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BackgroundFemale sex workers (FSWs) are an important population for HIV acquisition and transmission. Their risks are shaped by behavioral, sexual network, and structural level factors. Violence is pervasive and associated with HIV risk behavior and infection, yet interventions to address the dual epidemics of violence and HIV among FSWs are limited.MethodsWe used participatory methods to develop a brief, trauma-informed intervention, INSPIRE (Integrating Safety Promotion with HIV Risk Reduction), to improve safety and reduce HIV risk for FSWs. A quasi-experimental, single group pretest-posttest study evaluated intervention feasibility, acceptability and efficacy among FSWs in Baltimore, MD, most of whom were drug-involved (baseline n = 60; follow-up n = 39 [65%]; non-differential by demographics or outcomes). Qualitative data collected at follow-up contextualizes findings.ResultsBased on community partnership and FSW input, emergent goals included violence-related support, connection with services, and buffering against structural forces that blame FSWs for violence. Qualitative and quantitative results demonstrate feasibility and acceptability. At follow-up, improvements were seen in avoidance of client condom negotiation (p = 0.04), and frequency of sex trade under the influence of drugs or alcohol (p = 0.04). Women’s safety behavior increased (p < 0.001). Participants improved knowledge and use of sexual violence support (p < 0.01) and use of intimate partner violence support (p < 0.01). By follow-up, most respondents (68.4%) knew at least one program to obtain assistance reporting violence to police. Over the short follow-up period, client violence increased. In reflecting on intervention acceptability, participants emphasized the value of a safe and supportive space to discuss violence.DiscussionThis brief, trauma-informed intervention was feasible and highly acceptable to FSWs. It prompted safety behavior, mitigated sex trade under the influence, and bolstered confidence in condom negotiation. INSPIRE influenced endpoints deemed valuable by community partners, specifically improving connection to support services and building confidence in the face of myths that falsely blame sex workers for violence. Violence persisted; prevention also requires targeting perpetrators, and longer follow-up durations as women acquire safety skills. This pilot study informs scalable interventions that address trauma and its impact on HIV acquisition and care trajectories for FSWs.ConclusionAddressing violence in the context of HIV prevention is feasible, acceptable to FSWs, and can improve safety and reduce HIV risk, thus supporting FSW health and human rights.

Background Due to the concerns about the overtreatment of low-risk prostate cancer (PCa), active surveillance (AS) is now a recommended alternative to the active treatments (AT) of surgery and radiotherapy. However, AS is not widely utilized, partially due to psychological and decision-making factors associated with treatment preferences. Methods In a longitudinal cohort study, we conducted pretreatment telephone interviews (N=1,140, 69.3% participation) with newly diagnosed, low-risk PCa patients (PSA≤10, Gleason≤6) from Kaiser Permanente Northern California. We assessed psychological and decision-making variables, and treatment preference [AS, AT, No Preference (NP)]. Results Men were 61.5 (SD=7.3) years old, 24 days (median) post-diagnosis, and 81.1% white. Treatment preferences were: 39.3% AS, 30.9% AT, and 29.7% NP. Multinomial logistic regression revealed that men preferring AS (vs. AT) were older (OR=1.64, CI 1.07-2.51), more educated (OR=2.05, CI 1.12-3.74), had greater PCa knowledge (OR=1.77, CI 1.43-2.18) and greater awareness of having low-risk cancer (OR=3.97, CI 1.96-8.06), but also were less certain about their treatment preference (OR=0.57, CI 0.41 - 0.8), had greater PCa anxiety (OR=1.22, CI 1.003-1.48), and preferred a shared treatment decision (OR=2.34, CI 1.37-3.99). Similarly, men preferring NP (vs. AT) were less certain about treatment preference, preferred a shared decision, and had greater knowledge. Conclusions Although a substantial proportion of men preferred AS, this was associated with anxiety and uncertainty, suggesting that this may be a difficult choice. Impact Increasing the appropriate use of AS for low-risk PCa will require additional reassurance and information, and reaching men almost immediately post-diagnosis while the decision-making is ongoing.

Pre-exposure prophylaxis (PrEP) has the potential to be an empowering HIV prevention tool among female sex workers (FSW), yet little is known about PrEP awareness and interest in this population. Sex workers and Police Promoting Health in Risky Environments (SAPPHIRE) is a prospective cohort study of street-based FSW in Baltimore, MD. A cross-sectional analysis explored awareness and interest in PrEP among HIV-negative FSW. Multivariable Poisson regressions modeled associations between individual, interpersonal, and structural variables and PrEP awareness and interest. Of n = 232 FSW, 66% were white, half were less than 35 years old, 59% injected drugs daily, and 66% sold sex daily. Only 21% of FSW were aware of PrEP, though 74% were interested. PrEP awareness was associated with experiencing client condom coercion [adjusted incidence rate ratio (aIRR) = 0.50, 95% CI: 0.28-0.90] and condomless sex with an intimate partner (aIRR = 0.54, 95% CI: 0.30-0.98). PrEP interest was associated with perceiving PrEP as ''very easy'' to take (aIRR = 1.91, 95% CI: 1.49-2.45) and moving to an unfamiliar geographic area to sell sex (aIRR = 1.20, 95% CI: 1.04-1.39). Women who had a current gonorrhea or chlamydia infection were less likely to be interested in PrEP (aIRR = 0.75, 95% CI: 0.59-0.95). Though PrEP awareness among FSW is low, there are FSW who are significantly more likely to express interest in PrEP and outreach efforts should target these women. Results suggest that women-controlled HIV prevention methods may be important for reducing incidence among FSW.