Based on combined methods, this study investigated substance use and HIV risk behaviors among kathoey sex workers (KSWs) in Bangkok, Thailand. The study found that only half of the KSW participants reported having been tested for HIV, and that except for one participant, all others had not seen health care providers in the past 12 months. About one third of the participants reported having engaged in unprotected anal sex with customers in the past 6 months. Almost all participants reported alcohol use, as well as having had sex with customers under the influence of alcohol. The prevalence of marijuana and ecstasy use in the past 12 months was high (32% and 36%, respectively); as was for ketamine (20%) and non-injecting methamphetamine (yaba) use (10%). A multiple regression analysis showed that the participants who were post-operative status, had used illicit drugs, or had been abused by their father and brothers were less likely to use condoms for anal sex with customers. Three quarters of the participants sent money to their families and 35% of the participants expressed their willingness to engage in unsafe sex when customers offer extra money. The qualitative interviews revealed that many identified as girl or kathoey in early age and had been exposed to transphobia and violence from father and brothers. Some reported support for gender transition from their mothers. More than half of the participants currently had difficulties in living as kathoey, such as challenges in job market and relationship with family members. Family obligation for sending money and the Buddhist concept of karma were discussed in relation to risk behaviors among KSWs. The study provided implications for facilitating HIV testing and developing future HIV prevention intervention programs for KSWs in Thailand.
It is urgent to develop efficacious HIV prevention programs to curb the reported extremely high HIV prevalence and incidence among transgender women (male-to-female transgender persons) who reside in large cities in the USA. This study aimed to describe unprotected receptive anal sex (URAS) and unprotected insertive anal sex (UIAS) among high-risk transgender women in relation to partner types, psychosocial factors, and background variables. Based on purposive sampling from the targeted communities and AIDS service organizations in San Francisco and Oakland, a total of 573 transgender women who had a history of sex work were recruited and individually interviewed using a structured survey questionnaire. Significant correlates with URAS with primary, casual, and commercial sex partners were found (e.g., needs for social support, frequency of social support received, exposure to transphobia, self-esteem, economic pressure, norms toward practicing healthy behaviors, and self-efficacy toward practicing safe sex). Multiple logistic regression analyses revealed that transgender women who had engaged in URAS with commercial partners were more likely to have higher levels of transphobia or lower levels of the norms or self-efficacy to practice safe sex. Among the participants who did not have vaginoplasty (preoperative transgender women), 16.4% had engaged in insertive anal sex (IAS) with commercial partners in the past 30 days. The participants who were HIV positive and had engaged in IAS were more likely to be African-American or Caucasians, coinfected with sexually transmitted infections, or identified themselves as homosexual. Practices of IAS among transgender women have not been thoroughly investigated in relation to sexual and gender identity. UIAS with homosexual and bisexual men in addition to URAS may be a cause for high HIV incidence among transgender women. An HIV prevention intervention study must be developed and evaluated, which aims to reduce HIV-positive and -negative transgender women's URAS and UIAS.
These findings demonstrate the enormity of African-American transgender women's needs within the Bay Area. Greater resources are needed for social service provision targeting this marginalized group of people, particularly in Oakland.
Recently, the number of indirect female sex workers (FSWs) who work at bars/clubs and massage parlors is substantially increasing in Thailand; however, there are huge gaps in knowledge about HIV risk behaviors among indirect FSWs. This study aimed to describe and understand HIV risk behaviors among Thai FSWs in Bangkok in relation to sociocultural factors and work environment (e.g., bars/clubs, massage parlors, brothels, and street). Based on venue-based purposive sampling methods, Thai FSWs were recruited for qualitative interviews (n = 50) and survey interviews (n = 205). Based on mixed methods, the study revealed that HIV risk and substance use behaviors among FSWs significantly differed depending on work venues, although there were no significant differences between work venues on some key risk behaviors (e.g., inconsistent condom use with primary partners and customers; willingness to engage in unsafe sex with customers). A multiple linear regression analysis revealed that FSWs who had used illicit drugs, were young, had low levels of self-esteem, or reported STIs had frequently engaged in unprotected vaginal sex with customers. Also, FSWs who worked at bars/clubs, were young, had higher income, or reported STIs had frequently engaged in sex with customers under the influence of alcohol. Qualitative interviews illustrated FSWs’ alcohol and drug use due to their stressful life (e.g., long working hours and a large number of customers) and easy access to alcohol and drugs. FSWs had shown inaccurate knowledge about HIV prevention methods and engaged in risky behaviors, such as washing vagina with water or toothpaste after having had sex with customers. The HIV prevention strategies in Thailand need to be re-structured through implementing evidence-based HIV prevention intervention programs for FSWs, which must address sociocultural factors (e.g., self-esteem) and alcohol and drug use specific to work venues.
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