Physical and sexual violence, childhood sexual abuse and HIV/STI risk behaviour among alcohol-using women engaged in sex work in Mongolia
Although low, HIV prevalence in Mongolia could increase without strategic prevention strategies. Female sex workers (FSWs) often experience barriers to prevention, including interpersonal violence. This study investigated if childhood sexual abuse (CSA) or recent physical or sexual violence was associated with HIV sexual risk behaviours and if CSA modified associations between recent violence and HIV sexual risk behaviours.
Two-hundred twenty-two women who: (1) were at least 18 years old and clients at the National AIDS Foundation; (2) reported vaginal or anal sex in the past 90 days in exchange for money or goods; and (3) met criteria for harmful alcohol use in the past year were enrolled. In-person interviews assessed sexual risk behaviours and violence in childhood and adulthood. Negative binomial regression, ordinary least squares regression, and modified Poisson regression were performed.
Sexual risk with paying partners was associated with penetrative CSA and sexual violence by paying partners. CSA and recent violence were not associated with sexual risk behaviours with intimate partners. CSA modified the association between recent sexual violence and unprotected sex with intimate partners.
Findings highlight the need for integrated violence and sexual risk reduction services to ensure safe and effective prevention for FSWs.
Keywords: Violence, HIV, Alcohol, Sex work
Although the prevalence of HIV in Mongolia is low, Mongolia is at high risk of experiencing an HIV epidemic if rapid and strategic HIV prevention strategies are not instituted (UNGASS, 2010). One hundred cases of HIV have officially been reported, representing less than 0.1% of the adult population (Joint United Nations Programme on HIV/AIDS [UNAIDS] Mongolia, 2012). This represents a significant increase from just five reported cases as of 2004 (UNAIDS Mongolia, 2012).
A constellation of factors makes Mongolia vulnerable to rapid HIV spread. Mongolia is bordered by Russia to the North and China to the South and East, two countries with increasing numbers of people living with HIV/AIDS. Of new HIV infections in Eastern Europe and Central Asia, almost 90% occur in Russia or the Ukraine (UNAIDS, 2011). In China, while national HIV prevalence remains low, the number of people living with HIV/AIDS continues to increase (Ministry of Health of the People’s Republic of China, 2012). Moreover, groups at elevated risk of contracting HIV in China (e.g., female sex workers, men who have sex with men) report high rates of HIV sexual risk behaviours (Ministry of Health of the People’s Republic of China, 2012). A regional highway is under construction in Mongolia. Once completed, this highway will provide a trade route between Russia and China through Mongolia, likely increasing the migration of workers through Mongolia. Increased migration of workers has been associated with growing HIV epidemics across geographic boundaries on other continents (Elbright, Altantsetseg, & Oyungerel, 2003; Fages, 1999; Hagan & Dulmaa, 2007; UNAIDS, 2001).
In addition, since 1990 Mongolia has experienced a difficult economic transition from a centrally planned (Soviet-supported) to a free market economy, resulting in 27% of the population living below the poverty line (World Bank, 2013). Mongolia has a total population of 2.8 million, 40% of whom live in the capital city of Ulaanbaatar (World Bank, 2013). Ulaanbaatar has experienced increased alcoholism, unemployment and homelessness, a deteriorating health and social services system, and substantial increases in survival sex work among women (Davaalkham et al., 2009; National AIDS Foundation [NAF], 2001, 2003; Purevdawa et al., 1997). Sex work remains illegal in Mongolia, according to the 1998 Mongolian Law against Pornography and Prostitution which banned the organisation and facilitation of prostitution (Carlson, Tsai, Aira, Riedel, and Witte, forthcoming). Despite this law, there are approximately 4,000 commercial sex workers in Ulaanbaatar, the majority of whom are female (UNICEF, 2006). The number of women engaging in sex work in Mongolia fluctuates seasonally with many women engaging in sex work only during warmer summer months (Carlson et al., forthcoming).
