Harris Miriam T H, Shannon Kate, Krüsi Andrea, Zhou Haoxuan, Goldenberg Shira M
Grayken Center for Addiction, Boston Medical Center, One Boston Medical Center Place, Boston, MA, 02118, USA.
Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, Boston, MA, 02118, USA.
BMC Health Serv Res. 2025 Jan 24;25(1):134. doi: 10.1186/s12913-025-12275-x.
Due to social-structural marginalization, sex workers experience health inequities including a high prevalence of sexually transmitted and blood-borne infections, mental health disorders, trauma, and substance use, alongside a multitude of barriers to HIV and substance use services. Given limited evidence on sex workers' broader primary healthcare access, we aimed to examine social-structural factors associated with primary care use among sex workers over 7 years.
Data were derived from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women (cis and trans) sex workers in Metro Vancouver, from 2014 to 2021. Descriptive statistics were used to summarize the proportion of primary care use in the past six months and to assess primary care trends over time from 2014-2021. We used multivariate logistic regression with generalized estimating equations (GEE) to identify social-structural factors associated with primary care access (seeing a family doctor in the last six months), after adjusting for confounders.
Amongst the 646 participants, most (87.4%) accessed primary care at some point during the study period, and primary care use in the last 6 months was relatively stable (ranging from 60-78%) across each follow-up period. At first available observation, participants faced a high burden of sexually transmitted and blood-borne infections (STBBIs) (48.0%, 11.5%, and 10.4% were HCV, HIV, or STI seropositive, respectively), 56.8% were diagnosed with a mental health disorder, 8.1% had recently overdosed, and 14.7% were recently hospitalized. In multivariable GEE analysis, exposure to intimate partner violence was associated with reduced primary care use (Adjusted odds ratios (AOR) 0.63, 95% Confidence interval (CI): 0.49-0.82), and limited English fluency was marginally associated (AOR 0.76 CI: 0.51-1.14).
This study characterized primary care use and its social-structural determinants among sex workers over 7 years. Participants faced a high burden of STBBIs and other health disparities, and a proportion faced gaps in primary care utilization. Scale-up of trauma-informed, culturally and linguistically tailored, sex worker-friendly primary care models are needed, alongside structural interventions to decriminalize and destigmatize sex work and substance use.
由于社会结构边缘化，性工作者面临健康不平等问题，包括性传播和血源性感染、心理健康障碍、创伤和药物使用的高流行率，以及获得艾滋病毒和药物使用服务的众多障碍。鉴于关于性工作者更广泛的初级医疗保健获取情况的证据有限，我们旨在研究7年来与性工作者使用初级医疗保健相关的社会结构因素。
数据来自“性工作者健康获取评估”（AESHA），这是一项基于社区的开放前瞻性队列研究，研究对象为2014年至2021年大温哥华地区的女性（顺性别和跨性别）性工作者。描述性统计用于总结过去六个月内初级医疗保健的使用比例，并评估2014 - 2021年期间初级医疗保健的趋势。在调整混杂因素后，我们使用带有广义估计方程（GEE）的多变量逻辑回归来确定与初级医疗保健获取（在过去六个月内看家庭医生）相关的社会结构因素。
在646名参与者中，大多数（87.4%）在研究期间的某个时间点使用了初级医疗保健，并且在每个随访期内，过去6个月的初级医疗保健使用率相对稳定（范围为60 - 78%）。在首次可获得观察时，参与者面临性传播和血源性感染（STBBIs）的高负担（分别有48.0%、11.5%和10.4%的人丙型肝炎病毒、艾滋病毒或性传播感染血清学呈阳性），56.8%被诊断患有心理健康障碍，8.1%最近有过药物过量，14.7%最近住过院。在多变量GEE分析中，遭受亲密伴侣暴力与初级医疗保健使用率降低相关（调整后的优势比（AOR）为0.63，95%置信区间（CI）：0.49 - 0.82），英语流利程度有限与之有微弱关联（AOR 0.76，CI：0.51 - 1.14）。
本研究描述了7年来性工作者的初级医疗保健使用情况及其社会结构决定因素。参与者面临性传播和血源性感染以及其他健康差距的高负担，并且一部分人在初级医疗保健利用方面存在差距。需要扩大提供创伤知情、文化和语言上量身定制、对性工作者友好的初级医疗保健模式，同时进行结构性干预，以使性工作和药物使用合法化并消除污名化。
