Background: Female sex workers are a heterogeneous group and recent reports of declining incidence of sexually transmitted infections (STIs) do not apply to all populations. This is an observational study of street-based sex workers attending an inner-London genitourinary (GU) clinic between 1 July 2006 and 31 January 2007.
Methods: In July 2006 the local sex worker outreach project developed a weekly drop-in for street-based sex workers. From the drop-in, sex workers were fast tracked to attend a range of dedicated health services, including the GUM clinic.
Results: The outreach team made contact with 120 street-based sex workers in the borough. 40 of these attended the drop-in and 25 attended the GU clinic. 8 had tuberculosis. There were frequent reports of recent recreational drug use, unprotected sex with clients and no reliable contraception. 7 were pregnant, 6 were HIV positive and 12 had positive syphilis serology. A further 17 STIs were identified.
Conclusions: There was a high frequency of HIV, syphilis, other bacterial STIs and unwanted pregnancy among sex workers attending this clinic. There were considerable amounts of other physical ill health in this group, with frequently reported risky sexual behaviour. This study demonstrates the need for targeted development work to meet the multifactorial needs of these women.
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Recent work demonstrates a declining prevalence of HIV and bacterial sexually transmitted infections (STIs) among UK female sex workers over the past decade.1–3 However, sex workers are a heterogeneous group.
Hackney in East London was at the centre of an outbreak of infectious syphilis in 2004, concentrated among local sex workers.4 The Open Doors outreach project developed twice-weekly outreach and a weekly drop-in for street sex workers (SSWs) in the borough. This article reports on the sexual health needs of SSWs attending the local GU clinic in the first 6 months after the establishment of the drop-in.
All SSWs attending the Department of Sexual Health, Homerton Hospital, London, from 1 July 2006 to 31 January 2007 via the Open Doors outreach service were included. Data were recorded on a manual database. SSWs were assessed using a structured proforma including details of sex work and medical, sexual and contraceptive history. All SSWs were offered tests for gonorrhoea, chlamydia, trichomonas, syphilis, HIV, Hepatitis B and C and pregnancy. Hepatitis B vaccination was offered.
In accordance with the guidance from the National Research Ethics Service,5 this study was deemed to be a service evaluation, without allocation to intervention groups. Assessment was by post-hoc review of the notes by the clinician treating the participants and the study did not impact on the participants in any way. Accordingly, this was not presented before an ethics committee.
Open Doors had contact with 120 SSWs during the period of the study, of whom 40 regularly attended the drop-in. Eight of these women were found to have tuberculosis. Six were transferred to the primary care unit/emergency department for assorted medical complaints including soft tissue infections, pyelonephritis and pulmonary infections.
Twenty-five SSWs chose to attend the GU clinic accompanied by Open Doors (mean age 29.7 years (21 to 46 years)). Eighteen were UK-born, 4 were from Africa or The Caribbean and 3 were other European. Recreational drug use in the previous 3 months was reported by 24 women, including crack cocaine (n = 24), heroin (n = 7), cocaine (n = 3) and benzodiazepines (n = 2). Our clinic did not have sufficient resources to examine these women’s mental health in greater detail.
The 25 SSWs attending the GU clinic reported offering the following sexual behaviour with commercial partners: unprotected vaginal intercourse (n = 22), unprotected anal intercourse (n = 21) and unprotected oral intercourse (n = 25). Seventeen reported unprotected sex with a non-commercial male partner in the previous 3 months. Condoms were occasionally used by all women, although unprotected intercourse was the norm. Reliable contraception was used by one patient. Seven were pregnant, of whom 5 were referred for termination of pregnancy. Of the remaining 18, 2 accepted ongoing contraception.
Eight were non-immune to hepatitis B. They had all have initiated a course of hepatitis B vaccination but had not completed the vaccination schedule within the recommended time frame.
A number of STIs were identified. Some patients consented to chlamydia screening only, or declined syphilis or HIV testing. Of 25 SSWs who had chlamydia tests, 6 were positive. Six of 23 had trichomonas and 2 of 23 had gonorrhoea. Two cases of scabies and one of pelvic inflammatory disease were identified. Three of 18 had early syphilis and 6 of 18 had serological evidence of late latent syphilis. A further 3 cases of syphilis had been treated prior to attendance at this clinic. Six SSWs were known to be HIV positive.
In 1 out of 10 cases of non-commercial contacts of SSWs with STIs, those STIs were treated; none of the commercial contacts were identified.
Of 25 SSWs attending this GU clinic, 6 were HIV positive, 12 had positive syphilis serology and a further 17 with STIs were identified. The majority of patients did not use contraception, with 7 being pregnant. Eight had tuberculosis and 6 required treatment at the emergency department for other infections.
This is an observational study and does not comment on background prevalence. We have highlighted ongoing vulnerability and risk in a subset of commercial sex workers, contrary to reports of decreasing prevalence among UK sex workers in general.1 3 The aggregate data in these studies, involving much larger groups of women, show a higher number of non-UK-born sex workers than the current study, and have noted the reduction of SSWs compared with other sex workers.1 It is not known whether the subset of UK-born SSWs in these studies have similar levels of STIs those seen in the current study. The majority of women used crack cocaine, which has been associated with higher levels of STIs compared with non-crack-using sex workers.6 The client group in this study were not included in previous studies, and the numbers involved are small. As such, it cannot be assumed that this is indicative of a new trend and it is unlikely that this is representative of the sex working community as a whole. Further studies of SSWs are planned to clarify this matter.
By focusing on SSWs in a local context we have been able to identify a particularly high risk among a marginalised group of women. These data highlight the complex medical and psychosocial needs of SSWs. The authors support a holistic approach to the care of this group through outreach services in an effort to facilitate access to healthcare services.
A subset of street-based sex workers report high amounts of unprotected sexual intercourse.
Unwanted pregnancy rates were high and contraception use was low.
These women have numerous sexually transmitted infections, including HIV, syphilis, chlamydia, gonorrhoea and trichomonas.
SC collected the data from the GU clinic and wrote the first and last draft. GP provided data from outreach and, with ST, provided critical review of the manuscript.
Competing interests: None declared.