In Mongolia, HIV primarily remains clustered among high risk groups including female sex workers (FSWs) and men who have sex with men. Although the most recent Behavioural Surveillance Survey reported a 0% prevalence of HIV among FSWs surveyed, half of all reported female cases of HIV are among FSWs whose paying partners are considered a bridge population in Mongolia (UNAIDS Mongolia, 2012). Because rates of new sexual partner acquisition among FSWs are significantly higher than the general population, FSWs often serve as drivers of HIV in low prevalence settings, contributing disproportionately to the spread of HIV into the general population (Anderson, 1999; Morris and Ferguson, 2006; World Health Organization [WHO], 2011). Given the transmission dynamics of HIV, FSWs are uniquely positioned to prevent a generalised HIV epidemic in low prevalence settings such as Mongolia.
Alcohol use among FSWs is prevalent and normative across countries and commonly used by FSWs to facilitate participation in commercial sex. FSWs are often encouraged or coerced to drink alcohol by clients and pimps (Markosyan et al., 2007). FSWs often report using alcohol while looking for clients and having sex while intoxicated (Chersich et al., 2007; Markosyan et al., 2007; Nishigaya, 2002; Rogers, Ying, Xin, Fung, & Kaufman, 2002). Alcohol use has been consistently associated with violence and HIV risk behaviours among FSWs including unprotected sex, anal sex, STIs, and HIV (Chersich et al., 2007; Li, Li, & Stanton, 2010; Scorgie et al., 2010; Wechsberg, Luseno, & Lam, 2005; Wechsberg, Luseno, Lam, Parry, & Morojele, 2006; WHO, 2011; Yadav et al., 2005).
Studies of sex workers across the globe highlight that multiple traumas, including childhood sexual abuse (CSA) and intimate partner violence (IPV), are associated with HIV sexual risk behaviours among this population (El-Bassel et al., 2003; Paone, Cooper, Alperen, Shi, & Des Jarlais, 1999; Shahmanesh et al., 2009; Surratt, Kurtz, Weaver, & Inciardi, 2005; Ulibarri et al., 2009). FSWs are at particularly high risk of physical and sexual violence from paying and non-paying partners, managers, and the police (Decker et al., 2010; Karandikar & Prospero, 2010; Open Society Institute, 2009; Rhodes, Simic, Baros, Platt, & Zikic, 2008; Simic & Rhodes, 2009; Swain, Saggurti, Battala, Verma, & Jain, 2011). Violence has been consistently associated with increased HIV risk among FSWs, including increased risk of sexually transmitted infections (STIs), anal sex, and unprotected sex (Decker et al., 2012; Simic & Rhodes, 2009; Swain et al., 2011; Ulibarri et al., 2011).
Experiences of violence contribute significantly to increasing women’s risk of HIV acquisition through biological, behavioural, and social mechanisms (Adimora et al., 2013; El-Bassel et al., 2003; Surrat et al., 2005). Violence is often linked to conflicts over condom negotiation (Wingood, Hunter-Gamble, & DiClemente, 1993). Coercive sex puts women at increased risk of contracting an STI, as they have less control over the situation and safe sexual practices. STIs, in turn, enhance the probability of HIV transmission during unprotected sex (Choi, Chen, & Jiang, 2008). The prevalence of STIs is high and increasing in Mongolia (Davaalkham et al., 2009; Hagan & Dulmaa, 2007). STIs are currently the most prevalent type of communicable disease in Mongolia (UNGASS, 2010).
Research on violence against FSWs in Mongolia remains limited. One study examined the prevalence of violence among FSWs in Mongolia before and after implementing a risk reduction intervention. At baseline, across intervention groups, 38%–52% of FSWs reported recent physical violence from an intimate partner, 50%–62% reported recent physical violence from a paying partner, 12%–16% reported recent sexual violence from an intimate partner, and 26%–36% reported recent sexual violence from a paying partner (Carlson, et al., 2012).
