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Risk

Risk

Sex Workers

4 Reports by Jackie Powder

Baltimore: Help on Wheels

Just past dawn on Thursday mornings, she waits for the van at a street corner in East Baltimore. At 6:30 a.m., she steps inside and sits down. Soon she's sipping a cup of coffee. She chats with the other women who trickle in.

The 41-year-old sex worker and drug addict looks forward to the Women Outreaching to Women (WOW) van every week, as do other sex workers in the area who stop by the van for clean needles, condoms, HIV testing, coffee and compassion.

The Baltimore City Health Department launched WOW in January as its first effort to target services to women sex workers who are injection drug users—and core transmitters of HIV and other sexually transmitted diseases.

"It is supposed to be one-stop shopping as much as possible," says Susan Sherman, PhD, MPH, associate professor of Epidemiology, who, at the request of the Health Department, is evaluating the pilot project to document the women's drug use patterns and sexual behaviors and to assess which related services—including WOW referrals to drug treatment, medical care, housing or counseling—the women actually follow up on.

Once a week, from 6:30 to 9 a.m., the WOW van visits two city locations known to be hubs for sex workers. Partnering with Power Inside, a Baltimore nonprofit, the Health Department hired an all-female staff for the project—two workers based in the van, and two who do outreach in the area—so sex workers would feel more comfortable seeking services.

"We've had women walk two miles or so to make it on time to the van," says Jacqueline Reuben, an MHS student at the School who's working on the evaluation with Sherman and regularly goes out in the WOW van to gather preliminary data.

Sometimes Reuben joins the van's outreach staff, walking the surrounding streets to let women know about the van. "If they don't want to come to the van," she says, "we can offer them a bag of condoms or food."

"They're in difficult situations," says Reuben, "and a lot of them really want to make a change."

Moscow: Risk Roulette

From Ukraine, Belarus, Moldova and elsewhere, young women come to Moscow to sell sex. Jobs are scarce at home, and they plan to send money back to their children or elderly parents.

They don't plan on the pervasive violence of the sex trade, the pay that falls far short of what was promised, or the difficulty of accessing affordable health care.

"In a city of 12 million there's one functioning clinic in Moscow that has services for sex workers that are confidential—but you have to pay," says Epidemiology Professor Chris Beyrer, MD, MPH '90, co-author of a 2005 study that examined female sex work in Moscow.

"If there's one group you want to have free and widely available services, it's sex workers, since in many settings they have been at the nexus of STD and HIV epidemics," he says.

Sex workers' inability to access free health care in Moscow is a remnant of the old Soviet Propiska system, in which health care was tied to legal residence and citizens could not change residence without state permission. Few sex workers are legal residents and consequently have no rights to public health facilities. Their illegal status also excludes them from government assistance with housing and social services, as well as legitimate employment.

Street-based sex workers in Moscow typically are stationed at tochkas, secluded roadside spots, says Beyrer. After a client negotiates with a pimp or a mamochka (a former sex worker who has moved up in the hierarchy), he drives off with the sex worker. Investigators found that a third of the sex workers in the study were infected with a sexually transmitted infection (STI). There was also a direct, independent correlation with having an STI and not having Moscow legal residency.

One surprisingly positive finding that emerged from the research: a low HIV incidence among the sex workers, which reflects the client population. But with the Moscow sex trade expanding rapidly, Beyrer expects the HIV rates to follow. "I'm quite pessimistic about Russian HIV prevention policy," says Beyrer.

"It's unlikely to get more progressive. Quite the opposite is happening."

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