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The Sexual Health of Female Sex Workers Compared with Other STI Online First, published on February 3, 2014 as 10.1136/sextrans-2013-051381 Epidemiology Sex Transm Infect: first published as 10.1136/sextrans-2013-051381 on 3 February 2014. Downloaded from ORIGINAL ARTICLE The sexual health of female sex workers compared with other women in England: analysis of cross-sectional data from genitourinary medicine clinics Louise Mc Grath-Lone,1 Kimberly Marsh,2 Gwenda Hughes,2 Helen Ward1 1Department of Infectious ABSTRACT is based on information gathered from special studies Disease Epidemiology, School Background While female sex workers (FSWs) are which are usually small and reliant on self-reported of Public Health, Imperial College London, London, UK assumed to be at increased risk of sexually transmitted information. 2Department of HIV & STIs, infections (STIs), there are limited comparative data with The Genitourinary Medicine Clinic Activity Centre for Infectious Disease other population groups available. Using routine STI Dataset (GUMCAD) is a patient-level, electronic Surveillance and Control, Public surveillance data, we investigated differences in sexual dataset including diagnoses made and services pro- Health England, London, UK health between FSWs and other female attendees at vided at all genitourinary medicine (GUM) clinics in Correspondence to genitourinary medicine (GUM) clinics in England. England that enables analysis of associations Louise Mc Grath-Lone, Methods Demographic characteristics, STI prevalence between patients’ demographic characteristics and Department of Infectious and service usage among FSWs and other attendees in their use of sexual health services and sexual health Disease Epidemiology, School 2011 were compared using logistic regression. outcomes. Since 2011, it has included information of Public Health, Imperial 13 College London W2 1PG, UK; Results In 2011, 2704 FSWs made 8411 recorded on whether patients are sex workers (SWs) pre- Louise.mc-grath-lone@imperial. visits to 131/208 GUM clinics, (primarily large, FSW- senting a unique opportunity to undertake a com- ac.uk specialist centres in London). FSWs used a variety of prehensive analysis of SWs seeking sexual services, however, 10% did not have an STI/HIV test at healthcare in England using routine national surveil- Received 26 September 2013 presentation. By comparison with other female lance system data. For the first time, we compare the Revised 16 December 2013 Accepted 30 December 2013 attendees, FSWs travelled further for their care and had sexual health outcomes and service usage of FSWs increased risk of certain STIs (eg, gonorrhoea ORadj: with those of other females attending GUM clinics 2.76, 95% CI 2.16 to 3.54, p<0.001). Migrant FSWs in England in order to better determine the demo- had better sexual health outcomes than UK-born FSWs graphic and clinical characteristics of FSWs, their (eg, period prevalence of chlamydia among those tested: risk of STI acquisition and patterns of service access. 8.5% vs 13.5%, p<0.001) but were more likely to Such information could be used to inform the devel- experience non-STI outcomes (eg, pelvic inflammatory opment of sexual health services better tailored to disease ORadj: 2.92, 95% CI 1.57 to 5.41, p<0.001). the needs of this population. http://sti.bmj.com/ Conclusions FSWs in England have access to high- quality care through the GUM clinic network, but there METHODS is evidence of geographical inequality in access to these Source of data services. A minority do not appear to access STI/HIV Guidelines for collecting and reporting GUMCAD testing through clinics, and some STIs are more data have previously been published.14 Briefly, demo- prevalent among FSWs than other female attendees. graphic data is self-reported by patients at first attend- on September 28, 2021 by guest. Protected copyright. Targeted interventions aimed at improving uptake of ance (ie, gender, age, ethnicity, country of birth and testing in FSWs should be developed, and need to be postcode of residence) or during a clinical consult- culturally sensitive to the needs of this predominantly ation (ie, sexual orientation). (It should be noted that migrant population. self-reported sexual orientation may not always be congruent with sexual practice,15 ie, FSWs may engage in sex with men but identify as homosexual). INTRODUCTION For each consultation, relevant services and diagnoses Factors associated with sex work (eg, multiple sexual are recorded for a patient using a set of uniform partners, violence and drug use) pose a risk to the codes known as Sexual Health and HIV Activity health of female sex workers (FSWs).1 In a number Property Type (SHHAPT) codes. The SHHAPT code of countries the prevalence of HIVand sexually trans- ‘SW’ is attached to visits made by SWs but is not per- mitted infections (STIs) are higher among FSWs than manently attached to a patient’s clinic record; it is – other women,2 4 and some subpopulations, such as recorded independently at each attendance, thereby migrant FSWs, appear to have worse sexual health requiring active coding by healthcare workers. There To cite: Mc Grath-Lone L, outcomes.5 In England, FSWs are thought to be at are no guidelines provided to GUM clinics on how to – Marsh K, Hughes G, et al. increased risk of STI6 8 and to experience barriers to define sex work or ascertain patients’ SW status, Sex Transm Infect Published 9–11 Online First: [please include accessing prevention and treatment services. clinics may rely on self-disclosure by patients or on Day Month Year] Disparities in sexual health outcomes and service healthcare staff actively asking all or selected patients. doi:10.1136/sextrans-2013- usage between migrant and UK-born FSWs have also A subset of GUMCAD data containing all visits by 051381 been described.12 However, much of what is reported females between 1 January and 31 December 2011 McCopyright Grath-Lone L, et Article al. Sex Transm author Infect 2014;(or 0their:1–7. doi:10.1136/sextrans-2013-051381employer) 2014. Produced by BMJ Publishing Group Ltd under licence. 1 Epidemiology Sex Transm Infect: first published as 10.1136/sextrans-2013-051381 on 3 February 2014. Downloaded from was extracted from the GUMCAD database held by Public Health Table 1 Demographic characteristics of and use of services by England ((PHE), formerly the Health Protection Agency). This females attending GUM clinics in England in 2011 by sex worker subset contained a record of tests, services and diagnoses across status attendances within a clinic for each woman. Women recorded as SWs (by the application of the SHAPPT code ‘SW’ during one Female sex Other female visit in 2011) were classified as such for any other visits that year. workers attendees This was to ensure that visits without the ‘SW’ code attached, (n=2704) (n=696 941) either due to inconsistent disclosure by FSWs10 11 16 or coding Demographic characteristics n % n % p Value errors by staff, were not excluded from the analysis. Age* Data analysis <19 118 4.4 128 781 18.5 The demographic characteristics of attendees, number of clinic 20–24 681 25.2 210 452 30.2 visits and the following service use variables were compared 25–29 659 24.4 135 951 19.5 2 using Pearson χ tests: the proportion of patients receiving post- 30–34 483 17.9 81 062 11.6 exposure prophylaxis for HIV following sexual exposure 35–44 529 19.6 88 752 12.7 (PEPSE), contraception, STI testing or cervical cytology on any 45+ 228 8.4 51 865 7.4 <0.001 visit in the year and the proportion receiving HIV testing or Median 29 years 25 years <0.001 hepatitis B vaccination where appropriate (ie, excluding indivi- Ethnicity† duals who were hepatitis B immune, HIV positive, or recently White 1695 62.7 508 377 72.9 tested for HIV). Travel for care was investigated by comparing Mixed 129 4.8 23 972 3.4 the proportion of patients attending clinics outside their area of Asian or Asian British 99 3.7 24 523 3.5 residence. Differences in sexual health between FSWs and other Black or Black British 155 5.7 74 029 10.6 female attendees, and between migrant and UK-born FSWs, Other 346 12.8 16 860 2.4 <0.001 were assessed by comparing the period prevalence of STIs (ie, Sexual orientation‡ chlamydia, gonorrhoea, syphilis, HIV, herpes, genital warts, Heterosexual 2495 92.3 607 332 87.1 hepatitis B, hepatitis C, pelvic inflammatory disease (PID), Homosexual 57 2.1 9 314 1.3 trichomoniasis, scabies, molluscum contagiosum) and other con- Bisexual 56 2.1 3 023 0.4 <0.001 ditions (ie, bacterial vaginosis (BV), candidosis, urinary tract Migrant status§ infections (UTI), abnormal cervical cell cytology). Period preva- UK-born 858 31.7 527 065 75.6 lence was defined as the proportion of individuals tested for an Migrant 1666 61.6 124 663 17.9 <0.001 STI in 2011 who experienced an episode of that STI. Patients Services used with SHHAPT codes for chlamydia, gonorrhoea, syphilis and Sexual health screen 2424 89.7 467 676 67.1 <0.001 HIV tests were included in the denominator for estimating HIV test¶ 2405 89.5 443 740 64.4 <0.001 period prevalence of these infections. As there are no SHAPPT Contraception 878 32.5 73 702 10.6 <0.001 codes to describe the tests, or investigations used to diagnose Smear test 337 12.5 10 520 1.5 <0.001 other STIs/conditions, all individuals were included in the Vaccination (hepatitis B)** 853 31.9 6 595 1.0 <0.001 denominator. PEPSE 19 0.7 723 0.1 <0.001 http://sti.bmj.com/ Univariate associations between SW status and diagnoses and Significant differences (p Value <0.05) highlighted in bold.
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