In addition to violence during adulthood, FSWs are more likely to have experienced CSA compared to women not engaged in sex work (Foti, 1995; James & Meyerding, 1977; Potter, Martin, & Romans, 1999). CSA has been associated with HIV sexual risk behaviours, including multiple sexual partners, unprotected sex, anal sex, STI symptoms, and early sexual debut (Lalor & McElvaney, 2010). In addition, women who experience CSA are at increased risk of sexual violence in adulthood from intimate partners (Classen, Palesh, & Arggarwal, 2005; Dunkle et al., 2004; Fanslow, Robinson, Crengle, & Perese, 2007; Fergusson, Horwood, & Lynskey, 1997; Messman-Moore & Long, 2003).
Given that violence is highly prevalent among FSWs and associated with HIV sexual risk behaviours, greater understanding of the nature of these relationships is needed. Recent evidence indicates that, among FSWs, HIV risk may differ by type of violence. For example, among FSWs in Moscow, violence perpetrated by paying clients, but not pimps, was associated with increased STI prevalence (Decker et al., 2012). In addition, despite the high prevalence of both CSA and recent violence against FSWs, little is known about the combined influence of CSA and recent violence on sexual risk behaviours. More specifically, whether CSA interacts with recent sexual or physical violence to further increase FSWs’ risk of engaging in sexual risk behaviours remains understudied. Greater understanding of interactions between violence during childhood and adulthood with sexual risk behaviours is needed to develop effective and appropriate HIV prevention strategies for FSWs, particularly for those with extensive histories of violence. Such information can be used to inform more relevant HIV prevention intervention components targeting FSWs and avoid escalation of HIV transmission in other countries at similarly high risk of experiencing an HIV epidemic, particularly countries with rapidly growing economies like Mongolia.
The purpose of this study is to investigate if (1) CSA is associated with HIV sexual risk behaviours; (2) recent physical or sexual violence is associated with HIV sexual risk behaviours; and (3) CSA modifies the association between recent violence and HIV sexual risk behaviours among FSWs in Mongolia.
Data were collected from women receiving services at the National AIDS Foundation (NAF) in Ulaanbaatar, Mongolia. Founded in 2000, NAF is the central resource and distribution source for NGO education and training in HIV/STI risk reduction and transmission information in Mongolia. Data are part of a parent study recruiting women for a randomised clinical trial testing the efficacy of an HIV/STI prevention intervention to reduce alcohol abuse and sexual risk behaviours among FSWs (Witte et al., 2011).
A total of 270 women were recruited and screened from 2008 to 2009. Women were eligible for the study if they: (1) were at least 18 years of age; (2) were currently enrolled in the NAF programme; (3) reported having engaged in vaginal or anal sexual intercourse in the past 90 days in exchange for money, alcohol, or other goods; and (4) met criteria for harmful alcohol use in the past year [score of eight or above on the Alcohol Use Disorders Identification Test (AUDIT), an internationally validated screening measure for alcohol problems in the past year, where a score of at least 8 or more indicates hazardous or harmful alcohol consumption] (Saunders, Aasland, Babor, DeLaFuente, & Grant, 1993). Of those screened, 41 women were excluded because they did not meet one or more of the eligibility criteria. Of the remaining 229 eligible women, 222 (97%) completed informed consent and baseline interviews. Research assistants administered baseline surveys lasting 60 to 90 minutes in a private setting. Assessments were administered using a computer-assisted personal interviewing (CAPI) method.
The assessment interview was designed to elicit self-reported data. Measures were translated into Mongolian from English and then back-translated for accuracy. The assessment was pilot tested with seven NAF and research project staff and determined to have adequate face validity.
Sociodemographic variables included: age, race/ethnicity, education, employment status, income, marital status, having an intimate partner, current housing situation, and whether exchanging sex for money was the primary source of income.
