title: Condom negotiations among female sex workers in the Philippines: environmental influences.
abstract: BACKGROUND
  Social and structural influences of condom negotiation among female sex workers (FSWs) remain understudied. This study assesses environmental and individual factors associated with condom negotiation among FSWs at high risk for acquiring HIV in a large urban setting of Metro Manila, Philippines.
  
  
  METHODS
  Female bar/spa workers (N = 498), aged 18 and over, underwent interview-led surveys examining their sexual health practices in the context of their risk environments. Data were collected from April 2009-January 2010 from 54 venues. Multiple logistic regressions were conducted to assess socio-behavioral factors (e.g., age, education, length of time employed as an entertainer, and alcohol/drug use) and socio-structural factors (e.g., venue-level peer/manager support, condom rule/availability, and sex trafficking) associated with condom negotiation, adjusting for individuals nested within venues.
  
  
  RESULTS
  Of 142 FSWs who traded sex in the previous 6 months (included in the analysis), 24% did not typically negotiate condom use with venue patrons. Factors in the physical environment--trafficked/coerced into work (AOR = 12.92, 95% CI = 3.34-49.90), economic environment--sex without a condom to make more money (AOR = 1.52, 95% CI 1.01-2.30), policy environment--sex without a condom because none was available (AOR = 2.58, 95% CI = 1.49-4.48), and individual risk--substance use (AOR = 2.36, 95% CI = 1.28-4.35) were independently associated with FSWs' lack of condom negotiation with venue patrons.
  
  
  CONCLUSIONS
  Factors in the physical, economic, and policy environments, over individual (excepting substance use) and social level factors, were significantly associated with these FSWs' condom negotiations in the Philippines. Drawing upon Rhodes' risk environment framework, these results highlight the need for policies that support safer sex negotiations among sex workers in the context of their risk environments. Interventions should reduce barriers to condom negotiation for FSWs trafficked/coerced into their work, substance using, and impacted by economic conditions and policies that do not support condom availability.
authors.affiliation: Division of Global Public Health, Department of Medicine, University of California San Diego, La Jolla, United States of America. lurada@ucsd.edu
authors.forename: Lianne A
authors.initials: LA
authors.lastname: Urada
authors.forename: Donald E
authors.initials: DE
authors.lastname: Morisky
authors.forename: Nymia
authors.initials: N
authors.lastname: Pimentel-Simbulan
authors.forename: Jay G
authors.initials: JG
authors.lastname: Silverman
authors.forename: Steffanie A
authors.initials: SA
authors.lastname: Strathdee
mesh_terms: D000293:Adolescent; D000328:Adult; D017280:Condoms / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D003625:Data Collection; D005260:Female; D015658:HIV Infections / Q000517:prevention & control* / Q000635:transmission; D006801:Humans; D017008:Negotiating; D010679:Philippines; D012307:Risk Factors; D021841:Safe Sex / Q000523:psychology / Q000706:statistics & numerical data; D011477:Sex Work / Q000523:psychology / Q000706:statistics & numerical data*; D060386:Sex Workers / Q000523:psychology*; D012725:Sexual Behavior; D012747:Sexual Partners / Q000523:psychology*; D012931:Social Environment; D047568:Unsafe Sex / Q000523:psychology / Q000706:statistics & numerical data; D055815:Young Adult