Female sex workers (FSWs) are disproportionately affected by HIV and gender-based violence (GBV). Substance use has been shown to overlap with these co-occurring epidemics to further increase FSWs' risk for negative health outcomes. However, limited research has explored how aspects of the sex work environment shapes this risk. In this session, we will discuss findings from a mixed methods study that examined how aspects of the sex work environment facilitate alcohol use and increase FSWs' risk for GBV and HIV. We will then discuss the implications these results have for future interventions, with a special focus on the role technology can play in addressing aspects of the sex work environment to limit alcohol use and reduce FSWs' risk for GBV and HIV.

2. Alcohol use, gender-based violence and HIV risk
among female sex workers in Tanzania: Key
findings and ways forward
Anna M. Leddy, PhD MHS
University of California, San Francisco
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3. Background
● Female sex workers (FSWs) are disproportionately affected by gender-
based violence (GBV) and HIV.
● Alcohol use/abuse increases women’s risk for GBV and HIV.
● Limited research explores how the sex work environment shapes this
risk.
Beyrer et al. (2015)
Global burden of HIV among FSWs

4. Setting: Iringa, Tanzania
● Tanzanian-Zambian highway
○ Mobility & increased demand for sex work
● HIV prevalence among FSWs 33%
● Sex work venues: bars, night clubs, truck stops
● High alcohol consumption among FSWs & clients
○ 91% consumed alcohol during sex work in past week
● High prevalence of GBV
○ 52% physcial GBV & 47% sexual GBV in past 6 months

5. Study design & Methods
● Project Shikamana
○ Phase II community randomized controlled trial of a community
empowerment-based combination HIV prevention for FSW
○ Eligibility criteria: ≥ 18 years, exchanged sex for money in past
month, works in identified venue in one of two study communities
● Mixed methos:
○ Quantitative: Baseline data from Shikamana Cohort (N=496)
○ Qualitative: In-depth interviews with 24 cohort members

6. Quantitative Methods
● What is the relationship between substance use, GBV and consistent
condom use among FSWs and their clients?
Outcomes of interest:
1. Any GBV in the past 6
months
2. Consistent condom use in
the past 30 days with all
clients (new and regular)
Independent variables:
1. Almost always/always intoxicated
(drugs/alcohol) during sex work in
the past 30 days
2. Internalized sex work stigma
(α=0.86) 13 items
3. Ever denied payment for sex work
already completed
4. Monthly income > 120,000Tsh ($55)

7. Quantitative Findings
Demographic charcteristics of the Shikamana cohort at Baseline (N=496)
Characteristics n (%)
Age, mean (SD) 27 (7)
Monthly income > 120,000 Tsh/$55 244 (49)
HIV positive 203 (41)
Almost always/always intoxicated during sex work,
past 30 days
207 (42)
Drink one or more drinks on a typical day of work 408 (97)
Ever used drugs 34 (7)
Clients expect FSWs to consume alcohol during
sex work
324 (66)
Ever denied payment for sex work completed 158 (32)
Consistent condom use with all clients in past 30
days
158 (32)
Any GBV (physical or sexual), past 6 months 211 (43)

8. Quantitative Findings
Unadjusted and adjusted odds of experiencing any GBV in the past 6 months among
Shikamana cohort at baseline (N=496)
Characteristics
Bivariate Multivariable a
OR (95% CI) p-value AOR (95% CI) p-value
Almost always/always intoxicated during
sex work in the past 30 days
1.64 (1.14, 2.36) 0.007** 1.67 (1.08, 2.59) 0.02*
Ever denied payment for sex work
completed
2.25 (1.53, 3.31) <0.001*** 1.88 (1.22, 2.89) 0.004**
Internalized sex work stigma 1.04 (1.01, 1.07) 0.009** 1.05 (1.02, 1.09) 0.001**
*p<0.05; **p<0.01; ***p<0.001
a Controlling for: age, income, education, HIV status, relationship status, number of children, clients expect
FSW to consume alcohol during sex work, social cohesion, average amount earned for sex work, community,
work in a venue that sells alcohol, meet clients in bar

9. Quantiative Findings
Unadjusted and adjusted odds of consistent condom use with clients in the past 30 days
among Shikamana cohort at baseline (N=496)
Bivariate Multivariatea
Characteristics OR (95% CI) p-value OR (95% CI) p-value
Earn an average of 120,000 Tsh or more per
month (~$55 USD)
1.53 (1.04, 2.24) 0.03* 1.57 (1.01, 2.45) 0.05*
Any GBV in the past 6 months 0.90 (0.62, 1.31) 0.58 0.87 (0.56, 1.37) 0.56
Almost always/always intoxicated during sex work
in the past 30 days
0.54 (0.36, 0.79) 0.002** 0.59 (0.37, 0.95) 0.03*
Interaction term: Any GBV (6 mo) X almost always
intoxicated
0.68 (0.31, 1.49) 0.33
-- --
*p<0.05; **p<0.01; ***p<0.001
a Controlling for: age, education, HIV status, number of children, clients expect FSW to consume alcohol during
sex work, work in a venue that sells alcohol, meet clients in bar, social cohesion, internalized sex work stigma,
control community, access to condoms

