns and ultimately HIV transmission dynamics.⁸

Sex workers’ physical work environment is associated with HIV vulnerabilities. For instance, Krusi et al. (2012) discussed how unsanctioned indoor sex work venues, such as supportive housing, provided increased agency over sex work negotiations as well as reduced exposure to violence among sex workers in Canada.¹¹ Improved work environments, including access to HIV testing and condoms, have been linked with reduced HIV prevalence among sex workers across diverse contexts.¹² Safer work environments in urban Canada, such as working indoors in managed and supported settings, have been associated with reduced violence, less exposure to criminalization, and lower HIV and STI risks.¹¹,¹³ Conducting sex work in public spaces can be isolating with limited violence protection and reduced access to health and social services,¹³ and has been associated with lower enforcement of client condom use.¹¹,¹³

Sex work in public places also increases exposure to policing, and policing of sex workers in turn is associated with increased HIV vulnerabilities.¹⁴ A review of 800 articles reported that criminalization of sex workers enforced through policing can result in police harassment, beatings, sexual violence, arrest, and extortion.¹⁴ A study in Baltimore reported that most (78%) sex workers experienced lifetime abusive police encounters, and having experienced abusive police encounters was associated with increased likelihood of reporting client-perpetrated violence.⁹ Goldenberg et al.’s meta-synthesis of 24 studies with sex workers reported that minimizing exposure to negative interactions with law enforcement improved the ability to negotiate HIV prevention.¹⁵

The work environment can also be associated with mental health outcomes among sex workers. For instance, in studies in Canada¹⁶ and Australia,¹⁷ women sex workers with a mental health diagnosis, including depression, were more likely to report working in informal indoor or street/public places. Depression may be a barrier to engaging in HIV prevention as it can reduce safer sex efficacy and contribute to maladaptive coping strategies such as substance use during sex, condomless sex, and multiple sex partners.^19–22 Thus conducting sex work in precarious work environments contributes to stressors that can harm both sexual and mental health.

It is important to examine work environments among sex workers in Jamaica who experience the double burden of criminalization of sex work and same sex practices. There are numerous legal constraints targeting sex work in Jamaica, including sections of the Town and Communities Act, the Sexual Offences Act, and The Offences Against the Person Act. Sections of The Offences Against the Person Act have also been applied to MSM and trans women whose gender identities are not legally recognized.²³ There are no human rights protections for lesbian, gay, bisexual or transgender people in Jamaica.²³ A better understanding of HIV acquisition risks spanning work environment, macro-structural (policing), and individual (depression) levels can inform HIV prevention cascade strategies for sex workers in rights constrained contexts such as Jamaica.

Aims and objectives

These pathways from work environment to HIV exposure are underexplored among sex workers in Jamaica. Our study aimed to fill this knowledge gap by examining pathways from place of sex work to HIV-positive serostatus through the mediators of police harassment and depressive symptoms. We applied the Structural HIV Determinants Framework to better understand work environment and HIV risks, specifically how work environment could be associated with macro-structural (policing) and intrapersonal (depression) level outcomes that contribute to HIV exposure.⁸

Methods

Study design

This survey was part of a community-based research project with an AIDS service organization, Jamaica AIDS Support for Life, lesbian, gay, bisexual and trans (LGBT) groups, and a sex worker organization in Kingston, Ocho Rios, and Montego Bay, Jamaica. While recruitment occurred in these three cities, participants who lived in nearby towns (e.g. Negril) were welcome to participate. We conducted a cross-sectional survey administered by peer researchers who identified as LGBT and/or sex workers. Peer researchers provided feedback into survey development and facilitated convenience-based sampling using multiple methods of recruitment, including word-of-mouth, snowball, and venue-based with the community partner agencies. Tablet-based surveys were approximately 34–40 minutes in duration and all participants received the equivalent of $8 USD honorarium. Inclusion criteria were identifying as: a) a cisgender man, cisgender woman, or trans woman who reported engaging in sex work (exchanging sex for money or other goods) in the past 12 months; b) living in Kingston, Ocho Rios, Montego Bay or surrounding areas; c) being 18 years or older; and d) capable of providing informed consent. We aimed to recruit 330 people equally distributed between genders (n = 110 each for transgender women, cisgender men and cisgender women) to have a sufficient sample size to conduct structural equation modelling. There is no standard sample size calculation for structural equation models.²⁴ With binary and ordinal variables Bandalos et al. recommend a minimum sample size of 200 to achieve sufficient power for structural equation modelling, yet this sample size may need to be increased in models with observed vs. latent variables.²⁵ Research ethics approval was obtained from the University of Toronto and University of the West Indies, Mona.

