Women Introduction Factors associated with sex work eg, multiple sexual partners, violence and drug use pose a risk to the health of female sex workers FSWs. Since , it has included information on whether patients are sex workers SWs 13 presenting a unique opportunity to undertake a comprehensive analysis of SWs seeking sexual healthcare in England using routine national surveillance system data.
For the first time, we compare the sexual health outcomes and service usage of FSWs with those of other females attending GUM clinics in England in order to better determine the demographic and clinical characteristics of FSWs, their risk of STI acquisition and patterns of service access.
Such information could be used to inform the development of sexual health services better tailored to the needs of this population.
It should be noted that 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. This subset contained a record of tests, services and diagnoses across attendances within a clinic for each woman. Travel for care was investigated by comparing the proportion of patients attending clinics outside their area of residence. Differences in sexual health between FSWs and other female attendees, and between migrant and UK-born FSWs, were assessed by comparing the period prevalence of STIs ie, chlamydia, gonorrhoea, syphilis, HIV, herpes, genital warts, hepatitis B, hepatitis C, pelvic inflammatory disease PID , trichomoniasis, scabies, molluscum contagiosum and other conditions ie, bacterial vaginosis BV , candidosis, urinary tract infections UTI , abnormal cervical cell cytology.
Period prevalence was defined as the proportion of individuals tested for an STI in who experienced an episode of that STI. Univariate associations between SW status and diagnoses and demographic factors eg, age, ethnicity, sexual orientation, location, deprivation and migrant status were investigated using logistic regression. The index of multiple deprivation score for a patient's postcode of residence was used as a measure of deprivation, and non-UK born FSWs were defined as migrants.
Women experiencing a second infection with an STI more than 6 weeks after their original diagnosis was recorded as reinfections. Subsequent reinfections were not included in the analysis. This analysis was repeated to compare UK-born and migrant FSW in terms of their demographic characteristics, attendance patterns, service use and STI prevalence and reinfection.
Results Demographic characteristics In , there were women who attended GUM clinics in England, of whom 0. There were 98 countries of origin recorded for migrant FSWs, with They made more visits than other female attendees mean number of visits in ; 3. Visits by FSWs were geographically concentrated; they were more likely to attend a clinic in London than other attendees They were also more likely to attend London clinics even when residing elsewhere; Visits by FSWs were concentrated in large clinics providing SW-specific services; more than three-quarters These 12 clinics accounted for Service use FSWs were more likely to use non-testing services such as contraception, smear tests and hepatitis B vaccination than other attendees table 1 , and a greater proportion of FSWs had a HIV test or sexual health screen which tests for chlamydia, gonorrhoea and syphilis.
As FSW visits were not equally distributed across all clinics we investigated whether the higher proportion of FSWs tested may be due to higher levels of testing overall at the clinics they attended.
However, the significant association remained when the analysis was restricted to these clinics Sexual health There were no significant differences in the period prevalence of HIV or syphilis between FSWs and other female attendees. Chlamydia was the most prevalent STI diagnosed in both groups with a significantly higher period prevalence among FSWs table 3. FSWs were almost twice as likely to be diagnosed with chlamydia, and three times more likely to be diagnosed with gonorrhoea than other female attendees, adjusting for demographic factors.
As FSWs made more visits on average than other female attendees, this increased prevalence may have been linked to the higher number of opportunities FSWs had to be diagnosed. As our model did not adjust for number of visits, we also compared prevalence of STI diagnosis in those tested at first visit and found that FSWs were still twice as likely to be diagnosed with chlamydia 2.
While reinfections with some STIs were more common in FSWs than in other females, the only statistically significant differences were for chlamydia reinfections 6. Adjusting for demographic factors and other diagnoses, only differences in PID and trichomoniasis prevalence remained statistically significant.
There were no statistically significant differences in reinfections between migrant and UK-born FSWs. While services, such as STI testing, vaccination and contraception are more frequently accessed by FSWs than other attendees, there is evidence of missed opportunities.
