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Structural barriers to condom access in a community-based cohort of sex workers in Vancouver, Canada: influence of policing, violence and end-demand criminalisation
  1. Shira Goldenberg1,2,
  2. Ruchi Liyanage2,
  3. Melissa Braschel2,
  4. Kate Shannon2,3
  1. 1 Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
  2. 2 Centre for Gender and Sexual Health Equity, Vancouver, British Columbia, Canada
  3. 3 Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
  1. Correspondence to Dr Shira Goldenberg, Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada; dr.goldenberg{at}


Objectives Sex workers (SWs) face a disproportionate burden of HIV/sexually transmitted infections (STIs), violence and other human rights violations. While recent HIV prevention research has largely focused on the HIV cascade, condoms remain a cornerstone of HIV prevention, requiring further research attention. Given serious concerns regarding barriers to condom use, including policing, violence and ‘end-demand’ sex work criminalisation, we evaluated structural correlates of difficulty accessing condoms among SWs in Vancouver over an 8-year period.

Methods Baseline and prospective data were drawn from a community-based cohort of women SWs (2010–2018). SWs completed semi-annual questionnaires administered by a team that included lived experience (SWs). Multivariable logistic regression using generalised estimating equations (GEE) modelled correlates of difficulty accessing condoms over time.

Results Among 884 participants, 19.1% reported difficulty accessing condoms during the study. In multivariable GEE analysis, exposure to end-demand legislation was not associated with improved condom access; identifying as a sexual/gender minority (adjusted odds ratio (aOR) 1.62, 95% CI 1.16 to 2.27), servicing outdoors (aOR 1.52, 95% CI 1.17 to 1.97), physical/sexual workplace violence (aOR 1.98, 95% CI 1.44 to 2.72), community violence (aOR 1.79, 95% CI 1.27 to 2.52) and police harassment (aOR 1.66, 95% CI 1.24 to 2.24) were associated with enhanced difficulty accessing condoms.

Conclusions One-fifth of SWs faced challenges accessing condoms, suggesting the need to scale-up SW-tailored HIV/STI prevention. Despite the purported goal of ‘protecting communities’, end-demand criminalisation did not mitigate barriers to condom access, while sexual/gender minorities and those facing workplace violence, harassment or those who worked outdoors experienced poorest condom accessibility. Decriminalisation of sex work is needed to support SWs’ labour rights, including access to HIV/STI prevention supplies.

  • condom
  • sexually transmitted infections

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  • Contributors KS and SG had full access to all the study data and take full responsibility for the integrity of the data and the accuracy of the data analysis. SG and KS made substantial contributions to the study conception and design. KS and SG made substantial contributions to the data acquisition. MB conducted the statistical analysis. SG and RL drafted the manuscript. KS and SG made substantial contributions to the interpretation of the data and revised the article critically for important intellectual content. All authors have approved the final version to be published.

  • Funding This research was supported by operating grants from the US National Institutes of Health (R01DA028648) and Canadian Institutes of Health Research (HHP-98835, PTJ-153423) and MacAIDS. KS is partially supported by a Canada Research Chair in Global Sexual Health and HIV/AIDS and Michael Smith Foundation for Health Research.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval Approval provided by the Providence Health Care/University of British Columbia and Simon Fraser University Research Ethics Boards. REB number H09-02803.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Due to our ethical and legal requirements related to protecting participant privacy and current ethical institutional approvals, all relevant data are available upon request pending ethical approval. Please submit all requests to initiate the data access process to the corresponding author.