Measures

To assess workplace environment, specifically place of sex work, we asked: “where do you usually do sex work (check all that apply): a) club; b) massage room; c) street; d) beach; e) home; f) motel. We recoded this variable into two values: sex work in public location (1) if participants reported street or beach; and sex work in non-public location (0) if participants reported sex work only in a club, massage room, home or motel.

To assess police harassment, we adapted a scale by Shannon et al.² to assess police sexual and physical assault. We pilot tested the survey with peer researchers with sex work experience and integrated feedback to add other contextually specific police harassment items recommended by peer researchers and community partners, including incarceration, sexual harassment, robbery, and arrest. We specifically asked how often, on a scale from never (0) to many times (2) had the police: 1) thrown you in jail/lockup; 2) sexually harassed you (called you names/groped you); 3) beaten you up; 4) robbed you of money or drugs; 5) raped you or made you have sex to keep working; or 6) arrested you or charged you?” We summed the total score of these six items to assess police harassment experiences, with higher scores indicating a higher range and frequency of police harassment experiences (Cronbach’s α = 0.83 in this sample, scale range 0–12). We assessed if the inclusion of legal and illegal forms of police practices affected the scale reliability, and found that the 6-item measure including both legal and illegal forms of police harassment had slightly higher reliability (Cronbach’s α = 0.87) than the 4-item measure of illegal forms of police harassment (Cronbach’s α = 0.86).

Depression symptoms over the past 2 weeks were assessed using the two-item Patient Health Questionnaire-2 (PHQ-2) (Cronbach’s α = 0.75 in this sample; scale range 0–6), where a score of 3 or higher indicates depression symptoms.²⁶ HIV status was measured through self-report by using the question: “what is your HIV status: (1) positive; and (0) negative”. Socio-demographic characteristics were examined as covariates: age (continuous), education level (dichotomous: less than high school vs. high school or higher), and monthly income (continuous).

Statistical analysis

We first conducted descriptive analyses of all variables for the whole sample. Bivariate analyses were performed to identify differences in socio-demographic characteristics by gender (cisgender men, cisgender women, trans women). Unadjusted and adjusted logistic regression analyses were then conducted to estimate the odds ratios of HIV status for the entire sample, adjusting for gender identity and other socio-demographic variables that differed based on gender identity in bivariate analyses (age, income, education level, relationship status). There was insufficient sample size per group and in the outcome variable to conduct regression analyses separately by gender identity. Structural equation modeling was conducted using weighted least square estimation methods to test the direct effects of place of sex work (public location vs. non-public location) on the odds of self-reported HIV-positive serostatus, and the indirect effects via police harassment and depressive symptoms, adjusting for socio-demographic factors. Model fit was assessed using: Chi-square, Root Mean Square Error of Approximation (RMSEA) and Comparative Fit Index (CFI). A significance level for Chi-square of p>0.05, a score of <0.05 for RMSEA with 90% confidence interval between 0.02 to 0.08, and a score greater than 0.90 for CFI indicate acceptable model fit.²⁷ Statistical significance was set at the p $<$ $0$ .05 level. Multiple imputation techniques (10 times) were used to deal with missing responses in order to improve the statistical analysis unbiasedly and efficiently. All statistical analyses were performed using Stata (version 14.0) and Mplus (version 1.40). We conducted sensitivity tests, where we both included and excluded legal forms of police harassment (arrest, incarceration) for logistic regression and path analyses. As the regression coefficients did not significantly change and the significance pathways remained the same, we retained the 6-item measure that included all forms of police harassment in the final model as this aligns with the guiding Structural HIV Determinants Framework⁸ and the evidence base documenting the harms of sex work criminalization.¹⁵

Results

Table 1 reports sociodemographic characteristics for the whole sample and differences by gender. Among 340 participants (mean age: 25.77 years [SD = 5.71, range 17–57]), 124 (36.47%) were cisgender men, 101 (29.71%) were trans women, and 115 (33.82%) were cisgender women. The mean weekly income earned was USD $119.92 (SD = 131.50). Post-hoc test (Bonferroni) results showed that cisgender women were significantly older and earned a higher monthly income than both cisgender men and trans women.

Table 1.

Sociodemographic characteristics among sex worker participants in Jamaica (N = 340).

