Physical and Sexual Violence Affecting Female Sex Workers in Côte d’Ivoire Carrie Lyons, MPH Center for Public Health and Human Rights Johns Hopkins Bloomberg School of Public Health Daouda Diouf, Fatou Drame, Abo Kouamé, Ezouatchi Rebecca, Amara Bamba, Abo Kouame, Marguerite Thiam, Benjamin Liestman, Sosthenes Ketende, Ashley Grosso, Kate Shannon, Stefan Baral

Acknowledgements Study Participants Partners Enda Santé Programme National de Lutte Contre le SIDA Ministere de la Lutte Contre Le SIDA CeDRes Abidjan Other NGOs Key Populations Program Stefan Baral, Sosthenes Ketende, Gnilane Turpin-Nunez, Ben Liestman, Karleen Coly, Sheree Schwartz, Amrita Rao Center for Public Health and Human Rights

Outline HIV, Violence, and Female Sex Workers Context in Côte d’Ivoire Study Methods Prevalence and Perpetrators of Violence Determinants of Violence Local Policing Practices Economic Work Environment Access to health services

HIV, Violence, and Female Sex Workers FSW have 13.5 times the odds of HIV infection compared to women Physical and sexual violence are shown to be associated with increased HIV incidence Violence exposure amongst FSW is shown to be associated with: STI symptoms and lesions inconsistent condom use recent condom failure client refusal of condom use

Structural HIV Determinants Framework for Sex Work Shannon, K., et al., Global epidemiology of HIV among female sex workers: influence of structural determinants. Lancet, (9962): p

The Context in Côte d’Ivoire HIV & related health outcomes HIV prevalence among adults is 3.2% Pooled HIV prevalence amongst FSW West in and Central Africa the is estimated to be 34.9% Limited access to contraception High burden of unintended pregnancies Low retention in HIV treatment Violence Limited data exist regarding the experience of violence amongst FSW in Cote d’Ivoire.

Objectives Estimate the prevalence of physical and sexual violence experienced by female sex workers in Abidjan, Côte d’Ivoire Identify associations between violence and local policing practice and the economic work environment Assess the relationship between violence and access to health services

Methods Study Participation Respondent Driven Sampling 466 Participants Socio-behavioral questionnaire & HIV testing Statistical Analyses Demographic characteristics and prevalence of violence Crude numbers and proportions & RDS adjusted estimates Local policing practices & economic work environment Multivariable logistic regression Violence indicators were treated as outcome variables Access to service indicators Multivariable logistic regression Violence indicators were treated as explanatory variables of interest

Prevalence of Violence RDS Adjusted Estimates presented Crude estimates: Physical violence 250/466 ; Sexual violence 201/465

Perpetrators of Violence Data presented as RDS Adjusted Estimates Participants may report more than 1 perpetrator

Local Policing Practices Total Physical Violence Sexual Violence YesaOR°95%CI YesaOR°°95% CI N% N% N% Police refused to protection , *1.0, 4.9 Harassed/intimidated by the police , , 2.0 Ever been arrested **1.0, *1.0, 3.8 * < 0.10 ** < 0.05 ***<0.01

Economic Work Environment TotalPhysical ViolenceSexual Violence aOR°95%CIYesaOR°°95% CI N% N% Offered more money to have sex without a condom *1.0, 4.5 Share earnings with someone who provides a service related to sex work **1.3, 3.2 * < 0.10 ** < 0.05 ***<0.01

Access to Health Services TotalPhysical ViolenceSexual Violence YesaOR°95% CIYesaOR°°95% CI N%N% N% Fear of seeking health services *0.9, , 1.8 Avoided seeking health services **1.1, , 2.1 HIV Positive Status **1.0, , 1.9 * < 0.10 ** < 0.05 ***<0.01

Limitations Self-reported and may be subject to Individual recall bias Social desirability bias Limited generalizability

Conclusion Violence amongst FSW in Abidjan, Côte d’Ivoire is common, and severe, and linked to features of the work environment FSW experience multiple levels of barriers Limiting the realization of their human rights Limiting access to HIV prevention, treatment, and care services Need for improved work environments Addressing legal barriers Violence reduction interventions

Thank you! There are no conflicts of interest amongst any of the study investigators