title: The impact of violence on sex risk and drug use behaviors among women engaged in sex work in Phnom Penh, Cambodia.
abstract: BACKGROUND
  Violence, substance use, and HIV disproportionately impact female entertainment and sex workers (FESW), but causal pathways remain unclear.
  
  
  METHODS
  We examined data from an observational cohort of FESW age 15-29 in Phnom Penh, Cambodia for associations between violence exposure and sexual risk and drug use. Validated measures of physical and sexual violence were assessed at baseline. Self-reported outcomes measured quarterly over the next 12-months included past month sexual partners, consistent condom use by partner type, sex while high, and amphetamine type stimulant (ATS) use. Biomarkers measured quarterly included prostate specific antigen (PSA) and urine toxicology. Generalized estimating equations were fit adjusting for age, education, marital status and sex work venue.
  
  
  RESULTS
  Of 220 women, 48% reported physical or sexual violence in the preceding 12-months. Physical violence was associated with increased number of sex partners (adjusted incidence rate ratio [aIRR] 1.33; 95% CI: 1.04-1.71), greater odds of sex while high (adjusted odds ratio [aOR] 2.42; 95% CI: 1.10-5.33), increased days of ATS use (aIRR 2.74; 95% CI: 1.29-5.84) and increased odds of an ATS+ urine screen (aOR 2.80, 95%CI: 1.38-5.66). Sexual violence predicted decreased odds of consistent condom use with non-paying partners (aOR 0.24; 95% CI: 0.10-0.59) and greater odds of a PSA+ vaginal swab (aOR 1.83; 95% CI: 1.13-2.93).
  
  
  CONCLUSIONS
  Physical and sexual violence are prevalent among Cambodian FESW and associated with subsequent sexual risk and drug use behaviors. Clinical research examining interventions targeting structural and interpersonal factors impacting violence is needed to optimize HIV/AIDS prevention among FESW.
authors.affiliation: The Betty Irene Moore School of Nursing at UC Davis, 4610 X Street, #4202 Sacramento, CA 95817, United States. Electronic address: jdmoret@ucdavis.edu.
authors.forename: Jessica E
authors.initials: JE
authors.lastname: Draughon Moret
authors.affiliation: University of California San Francisco, School of Nursing, 2 Koret Way, San Francisco, CA 94143, United States. Electronic address: adam.carrico@ucsf.edu.
authors.forename: Adam W
authors.initials: AW
authors.lastname: Carrico
authors.affiliation: UCSF Global Health Sciences/Prevention and Public Health Group, Mission Hall, 550 16th St., Third Fl., Box 1224, San Francisco, CA 94158, United States. Electronic address: jennifer.evans@ucsf.edu.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Evans
authors.affiliation: UCSF Global Health Sciences/Prevention and Public Health Group, Mission Hall, 550 16th St., Third Fl., Box 1224, San Francisco, CA 94158, United States. Electronic address: ellen.stein@ucsf.edu.
authors.forename: Ellen S
authors.initials: ES
authors.lastname: Stein
authors.affiliation: University of San Francisco, School of Nursing and Health Professions, Department of Population Sciences, 2130 Fulton St., San Francisco, CA 94117, United States. Electronic address: mcouture@usfca.edu.
authors.forename: Marie-Claude
authors.initials: MC
authors.lastname: Couture
authors.affiliation: The Kirby Institute for Infection and Immunity, UNSW Australia, Sydney, NSW 2052, Australia. Electronic address: lmaher@kirby.unsw.edu.au.
authors.forename: Lisa
authors.initials: L
authors.lastname: Maher
authors.affiliation: Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Department of Internal Medicine, MSC 10 5550, 1 University of New Mexico, Albuquerque, NM 87131, United States. Electronic address: pagek@salud.unm.edu.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Page
mesh_terms: D000293:Adolescent; D000328:Adult; D019969:Amphetamine-Related Disorders / Q000453:epidemiology* / Q000652:urine; D002160:Cambodia / Q000453:epidemiology; D017280:Condoms / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D015995:Prevalence; D017430:Prostate-Specific Antigen / Q000378:metabolism; D012307:Risk Factors; D057566:Self Report; D012742:Sex Offenses / Q000523:psychology* / Q000706:statistics & numerical data*; D011477:Sex Work / Q000523:psychology / Q000706:statistics & numerical data; D060386:Sex Workers / Q000523:psychology* / Q000706:statistics & numerical data*; D012747:Sexual Partners; D047568:Unsafe Sex / Q000523:psychology*; D014621:Vagina / Q000378:metabolism; D014754:Violence / Q000523:psychology* / Q000706:statistics & numerical data*; D055815:Young Adult
chemical_list: D017430:Prostate-Specific Antigen
keywords: Amphetamine; Cambodia; Female sex workers; Prostitution; Sexual risk; Violence