Characteristics	Total, N (%)/Mean (SD, range)	Missing	Cisgender men, N (%)/Mean (SD, range)	Cisgender women, N (%)/Mean (SD, range)	Transgender women, N (%)/Mean (SD, range)	P (ANOVA/Chi-square)
Total	N = 340		N = 124 (36.47%)	N = 115 (33.82%)	N = 101 (29.71)
Age (years)	25.77 (5.71, 17–57)	13	24.72 (4.11, 17–38)	28.07 (6.54, 17–57)*	24.57 (5.75, 17–51)	<0.001
Weekly income in USD	119.92 (131.50, 0–1580)		95.03 (84.62, 0–711)	152.64 (166.64, 0.079–1580)*	109.84 (126.72, 0.079–790)	<0.01
Education: completed high school or higher	266 (78.24)		106 (85.48)	81 (70.43)	79 (78.22)	<0.05
City						<0.001
Kingston	101 (29.71)		21 (16.94)	27 (23.48)	53 (52.48)
Montego Bay	72 (21.18)		30 (24.19)	32 (27.83)	10 (9.90)
Negril	20 (5.88)		12 (9.68)	7 (6.09)	1 (0.99)
Spanish Town	25 (7.35)		5 (4.03)	8 (6.96)	12 (11.88)
Ochos Rios	71 (20.88)		34 (27.42)	27 (23.48)	10 (9.90)
Others	51 (15.00)		22 (17.74)	14 (12.17)	15 (14.85)
Relationship status		3				<0.001
Married or living together	43 (12.76)		13 (10.57)	22 (19.13)	8 (8.08)
Dating -- not living together	58 (17.21)		18 (14.63)	17 (14.78)	23 (23.23)
Casual dating	45 (13.35)		24 (19.51)	11 (9.57)	10 (10.10)
No current partner	96 (28.49)		42 (34.15)	32 (27.83)	22 (22.22)
Multiple partners/polyamorous	95 (28.19)		26 (21.14)	33 (28.70)	36 (36.36)
Police harassment (any)	173 (51.18)	2	52 (41.94)	55 (47.83)	66 (66.67)	<0.01
Police harassment (continuous scale)	Mean 1.96 (2.68)	2	1.24 (1.92)	1.70 (2.29)	3.15 (3.44)	<0.001
Sexual orientation		18				<0.001
Heterosexual	119 (36.96)		9 (7.83)	80 (74.77)	30 (30.00)
Bisexual	86 (26.71)		53 (46.09)	25 (23.36)	8 (8.00)
Gay/Lesbian	111 (34.47)		51 (44.35)	2 (1.87)	58 (58.00)
Queer	6 (1.86)		2 (1.74)	0	4 (4.00)
Conduct sex work in public location	194 (60.44)	19	69 (60.00)	61 (57.55)	64 (64.00)	0.634
Self-reported HIV-positive serostatus	50 (16.23)	32	15 (13.27)	3 (2.78)	32 (36.78)	<0.001
Depressive symptoms (raw score)	Mean 4.15 (1.75)	76	3.86 (1.81)*	4.20 (1.65)	4.52 (1.67)	<0.05
Depressive symptoms (score > = 3)	231 (80.68%)	76	93 (75.00)	74 (87.06)	46 (83.64)	0.078

Over half (60.44%) of participants reported conducting sex work in a public location (the street, beach); there were no gender differences in place of sex work. More than half of the participants (51.18%) reported any experience of police harassment. Trans women reported significantly higher police harassment than cisgender women or cisgender men, and there were no significant differences in police violence prevalence between cisgender men and cisgender women. Overall 16.23% of the participants self-reported being HIV positive, and self-reported HIV serostatus significantly differed by gender, whereby trans women’s self-reported HIV prevalence of 36.78% was significantly higher than cisgender men’s (13.27%) or cisgender women’s (2.78%). Cisgender men’s self-reported HIV prevalence was also significantly higher than among cisgender women. Most participants (n = 213; 80.68%) scored 3 or higher on the depression screen, indicating depression symptoms. Trans women had significantly higher depression scores than cisgender men, and there were no significant differences in depression scores between cisgender men and cisgender women.

