Adolescent Girls in Sex Work in Mexico and Guatemala:

Violence, Migration and HIV

Jay Silverman, Ph.D. Director of Research, Center on Gender Equity and Health

Professor of Medicine and Global Public Health

University of California San Diego School of Medicine UC Summer Institute on Migration and Health June 24, 2015

Adolescents Girls in Sex Work: Prevalence

Across multiple regions and populations, many FSWs enter sex work as adolescents:

• Pretoria, SA – mean age at entry = 16 yrs (Wechsberg et al., 2006)

• Pune, India – 43% entered < 16 yrs (Brahme et al., 2006) • West Bengal, India - 56% entered < age 20, 10% < age 16

(Sarkar et al., 2008) • Mumbai, India – 51% entered < age 18; 15% < age 15

(Silverman et al., 2011) • Corumba, Brazil – 42 % entered < age 18 (Lippman et al., 2009) • Vancouver, CA – median age at entry = 15 yrs (Shannon et al.,

2009) • Guatemala – 18.3% entered < age 18 (Silverman et al.,

forthcoming) • Tijuana and Cd. Juarez, MX – 24% entered < age 18 (Silverman

et al., forthcoming)

Why Does Age Matter?

• Traditional Public Health:

– Significantly increased HIV risk and infection

• Health and Human Rights:

– Violence and rights violations

Adolescent Girls in Sex Work: Far Greater Risk for HIV

• Across multiple regions, AFSWs at increased risk for HIV:

– West Bengal – incr. risk based on current age < 20 yrs (24% vs. 11%; Sarkar et al., 2008)

– Kolkata – incr. risk based on current age < 20 yrs (13% vs. 5%; Sarkar et al., 2006)

– Andra Pradesh – incr. risk based on entering < 20 years (20% v 13%; Ramesh et al., 2008)

– Nepal – 31% among 18+ yrs, 40% among ages 15-17 yrs, 61% < age 15 (Silverman et al., 2007)

Why are Adolescents at Higher Risk?

– Biology – larger area of cervical ectopy

– Reduced condom negotiation ability with clients

– Pressure from managers to not use condoms

– Higher numbers of clients

– Lower HIV knowledge

– May be more vulnerable to violence from police

– Violence from clients/managers, especially at initiation

Migration - Sex Trafficking of Adolescents, Violence and HIV risk

– Although part of the common conception of human trafficking, migration is not a required element

– Migration and vulnerability to

• Forced or coerced entry to sex work?

• Adolescent entry to sex work

• Violence and HIV risk in sex work?

• Examples: Europe, India, China

• Latina America?

RECENT RESEARCH

ADOLESCENTS, SEX WORK, MIGRATION AND HIV IN LATIN AMERICA

NORTHERN MEXICO

ESTIMA - Nature and prevalence of adolescent and forced/coerced sex work entry in Tijuana and Ciudad Juarez (NIDA-funded)

• TLS - surveys from 603 FSWs, 30 interviews

• Biologic HIV/STI testing

NORTHERN MEXICO BORDER Age at entry:

• 25.4% enter sex trade <18 years

• 11.8% entered <16 years

Migration at entry

• 7.7% entered sex work at time of migration

– 23.9% of which entered <18 years

– No association of migration and age at entry

NORTHERN MEXICO BORDER

• During initiation (first 30 days), at greater risk for:

–Violence to force commercial sex • 19.7% among <16 years vs. 8.7% among adults • AOR 2.5, 95%CI, 1.2-5.2 • 14.6% among 16-17 years, AOR 2.0 (1.0-4.2)

–High client volume - >10 clients per day • 21.1% among <16 years vs. 9.6% among adults • AOR 2.4, 95% CI, 1.2-5.0 • 19.5% for 16-17 years vs. 9.6% among adults • AOR 2.4, 1.3-4.6

(DO NOT CITE: JAMA, in press)

NORTHERN MEXICO BORDER

• During initiation (first 30 days), at greater risk for:

–No use of condoms with clients

• 35.2% among <16 years vs. 8.0% among adults

• AOR 6.6, 95% CI, 3.3-13.2

• 12.2% among 16-17 years - ns (DO NOT CITE: JAMA, in press)

NORTHERN MEXICO BORDER

• HIV

–5.9% among those entering <18 years

–1.6% among entering as adults

• AOR 3.1, 95% CI, 1.1-9.3

• Adjusted for recent condom use and lifetime IDU (DO NOT CITE: JAMA, in press)

• Primary risk factor for adolescent entry – Adolescent pregnancy!