10. Qualitative Methods
● To describe the role alcohol plays in both HIV and GBV-related risk in the
context of venue-based female sex work
● In-depth interviews with 24 FSWs in the Project Shikamana cohort
○ Purposively sampled based on: HIV status, sex work venue, level of engagment in
intervention
● Interviews conducted in Kiswahili by two trained female qualitative
interviewers
● Interviews transcribed, translated and uploaded into Atlas.ti for analysis
● Analysis guided by framework approach

11. Qualitative Findings
● FSWs and their clients engage in routine interactions across
three moments in the sex exchange process that faciliate
alcohol consumption and increase women’s risk for GBV
and HIV.
○ Attracting and meeting clients in the bar
○ Transitional/negotiation space
○ Room/sex exchange space

12. Qualitative Findings
● Attracting and meeting clients in the bar
○ Clients purchase FSWs alcohol to signal their interest in securing their services
■ “[Clients] can’t just come from nowhere [and say] ‘you lady, I want to sleep with you.’ No!
So he uses a certain way to get you attracted . [He tells a barmaid] ‘give that lady over
there a beer.’ After you drink it, he gives you an offer. He tells [the barmaid] ‘please call
for me that lady I want to talk to her.’ You go and talk to him. He tells you ‘I want you for
today, maybe we can go [have sex]?” (23 years, modern bar, HIV-uninfected)
■ “By taking his alcohol it means you are ready (to have sex), you can’t drink someone’s
alcohol when you are not ready.” (34 years, traditional bar, HIV-infected)

13. Qualitative Findings
● Transitional/negotiation space
○ FSWs experience violence if they refuse to have sex after consuming alcohol purchased by
a client
■ “He can buy me two, three beers and want to leave with me (to go have sex). If I don’t
want, he decides to beat me… those things happen a lot. When clients get drunk in the
bar, that is when they do that.” (30 years, modern bar, HIV-infected)
○ Difficult to negotiate condom use when clients are drunk

14. Qualitative Findings
● Room/sex exchange space
○ If FSWs drink to the point where they lose consciousness, clients sexually assault them.
■ “There was a friend of mine… she drank the beers of people who arranged to rape her
after she was drunk. She was very drunk, to the extent that she could not move. So they
raped her… they raped her both sides (vaginally and anally). When she got her mind
(when she became conscious) she said there were like five men.” (34 years, traditional
bar, HIV-infected)
○ FSWs experience violence if they consume alcohol purchased by a client but do not agree to
his new terms regarding the sex exchange.
■ “First he (client) told her ‘I want to go with you.’ She agreed… but she told him clearly ‘I
want us to use condom.’ The client agreed but inside [the room], the client turned [and
said], ‘you can’t tell me to use condom while you have already drank my beers, I can
decide anything.’ She refused [to have unprotected sex] and that is when she was
beaten.” (23 years, modern bar, HIV-uninfected)

15. Qualitative findings
● FSWs already mobilizing to address alcohol consumption, GBV and HIV
risk.
○ Fill beer cans with water to avoid becoming intoxicated
○ Cover shifts for colleagues who become too intoxicated to work, and bring them home when
they become unconscious from drinking
○ Mobilizing sex workers to respond to violence through whistles and mobile phones
■ “Our fellow [FSW] agreed to have sex with a customer. After getting inside [the room] she
found two clients. Because she was already educated by then (participated in the
intervention)…she blew the whistle. After she blew the whistle there are some women
who went there and some … were called through phones. After been called, we as
[FSWs], we ran there. [When we arrived] that customer ran…we went to report [the
violence] to the police station.” (25 years, traditional bar, HIV-uninfected)

16. Summary of findings
● High levels of alcohol use and intoxication during sex work
● Intoxication during sex work associated with increased odds of GBV and
reduced odds of consistent condom use
● Qualtitative results demonstrate that norms within the sex exchange
process facilitate alcohol consumption and place FSWs at risk for GBV
and unprotected sex
● FSWs already starting to mobilize to limit alcohol consumption and
prevent GBV and HIV.

17. Implications and ways forward
● Address role alcohol plays in increasing FSWs’ risk for GBV and HIV
○ Bring FSWs together with bar managers/owners to change norms about the role of
alcohol in the sex exchange process
○ Role for technology:
■ SMS messages about alcohol reduction and condom
use
■ Mobile app listing strategies to avoid violence or
dangerous clients
■ Phone network/hotline to mobilize sex workers in the
event of violence
Avahan crisis hotline www.gatesfoundation.org/avahan

18. Acknowledgements
● The women who participated in this study
● The Shikamana study team and the qualitative interviewers Grace
and Lilly
● This work was supported by the National Institutes of Mental Health
R01MH104044 (PI: Kerrigan) and F31MH110303 (PI: Leddy). This
work is solely the responsibility of the authors and does not
necessarily represent the official views of the sponsors.

19. Anna Leddy, PhD, MHS
Division of Prevention Science
Center for AIDS Prevention Studies
University of California, San Francisco
anna.leddy@ucsf.edu