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Drivers of HIV Infection Among Cisgender and Transgender Female Sex Worker Populations in Baltimore City

Results From the SAPPHIRE Study

Sherman, Susan G. PhD, MPHa; Park, Ju Nyeong MHSa; Galai, Noya PhDa,b; Allen, Sean T. DrPHa; Huettner, Steve S. BSc; Silberzahn, Bradley E. MAa; Decker, Michele R. PhDa; Poteat, Tonia C. PhDa; Footer, Katherine H.A. LLB, MSca

JAIDS Journal of Acquired Immune Deficiency Syndromes: April 15, 2019 - Volume 80 - Issue 5 - p 513–521
doi: 10.1097/QAI.0000000000001959

Objective: To determine and compare risk factors for HIV infection among cisgender female sex workers (CFSWs) and transgender female sex workers (TFSWs).

Design: Baseline data from a cohort study (SAPPHIRE) of street-based CFSW and TFSW in Baltimore, MD.

Methods: Women were queried about individual (eg, drug use), interpersonal (eg, sexual abuse), and structural (eg, housing) risk factors and questioned on their sex work risk environment. Women were tested for HIV/sexually transmitted infections. We used logistic regression to identify key risk factors for prevalent HIV in each population.

Results: We recruited 262 CFSW and 62 TFSW between 2016 and 2017. Compared with TFSW, CFSW were more likely to be white (66% vs. 0%), recently homeless (62% vs. 23%, P < 0.001), regularly gone to sleep hungry (54% vs. 16%, P < 0.001), and to inject drugs (71% vs. 4%, P < 0.001). HIV prevalence was 8 times greater in TFSW than in CFSW (40% vs. 5%, P < 0.001). All participants reported high rates of lifetime physical and sexual violence. Cocaine injection [adjusted odds ratio (aOR) = 3.65, 95% confidence interval (CI): 1.12 to 11.88], food insecurity (aOR = 1.92, 95% CI: 1.22 to 3.04), and >5 years in sex work (aOR = 5.40, 95% CI: 2.10 to 13.90) were independently associated with HIV among CFSW. Childhood sexual abuse (aOR = 4.56, 95% CI: 1.20 to 17.32), being in sex work due to lack of opportunities (aOR = 4.81, 95% CI: 1.29 to 17.90), and >5 years in sex work (aOR = 5.62, 95% CI: 1.44 to 21.85) were independently associated with HIV among TFSW.

Conclusions: Although distinct, both populations share a history of extensive childhood abuse and later life structural vulnerability, which drive their engagement in street-based sex work and their HIV risk profiles.

aDepartment of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;

bDepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, University of Haifa, Haifa, Israel; and

cDepartment of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.

Correspondence to: Susan G. Sherman, PhD, MPH, Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway Street, Hampton House Suite 749, Baltimore, MD 21205 (e-mail:

Supported by the National Institute on Drug Abuse (R01DA038499-01) and Johns Hopkins University Center for AIDS Research (1P30AI094189). The funders had no role in the study design, data collection, or in the analysis and interpretation of the results, and this paper does not necessarily reflect views or opinions of the funders.

The authors have no funding or conflicts of interest to disclose.

S.G.S. and K.H.A.F. conceived and designed the study. S.H. and B.S. implemented and supervised data collection activities. J.P. conducted the data analysis with input from N.G., K.H.A.F., and S.G.S. S.G.S. led the writing of the manuscript with assistance from J.P. and K.F. All authors provided critical feedback on the analysis, interpretation, and provided final approval for the manuscript.

Received June 01, 2018

Accepted December 12, 2018

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