Exploring the Influence of Age, Ethnicity and Education as Risk Factors for HIV Transmission among Adolescent and Young Female Sex Workers in Romania

"Recent research shows that most commercial sex workers (CSWs) in Europe are Romanians..., but studies on their risk behaviors are rare..."

The objective of this study was to identify risk factors for HIV and other adverse reproductive and sexual health outcomes among adolescent and young female sex workers (FSW) from three large cities of Romania. [Footnotes are removed by the editor.] The study formed part of a wider regional programme of research and intervention design implemented by the United Nations Children's Fund (UNICEF) and funded through Irish Aid.

A snowball sample between November 2007 and March 2008 of 300 FSW aged 13-24 years old identified the main risk factors for HIV infection. Participants were initially recruited through the outreach programme implemented by the only non-governmental organisation (NGO) providing harm reduction services to sex workers, Romanian Association Against AIDS (ARAS); these included both street- and brothel-based sex workers. The sample was then extended through the social networks of respondents. Trained outreach workers with experience of working with FSW and injecting drug users (IDU) administered the questionnaires. Interviews were conducted on the street or in a van of the mobile/outreach team of ARAS.

Data analysis was based on measures of association between variables, tests for differences of means (t tests), and logistic regressions for predicting the vulnerabilities of respondents. "The main risks identified were: injecting drugs and selling sex, being younger (under 18 years old), inconsistent condom use, belonging to the Roma ethnic group, and having low education."

"Context-specific indicators of vulnerability include not having ID [identity] papers, having forced sex (reported by more than half of FSW) or having anal sex. Data reveal that younger FSW (under 18 years old) and of Roma ethnicity are experiencing higher risks than older ones and non Roma. While increased vulnerability among younger FSW has previously been identified, this study reveals that ethnic Roma FSW are overrepresented within this group and are particularly at high risk for HIV transmission." The study suggests that condom use is not as high as reported, based upon pregnancy rates. It describes a lack of access to health services for those without ID papers and for those under 18 and without parental consent.

Policy implications include the following:

• "..., [T]here is a need to address adolescent and young FSW with appropriate services e.g. a national public health program for vulnerable groups which should include a wide range of free services, starting from monitoring pregnant women, HIV counseling and testing, harm reduction services, drug addiction treatment, free treatment of sexually transmitted infections, HIV/AIDS, of dermatological diseases, TB, as well as of other specific conditions." Thus, those without health insurance and/or ID papers could access services.
• "Specific for FSW, decriminalization of sex work could improve their work conditions and create an enabling environment for them to practice safer sexual and health- seeking behavior."
• Future research should focus on FSW access to services, perceived quality of life, sexual/reproductive health, the risk environment of sex work, and conditions that would provide an enabling environment for increased use of condoms with both commercial and steady partners.