Table 2 illustrates the results of univariate and multivariate logistic regression on self-reported HIV status. Univariate logistic regression shows that the odds of reporting an HIV-positive serostatus were associated with conducting sex work in public location, depression, and police harassment. In multivariate logistic regression analyses, police harassment (AOR: 1.19, 95% CI: 1.05–1.35, p < 0.01) and depression (AOR: 1.32, 95%CI: 1.01–1.73, p < 0.05) were associated with increased odds of self-reporting an HIV-positive serostatus.

Table 2.

Univariate and multivariate logistic regression on HIV-positive serostatus among sex worker participants in Jamaica (N = 308).

Variables	HIV-positive serostatus (among all participants)
Variables	Unadjusted OR (95% CI)	Adjusted OR (95% CI)*
Sex work in public location	2.85 (1.36–5.97)**	1.67 (0.70–3.99)
Police harassment	1.22 (1.11–1.35)***	1.19 (1.05–1.35)**
Depressive symptoms in the last two weeks	1.47 (1.15–1.88)**	1.32 (1.01–1.73)*

Note: *p < 0.05, ** p < 0.01, *** p < 0.001. Covariates include: age, weekly income, education level, relationship status and gender identity.

In the structural equation model that examined the direct and indirect effects of place of sex work on HIV positive serostatus, the final model fit indices suggested that the model fit the data well (df = 4, chi2 = 1.4705, p = 0.790, CFI/TLI = 0.998/0.977; RMSEA = 0.001 [90% CI: 0.001–0.056]). Table 3 displays the results of the final model.

Table 3.

Final path of structural equation modeling on HIV-positive serostatus among sex worker participants in Jamaica (N = 308).

Parameter	Coefficient (SE)	Critical Ratio	P	Standardized estimate
HIV-positive serostatus ON
Sex work in public location	0.359 (0.221)	1.626	0.104	0.161 (0.097)
Police harassment	0.102 (0.028)	3.714	<0.001	0.252 (0.070)
Depressive symptoms in the last two weeks	0.112 (0.059)	1.985	0.048	0.174 (0.094)
Depressive symptoms ON
Police harassment	0.107 (0.037)	2.885	0.004	0.170 (0.057)
Sex work in public location	1.055 (0.218)	4.831	<0.001	0.305 (0.056)
Police harassment ON
Sex work in public location	0.831 (0.378)	2.198	0.028	0.152 (0.069)

Covariates include: age, weekly income, education level, relationship status and gender identity.

Figure 1 illustrates the model with standard coefficients and the significance levels of each pathway. The standardized coefficient indicates that with a standard deviation of an increase in the independent variable, the dependent variable would increase by x standard deviation, holding all other variables constant. Standard errors are included in parenthesis.

Figure 1.

Final model for public place of sex work, police harassment and depression on HIV-positive serostatus among sex workers in Jamaica.

The indirect path from public place of sex work to HIV-positive serostatus was significant (β = 0.161, p = 0.104 for direct effect; β = 0.096, p < 0.05 for indirect effect). There was a significant direct effect of public place of sex work on depressive symptoms (β = 0.305, p < 0.001 for direct effect; β = 0.026, p = 0.073 for indirect effect). Police harassment and depressive symptoms mediated the relationship between public place of sex work and HIV-positive serostatus, where police harassment explained 39.6% of the variance (Standardized regression coefficient β: 0.038/0.096) and depressive symptoms accounted for 55.2% (Standardized regression coefficient β: 0.053/0.096) of the total indirect effect of public location of sex work on HIV-positive serostatus.

Discussion

We found that most (60.4%) sex workers we surveyed in Jamaica conducted sex work in a public location, and this was associated with increased depression and police harassment; these in turn were associated with increased odds of an HIV-positive serostatus. While approximately half of participants reported ever experiencing police harassment, trans women reported more police harassment than cisgender men or women. Findings signal the importance of employing a social ecological perspective that considers sex workers’ work environment and its associated individual (depression) and macro-structural (police harassment) factors that shape HIV prevention needs.²⁸

Findings document the utility of the Structural HIV Determinants Framework for understanding the work environment among sex workers in Jamaica.⁸ Specifically, in this context the criminalization of both sex work and same-sex practices reflect macro-structural factors²⁹ that underpin and perpetuate police harassment targeting sex workers and trans women in particular. Our findings corroborate prior research with MSM in Jamaica that show associations between police harassment and a) sex work and b) HIV-positive serostatus, and among trans women in Jamaica that show associations between police harassment and HIV-positive serostatus.^6,7 The current study builds on these findings to underscore linkages between precarious work environments for sex workers and HIV vulnerabilities. Statistical modelling with cisgender women sex workers reveals that decriminalization of sex work could reduce global new HIV infections by 33–46% in the next decade.²⁹ Decriminalization of same-sex practices is another structural intervention key to reducing HIV vulnerabilities,³⁰ and in fact, studies have documented the adverse health effects of criminalization of same-sex practices in real-time.³¹

