title: Sex work and HIV incidence among people who inject drugs.
abstract: OBJECTIVE
  Although the global burden of HIV infection among sex workers (SW) has been well recognized, HIV-related risks among sex workers who inject drugs (SW-IDU) have received less attention. We investigated the relationship between sex work and HIV incidence among people who inject drugs (IDU) in a Canadian setting.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Using Kaplan-Meier methods and the extended Cox regression, we compared HIV incidence among SW-IDU and non-SW-IDU in Vancouver, Canada, after adjusting for potential confounders.
  
  
  RESULTS
  Between 1996 and 2012, 1647 participants were included in the study, including 512 (31.1%) IDU engaged in sex work. At 5 years the HIV cumulative incidence was higher among SW-IDU in comparison to other IDU (12 vs. 7%, P = 0.001). In unadjusted Cox regression analyses, HIV incidence among SW-IDU was also elevated [relative hazard: 1.69; 95% confidence interval (CI): 1.13-2.53]. However, in a multivariable analysis, sex work did not remain associated with HIV infection (adjusted relative hazard: 0.74; 95% CI: 0.45-1.20), with cocaine injection appearing to account for the elevated risk for HIV infection among SW-IDU.
  
  
  CONCLUSIONS
  These data suggest that local SW-IDU have elevated rates of HIV infection. However, our exploration of risk factors among SW-IDU demonstrated that drug use patterns and environmental factors, rather than sexual risks, may explain the elevated HIV incidence among SW-IDU locally. Our findings highlight the need for social and structural interventions, including increased access to harm reduction programs and addiction treatment.
authors.affiliation: aBritish Columbia Centre for Excellence in HIV/AIDS bDepartment of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, British Columbia, Canada cDivision of Global Public Health, University of California San Diego Department of Medicine, San Diego, California, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Kerr
authors.forename: Kate
authors.initials: K
authors.lastname: Shannon
authors.forename: Lianping
authors.initials: L
authors.lastname: Ti
authors.forename: Steffanie
authors.initials: S
authors.lastname: Strathdee
authors.forename: Kanna
authors.initials: K
authors.lastname: Hayashi
authors.forename: Paul
authors.initials: P
authors.lastname: Nguyen
authors.forename: Julio
authors.initials: J
authors.lastname: Montaner
authors.forename: Evan
authors.initials: E
authors.lastname: Wood
mesh_terms: D000328:Adult; D002170:Canada / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D008297:Male; D016273:Occupational Exposure; D011446:Prospective Studies; D060386:Sex Workers; D015819:Substance Abuse, Intravenous / Q000150:complications*