“ Maher L, Phlong P, Mooney-Somers J, Sichan K, Masy T, Stein E, Couture MC, Sansothy N, Page K (on behalf of the YWHS Collaborative) “It makes us dare to do what we did not dare to do before”: ATS use and HIV/STI risk behaviour among young female sex workers in Phnom Penh, Cambodia

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh Heterosexual epidemic Key drivers: Poverty High STI prevalence Mobile workforce Patronage of FSWs Declining population HIV prevalence: 2.7% (2001) - 0.9% (2006) INTRODUCTION: HIV in Cambodia

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh HIV prevalence in Cambodian FSW by survey year Source:

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh Increase in ATS use 2 main types: MA in pill form (yama) MA in crystalline form (ice/crystal) MA use associated with increased risk behaviour and HIV/STI incidence in MSM and heterosexuals Concerns that ATS use may reverse downward trend in HIV prevalence in Cambodia INTRODUCTION: ATS use

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh YWHS documented high HIV/STI prevalence among young FSWs (Couture et al. STD in press) Results indicate need to understand how socio- cultural factors shape outcomes such as HIV/STI infection Qualitative research to further explore the relationships between ATS use, sexual risk behaviour and vulnerability to infection INTRODUCTION: HIV/STI in FSWs in Phnom Penh

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh Dedicated training course + refresher module Participants included NCHADS & CWDA staff and women leaders (current/former FSWs) Modules included ethics, outreach and fieldwork, sampling and recruitment, in-depth interviews, focus groups, data management and data analysis Interview guide developed as part of the training Phase 1: 33 individual in-depth interviews Interviews conducted in Khmer, supervised by 2 medical anthropologists METHODS

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh Interviews ranged 40 – 120 mins, participants reimbursed $USD5 Ethical approval from Cambodian NEC, UCSF IRB and UNSW HREC Interviews digitally-recorded and transcribed verbatim in Khmer Data analysed in Khmer and English following general tenets of grounded theory Identification of final themes and interpretation of results performed by consensus METHODS

RESULTS: Availability and use of ATS ATS cheap, widely available and commonly used Patterns of use: Occassional, binge and heavy I use it occasionally whenever I want to be happy (laughs) … once a week because I wanted to be happy or when I am upset, I wanted to use it (Sophea, 24 year-old woman). When we are addicted to drug, no matter how much money we have, we spend all the money on it. We provide sex service to customer to earn money and just enough to spend on buying drug (Mealea, 23 year-old woman). Route of administration They normally make kan-toung (a container) to smoke it … We make a kan-toung like this. We fold paper (foil), slightly burnt it with the lighter and then put the pill or piece of ice into it (Chantha, 29 year-old woman). They take a piece of chewing gum wrapping paper. They put drug on it. They put on some fire beneath it and they inhale (Kannitha, 20 year-old woman). ATS and HIV/STI risk behavior among young FSWs in Phnom Penh

Women described yama as thnam kamlang (power drug) which enabled them to work longer hours: [T]his drug is also called “power drug” (thnam kamlang) … women work for money to buy this drug so that they have power to continue working (Davy, 20 year-old woman). [I]t made us energetic in earning money by having sex with customers, then we earn income for the boss. That is why the boss buy drugs for us (Srey Sor, 25 year-old woman). RESULTS: Functionality of ATS in the context of sex work

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh Yama was described as conducive to longer working hours and increased strength and endurance, enabling women to see more customers and obviating the need for rest or food: When we use it, it makes us not sleepy. So we don’t sleep and we can get more customers. When I take it, I can make time to sit. If I don’t take it, I would be sleepy and go to bed and have no time to make money. If I use it, I can be awake for whole night. I can sit and serve many customers, one after another (Any, 20 year-old woman). Use of ATS in the context of sex work viewed as functional and conducive to income generation RESULTS: Functionality of ATS in the context of sex work