One limitation of our study is the likely underestimation of the number of FSWs attending GUM clinics, partly due to under-disclosure by FSWs but also because of an absence of guidelines on how SW status should be ascertained, or lack of coding by staff. Lack of knowledge about the different health-seeking behaviours among FSWs limits the generalisability of the conclusions that can be drawn from this analysis to FSWs who attend GUM clinics. Nonetheless, by comparison with special SW studies, our study provides a national picture of the sexual health of FSWs attending GUM clinics and their use of services, enabling geographic variations in service access to be explored and specific sexual health needs of FSWs to be investigated.
In our study, FSWs were older, a greater proportion lived in London and, most notably, three times as many were migrants compared with other attendees. Sociodemographic differences such as these may be useful for tailoring interventions and services for FSWs, for example, deciding on the location of outreach services and deciding which languages to offer them in. FSWs living outside of London were more likely to attend services in London than other female attendees which may be a reflection of FSWs working patterns.
FSWs working in London but living elsewhere in the country may choose to attend a clinic near their workplace rather than their area of residence. However, the pattern of visiting clinics in London when living elsewhere, the concentration of visits at large, specialist centres and the low number, or absence, of FSW attendances in some areas of the country, could also signify geographical inequalities in terms of access to, or awareness of, suitable services for FSWs.
For example, in Cumbria, there were no attendances by FSWs reported to our surveillance system in even though a study mapping the sex market in the region identified more than male and female SWs. Using routine surveillance data to identify clinics that are frequently and rarely visited by SWs may be useful for commissioners and service planners to investigate areas of potential unmet needs, and to strategically plan services and outreach programmes.
These FSWs may have been assessed not to need testing when they attended, or may access testing through primary health care providers, 11 which do not report to our surveillance system; however, it is likely that there remains a minority of FSWs who are not testing for STIs at all, as has been seen in other UK studies.
A greater proportion of migrant FSWs also used other services, such as contraception and cervical cytology, which highlights the vital role GUM clinics play in meeting their broader sexual and reproductive healthcare needs, but may also indicate unmet need for primary care-type services, similar to that expressed by FSWs in Bristol. This may have implications for service planning and intervention design for FSWs which may need to adopt an integrated approach to improving sexual health in the wider context of improving their general health.
Our calculated odds of infection for FSWs by comparison with other females may be lower than those reported elsewhere, as our comparative population of GUM clinic attendees is likely to be at higher risk than the GHS population.
The increased risk of certain STIs among FSWs that we identified may not be a consequence of sex work per se, but rather of other factors associated with sex work. STI acquisition among FSWs has been shown to be associated with intravenous drug use IDU and the use of condoms with, and number of, non-paying casual partners 6 , 24 rather than the number of clients or duration of sex work.
As our surveillance system does not gather data on sexual and drug-injecting behaviours, the influence of these factors on STI risk could not be determined. Previous studies reporting poorer sexual health outcomes among migrant FSWs have also shown they have poorer access to services such as GPs, 12 thus, the comparatively better sexual health outcomes observed among the migrant FSWs in our study may be a reflection of their increased use of services.
The differences in their working conditions could also be a contributing factor; it is thought migrant FSWs in England work almost exclusively indoors, 12 , 26 a lower-risk occupational environment, 23 , 25 however, this hypothesis was not tested in this study as this type of information is not gathered routinely through GUMCAD. Understanding the cause of the variation in sexual health between migrant and UK-born FSWs in the future will be important for effective intervention design.
Overall, FSWs in England have access to high-quality sexual health care through the GUM clinic network, but there is evidence of geographical inequality in access to these services. Targeted interventions aimed at improving uptake of testing and reducing the risk of repeat infection in this population should be developed, and need to be culturally sensitive to the needs of this predominantly migrant population.
Key messages FSWs appear to be at higher risk of certain sexually transmitted infections and reinfections compared with other female genitourinary medicine GUM clinic attendees, even adjusting for demographic factors.
FSWs have access to high-quality sexual healthcare through the GUM clinic network, but there is evidence of geographical inequality in access to services. Differences in service usage among FSWs by migrant status may indicate migrant FSWs experience unmet needs for primary care-type services.