Taken together, findings highlight the need for an intersectional approach to advance sex workers’ health and rights.³² The self-reported HIV prevalence in this study aligns with other Jamaican studies with cisgender women sex workers,¹⁰ gay, bisexual and other men who have sex with men who sell sex,⁶ and trans women who sell sex.⁷ Yet there are a heterogeneity of risks experienced by sex workers, with trans women more likely to report police harassment and depression than their cisgender men or women counterparts. Thus, securing indoor and supportive work environments for sex workers is necessary but not sufficient to address the social and health disparities experienced by trans women in Jamaica.

Syndemics theory, developed by Singer, points to the ways that socio-political and biological factors shape the clustering of diseases and health disparities.33 Our study revealed that HIV and depression are health issues that cluster, and are both associated with larger socio-political contexts including police harassment. Public environment of sex work and police harassment were both associated with depression, aligning with research from high income contexts that reveals associations between working in public spaces and mental health concerns among women sex workers.¹⁷,¹⁸ Pathways between depression and HIV acquisition risks require both research and action to promote mental health alongside sexual health with sex workers.^19–22 Research is urgently needed to address the mechanisms underpinning HIV vulnerabilities among sex workers in Jamaica.

There are study limitations that need to be considered. Self-reported HIV serostatus likely underestimates HIV prevalence, and future studies should collect biomarkers for HIV infection and other sexually transmissible infections. Some persons may not have known their HIV status and selected HIV negative, thus we may have underestimated HIV prevalence. Alternatively, as we recruited from a community-based organization, we may have oversampled HIV-positive sex workers. This was a non-random sample, thus we are not able to generalize findings across sex workers in Jamaica. Future studies could conduct respondent driven or starfish sampling to enhance the representativeness of the sample.³⁴ Depression symptoms were assessed over the past two weeks, while HIV serostatus was assessed over the lifetime. It is possible that there is a bidirectional association between depression and HIV-positive serostatus that we were unable to assess in this cross-sectional study. Notably, there was an insufficient sample size to conduct regression or SEM analyses separately by gender, precluding understanding of the ways that the pathways to HIV acquisition may differ by gender identity. There is a pressing need for studies with larger and more representative samples of sex workers to further explore HIV vulnerabilities.

Despite these study limitations, this study is unique in both applying the Structural HIV Determinants Framework in a middle-income context with human rights constraints for sex workers and LGBT people, as well as exploring its applicability to trans women and cisgender men sex workers.⁸ Contextually tailored, and sexual and gender identity affirmative, mental health support is urgently needed in low- and middle-income countries at large,³⁵ and particularly for sex workers in Jamaica, alongside social and policy change. Future HIV and human rights interventions grounded in an intersectional social geography of sex work lens^36–38 can focus on decriminalizing sex work and same-sex practices, and ensuring human rights protections, secure work environments, and accessible HIV prevention and care for sexually and gender diverse sex workers.

Footnotes

Acknowledgments

We would like to thank all of the participants, peer research assistants and collaborators: Jamaica AIDS Support for Life, JFLAG: Jamaica Forum for Lesbians, All-Sexuals and Gays, Caribbean Vulnerable Communities (CVC), Transwave, Aphrodite’s Pride, and the Sex Work Association of Jamaica. We recognize funding from the Canadian Institutes of Health Research (CIHR) Institute of Gender & Health. Dr. Logie’s efforts were also supported by an Ontario Ministry of Research & Innovation Early Researcher Award, the Canada Research Chair in Global Health Equity and Social Justice with Marginalized Populations, and the Canada Foundation for Innovation. Logie also received support from a Fulbright Canada Research Chair in Public Health at Johns Hopkins University.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Canadian Institutes of Health Research (CIHR) Operating Grant 0000303157; Fund: 495419, Competition 201209. Dr. Logie’s efforts were in part supported by an Ontario Ministry of Research and Innovation Early Researcher Award, the Canada Research Chair in Global Health Equity and Social Justice with Marginalized Populations, the Canada Foundation for Innovation, and a Fulbright Canada Research Chair in Public Health at Johns Hopkins University.

ORCID iD

Carmen H Logie

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