Using a method consistent with the Timeline Followback, participants provided data on the proportion and number of times they engaged in unprotected vaginal and anal sex with paying partners and intimate partners in the past 90 days (Sobell & Sobell, 1992). Measures were assessed separately for paying and intimate partners. A paying partner was defined as someone with whom you have sex in exchange for money, alcohol or other goods. An intimate partner was defined as a spouse, boyfriend, lover, or regular sexual partner who is not a paying partner.
Physical and Sexual Violence
To examine IPV as well as violence related to sex work, an adaptation of the Revised Conflict Tactics Scale was used which combined questions from similar categories (moderate vs. severe) assessing lifetime and recent physical and sexual violence perpetrated by intimate or paying partners (Straus, Hamby, Boney-McCoy, & Sugarman, 1996). ‘Mild’ violence questions, psychological aggression and negotiating behaviours were dropped to reduce questionnaire length. Recent violence was defined as violence that occurred within the past 90 days. The Cronbach’s alpha for the modified scale was 0.75 and 0.76 when measuring violence from intimate and paying partners, respectively.
CSA was measured using a modified version of the Childhood Sexual Abuse Interview (CSAI). The modified CSAI consisted of 7 of the original 11 items which assessed experiences with someone 5 or more years older than the respondent, ranging from an attempt to have intercourse to forced intercourse. Exposure variables considered less severe and perhaps with less face validity in the Mongolian context were dropped. Each item was scored by assigning ‘1’ for the presence or ‘0’ for the absence of the item. Any CSA was measured by summing the seven items. A summed score of 0 was coded as no CSA; a summed score greater than 0 was coded as positive for any CSA. Penetrative CSA was quantified using four items from the CSAI (i.e., did anyone ever put his penis in your mouth or put their mouth on your private sexual parts, have intercourse with you against your will, insert an object into your vagina or put their penis or object in your bottom?) (Finkelhor, 1978; Sgroi, 1982). A summed score of 0 on these four items was coded as no penetrative CSA; a summed score greater than 0 on these four items was coded as positive for penetrative CSA. The Cronbach’s alpha for the modified scale was 0.72.
Data were collected using a computer-assisted data entry program. A faulty gate question to a single section of the assessment was discovered that affected the first 30 participants. Sexual risk variables with paying partners were missing for these participants. Bivariate analyses were conducted comparing those with and without missing data. There were no significant differences between groups in relation to reported alcohol use, sexual risk with trust partners or experiences of violence. However, those with missing data were significantly younger than those without missing data. No other significant sociodemographic differences were identified. Because the dates that participants completed the assessment were not conditioned on any particular variable, data were missing at random and multiple imputation was performed to complete the data set prior to analyses (Rubin, 1987).
Univariate statistics were used to describe sociodemographic characteristics, sexual behaviours, frequency and types of violence. Negative binomial regression was performed to estimate the incidence rate ratio (IRR) of unprotected vaginal and anal sex in the past 90 days. Ordinary least squares (OLS) regression was performed to estimate the b coefficient of the proportion of unprotected vaginal or anal sex in the past 90 days. Modified Poisson regression was performed to estimate the relative risk reduction (RRR) of the prevalence of unprotected vaginal or anal sex in the past 90 days. All analyses were adjusted for age, education, income, marital status, and alcohol use and performed separately for intimate and paying partners. Effect measure modification of the association between recent violence and HIV sexual risk behaviour by CSA was assessed by examining the magnitude and significance of product terms between recent physical or sexual violence and CSA.
Descriptive statistics for the study sample are provided in Table 1. The average age of respondents was 34 years (range 18–67); the average age of initiation of sex work was 28 years (range 14–50). Participants were relatively well-educated with 64% having completed secondary school. Almost all (99%) participants were unemployed in formal sectors and reported sex work as their main form of income (93%). Most (60%) participants reported being divorced, widowed, or separated. Forty-four per cent of respondents reported currently having an intimate partner. Because eligibility was limited to women who scored 8 or higher on the AUDIT, all women in the sample were alcohol users. The overwhelming majority (93%) of women screened positive for alcohol dependence (i.e., scored 20 or greater on AUDIT).