Impact of Structural Policy Reform on HIV/STI Risk and Access to Care among SWs

 描述(由申请人提供)：本次竞争性更新的目标是研究性工作法律改革在减轻或加强艾滋病毒/性传播感染风险以及在女性性工作者中获得艾滋病毒/性传播感染相关护理方面的影响。加拿大政府最近推出了新的立法(法案C-36)，将购买性交易(客户)和任何从卖淫中获得经济利益的人(例如第三方，如妓院经理)定为犯罪，同时将性交易视为合法。这种将客户和第三方定为犯罪的方法，而不是将SWS定为犯罪， 这一模式通常被称为“北欧模式”，在过去一年里受到了越来越多的国际关注，欧盟、英国和越来越多的美国城市也出台了类似的法律/政策，尽管对其预期和非预期影响的研究完全缺乏。科学家、卫生专业人员和社区表达了强烈的担忧，认为这项法律将加剧社会福利机构之间的污名和社会凝聚力，将社会福利机构转移到隐藏和不安全的场所以避免警察迫害，并增加暴力和凶杀的发生率和空间聚集性，从而加剧结构性艾滋病毒/性传播感染风险。人们还越来越担心，警方将使用新的手段骚扰和瞄准性服务者，包括行政法(例如，公共滋扰、游荡)、毒品犯罪以及法院规定的针对注射毒品的性服务者的药物治疗(SW-PWID)，这可能进一步提高与性和毒品相关的艾滋病毒/性传播感染的风险。这些新的卖淫法律是否以及如何影响性工作者的结构性艾滋病毒/性传播感染风险以及与性和毒品相关的伤害，将对国际和美国社会以及全球政策产生重要影响。通过R01的支持，我们的团队自2005年以来在温哥华组建、招募和跟踪了一大批以社区为基础的街头和非街头女性SWS，他们被称为Aesha队列(&gt；90%保留)。温哥华是这项研究的理想地点，原因有几个：迫在眉睫的政策改革机会；北美仅有的纵向SWS队列之一的所在地；针对西南PWID的渐进减少伤害计划(例如，有监督的注射设施)；政府资助的艾滋病毒寻找、检测、治疗和保留的地点 以及全民健康覆盖，使我们能够将调查和生物数据与行政数据库联系起来，从而能够评估医疗障碍，而不会受到医疗健康保险的混淆影响。鉴于大量国家和美国城市在缺乏实证数据的情况下考虑围绕性工作进行立法改革，这项研究提供了一个前所未有的机会，可以评估性工作法律改革的结构性干预，将其作为对性工作者中艾滋病毒/性传播感染风险和其他健康后果的自然发生的实验。对结构性干预措施的评估很少见，在2014年跨国立卫生研究院艾滋病毒研究计划中是一个高度优先的项目。

 DESCRIPTION (provided by applicant): The goal of this competing renewal is to study the impact of sex work law reform on mitigating or potentiating HIV/STI risks and access to HIV/STI-related care among female SWs. The Canadian government has recently introduced new legislation (Bill C-36) that will criminalize the purchase of sex (clients) and anyone who economically profits from prostitution (e.g., third parties, such brothel managers) while leaving the selling of sex as legal. This approach of criminalizing clients and third parties, but not SWs, often referred to as the "Nordic model," has received increasing international attention over the last year, with similar laws/policies introduced in the EU, UK, and a growing number of US cities, despite a complete dearth of research on its intended and unintended impacts. Scientists, health professionals, and community have expressed strong concern that this law will escalate structural HIV/STI risks through heightened stigma and reduced social cohesion among SWs, displacement of SWs to hidden and unsafe venues to avoid police persecution, and increased rates and spatial clustering of violence and homicide. There is also increasing concern that police will use new means to harass and target SWs, including administrative laws (e.g., public nuisance, loitering), drug offenses, and court-mandated drug treatment for SWs who inject drugs (SW-PWIDs), which may further elevate sexual- and drug-related HIV/STI risks. Whether and how these new prostitution laws will affect structural HIV/STI risks and sexual- and drug-related harms for SWs will be important for international and US community and global policy. Through support from an R01, our team has assembled, recruited, and followed a large community-based cohort of street and off-street female SWs across Vancouver since 2005, known as the AESHA cohort (>90% retention). Vancouver is an ideal location for this research for several reasons: the imminent policy reform opportunity; site of one of the only longitudinal cohorts of SWs in North America; progressive harm reduction programs (e.g., supervised injection facilities) for SW- PWID; site of government-sponsored `seek, test, treat and retain' HIV efforts; and universal health coverage that allows us to link survey and biological data with administrative databases, permitting assessment of health care barriers free of the confounding effects of medical health insurance. Given the large number of countries, as well as US cities, contemplating legislative reform around sex work in the absence of empirical data, this study allows an unprecedented opportunity to evaluate a structural intervention of sex work law reform as a naturally-occurring experiment on HIV/STI risks and other health outcomes among SWs. The evaluation of structural interventions is rare and a high priority in the 2014 Trans-NIH Plan for HIV Research.