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Incidence and Predictors of Chlamydia, Gonorrhea and Trichomonas Among a Prospective Cohort of Cisgender Female Sex Workers in Baltimore, Maryland

Park, Ju Nyeong PhD, MHS*; Gaydos, Charlotte A. DrPH, MS, MPH; White, Rebecca Hamilton MSPH*; Decker, Michele R. ScD, MPH; Footer, Katherine H.A. LLB, MSc*; Galai, Noya PhD§,¶; Silberzahn, Bradley E. MA*; Riegger, Katelyn MPH, MSW*; Morris, Miles MPH*; Huettner, Steve S. BS; Allen, Sean T. DrPH, MPH*; Sherman, Susan G. PhD, MPH*,§

doi: 10.1097/OLQ.0000000000001085
Original Studies

Background Cisgender female sex workers (CFSWs) have elevated rates of sexually transmitted infections (STI) yet are underrepresented in targeted programming and research in the United States. We examined the prevalence, incidence and predictors of chlamydia, gonorrhea, and trichomonas infection among CFSW.

Methods Two hundred fifty street-based CFSWs were recruited into a prospective observational cohort in Baltimore, Maryland using targeted sampling in 2016 to 2017 and completed surveys and STI testing at baseline, 3, 6, 9, and 12 months. Cox proportional hazards regression was used to model the predictors of STI.

Results Mean age was 36 years, and 66.5% of respondents were white. Baseline prevalence of chlamydia, gonorrhea, trichomonas was 10.5%, 12.6%, and 48.5%, respectively. The incidence of chlamydia, gonorrhea, and trichomonas was 14.3, 19.3, 69.1 per 100 person-years. Over one year of observation, past year sex work initiation predicted both chlamydia incidence (adjusted hazard ratio [aHR], 2.7; 95% confidence interval [CI], 1.3–6.0) and gonorrhea incidence (aHR, 1.7; 95% CI, 1.0–2.8). Client sexual violence predicted gonorrhea incidence (aHR, 2.9; 95% CI, 1.2–7.1) and having female sexual partners predicted trichomonas incidence (aHR, 3.4; 95% CI, 1.3–8.5). Having a usual health care provider (aHR, 0.6; 95% CI, 0.5–0.7) was inversely associated with trichomonas.

Conclusions In this study of urban US street-based CFSW, interpersonal and structural factors differentially predicted STIs, and infection rates remained elevated through follow-up despite regular testing, notification, and treatment referral. Focused and multifaceted interventions for sex workers and their sexual partners are urgently needed.

In a prospective study of street-based female sex workers in Baltimore, Maryland, recent entry into sex work, sexual violence, having same-gender partners elevated sexually transmitted infection risk.

From the *Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health

Johns Hopkins School of Medicine

Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health

§Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

University of Haifa, Haifa, Israel

Acknowledgments: The authors gratefully acknowledge the SAPPHIRE study participants, research staff and community advisory board.

Conflicts of Interest and Sources of Funding: This work was supported by the National Institute on Drug Abuse (R01DA038499-01) and Johns Hopkins University Center for AIDS Research (1P30AI094189). J.N.P. is supported by a Faculty Development Grant from the Johns Hopkins University Center for AIDS Research. C.A.G. was supported by the National Institute of Biomedical Imaging and Bioengineering (U54007958) and the National Institute of Allergy and Infectious Diseases (U01068613). S.T.A. is supported by the National Institutes of Health (K01DA046234). The funders had no role in study design, data collection, or in analysis and interpretation of the results, and this paper does not necessarily reflect views or opinions of the funders. S.G.S. is an expert witness for plaintiffs in opioid litigation.

Correspondence: Ju Nyeong Park, PhD MHS, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway St., Hampton House Suite 186, Baltimore, MD 21205. E-mail:

Received for publication July 20, 2019, and accepted October 6, 2019.

Online date: October 31, 2019

© Copyright 2019 American Sexually Transmitted Diseases Association