CENTRAL AMERICA

• Agreement with U.S. CDC and multiple agencies in Central America to incorporate assessments into 4 IBBS surveys

– Guatemala, Belize and Honduras (2012-2013), Nicaragua (2013-2014)

– 4400 FSWs and 2700 MSM sampled via TLS and RDS

– First large-scale, population-based data on sex trafficking (age and force/coercion) in the region

• N=1216 • 18.3% entered SW < age 18

- 7.9% entered < age 16 • 10.3% entered at time of migration

• 34% Nicaragua, 27% El Salvador, 23% Honduras

• Age at entry and migration • Entering 18+ - 16.0% migration • Entering <18 – 18.5% migration - ns

Guatemala IBBS - FSWs

GUATEMALA: AGE AND HIV RISK

• During initiation (first 30 days), at greater risk for: – Violence to force commercial sex – 7.7% among 18+

• 25.9% among <16 years - AOR 4.6 (2.2 – 9.7) • 16.9% among 16-17 years - AOR 2.9 (1.5 – 5.7)

– No use of condoms with clients – 7.3% among 18+ • 19.6% among <16 years AOR 2.9 (1.3 – 6.2) • 5.7% among 16-17 years - ns

• During first year, at greater risk for: – No HIV education – 50.8% among 18+

• 76.5% among <16 years – AOR 2.8 (1.5 – 5.4) • 61.3% among 16-17 years - ns

Adjusted for age, education and site

GUATEMALA: AGE AND HIV RISK

HIV infection - 0.9% among 18+

• 4.6% among <16 years

– AOR 4.6 (1.6 – 13.0)

• 4.8% among 16-17 years

– AOR 5.8 (2.0 – 17.3)

Adjusted for age, education, study site, lifetime injection drug use, and condom use in the past 30 days

GUATEMALA: MIGRATION AND HIV RISK

• During initiation (first 30 days), at greater risk for:

– Violence to force commercial sex – 9.2% among not migrating from another country • 20.8% among migrating from another country • AOR 2.5 (1.3 – 5.0)

– No use of condoms with clients – 8.1% vs. 7.9% - NS

• During first year, at greater risk for:

– No HIV education – 55.3% vs. 41.3% - NS

Adjusted for age, education and site

GUATEMALA: MIGRATION AND HIV RISK

HIV infection – 1.5% among not migrating

from another country at entry

• 2.9% among migrating from another country at entry

– AOR 2.5 (0.8 – 7.4) – ns at p<.05

Adjusted for age, education, study site, lifetime injection drug use, and condom use in the past 30 days

CONCLUSION

• Adolescents are present in sex work in large numbers

• Greater risk for violence, HIV risk/infection • Migration also relates to greater risk for

violence, HIV risk/infection – context-specific

• Need to develop and evaluate approaches – to protect girls and migrants vulnerable to sex trade

entry and – to assist adolescents, migrants, others most

vulnerable in the sex industry

ACKNOWLEDGEMENTS Collaborators: Dr. Kimberly Brouwer, Dr. Sonia Morales,

Dr. Argentina Servin, Leah Gordon, Julie Ritter, Dr. Shira Goldenberg, Dr. Anita Raj

Funding: NIDA (R01DA033194); UCSD CFAR

We’d also like to thank our study participants and field team, as well as the following organizations:

• Universidad Autónoma de Ciudad Juárez

• Centro Nacional para la Prevención y el Control del VIH/SIDA

• Salud y Desarrollo Comunitario de Ciudad Juárez, A.C.

• Universidad de Valle de Guatemala