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh RESULTS: Functionality of ATS in the context of sex work Few women aware of the potential negative effects of ATS on health - limited to physical symptoms including headaches, weakness, fatigue, weight loss and “loss of beauty”: It destroys our beauty - it makes us from being fat to skinny (Srey Mom, 20 year-old woman). Limited awareness of potential mental health side-effects: When I use it for almost a day I see customers as policeman and I ran alone. They said that I am paranoid (bek). When I see customer, I see him as policeman. I said it is crazy to go down to see policeman. When it is quiet, I walk slowly to see that policeman. I am completely paranoid. (I see). Policeman is chasing me when I am paranoid. [In fact] customer is asking me and there is no policeman. I used it (ma) for a day and a night without sleep so I am paranoid now. I am scared (Phalla, 19 year-old woman).

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh RESULTS: ATS, sex work and disinhibition Women felt ATS made them disinhibited or ‘brave’, encouraging them to do things they normally would not: I am brave... When we use this drug, if customers want to bring us to a far away place, we dare to jump off from motor bike, or we dare to switch off the bike’s power in order to stop it (Srey Mom, 20 year-old woman). It made us powerful. It made us brave to do what we dare not to do before (Srey Noch, 24 year-old woman). Disinhibition sometimes resulted in inconsistent condom use: [I]t made us happy, not afraid and have many partners without condom. [Really?] Yes, not afraid and disease can be transmitted … and dare to steal and even dare to have sex without condom and not afraid of other diseases such as AIDS (Rany, 20 year-old woman). We forgot because we were happy … When the drugs effect gone we realized we forgot condom (Mom, 28 year-old woman)

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh RESULTS: ATS, sex work and disinhibition Women described “losing control” and “forgetting” [to use condoms] under the influence of ATS: It affects me when I am working. It makes me forgetful. The boss and manager blame me often. And also forget to use condom (Phary, 19 year-old woman) Using drugs makes us happy … We only know that we are happy and we want to be happy, so we forget condom (Leak, 23 year-old woman ). Only 3 women reported that ATS increased their sexual desire: Mostly, the drug makes us want to have sex. We can serve many customers. We become imaginative and want to have sex. For instance, when we see men we desire to have sex. We can have sex for many hours, from one to two hours (Mealea, 23 year-old woman).

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh RESULTS: ATS use with and by clients Sexual risk taking was also influenced by client ATS use - clients often provided drugs and encouraged women to use them: When they [clients] came, they asked me to join them taking yama and then they take it. [So, it means that they use it before having sex?] Yes, they take it before having sex. Then they have sex with me (Bophha, 24 year-old woman). Requests for unprotected sex more common among intoxicated clients and negotiation strategies less effective in this context - “It is useless to talk. I have to follow him”: They usually force me not to use condom … I do not agree. They want to hit me and they don’t pay me (Bophha, 24 year-old woman).

ATS and HIV/STI risk behavior among young FSWs in Phnom Penh RESULTS: ATS use with and by clients Women reported ATS use by clients delayed ejaculation and resulted in prolonged sexual activity: [F]or a man who uses the drug, he can have sex for so long and it takes long time for sperm to come out. Too much makes us hard in body. If the customer uses it, his sperm takes very long time to come out. It is hard when meeting customer who uses drug (Sophea, 24 year-old woman). Some customers use it to have a longer sex. I did not know the customer uses drug and he had sex with me for more than one hour. [And you were patient to stay for a long sex with him?] Yes. Some customers listen to me and pay some money when I said they have sex too long and I want to stop. They know they use drug and have longer sex, so they give us money (Srey Sor, 25 year-old woman). Women typically not paid more for longer transactions which potentially expose them to increased HIV/STI risk associated with tissue damage as a result of extended sex

CONCLUSIONS For women, ATS use increased functionality, enabling them to cope with the conditions of employment, including long hours and high client turnover ATS use also increased the potential for risky sexual practices, including inconsistent condom use and extended sexual transactions While some women reported experiencing harms associated with ATS use, these were balanced against strong associations with workplace functionality Recent intensification of anti-prostitution/anti-trafficking efforts has increased number of freelance FSWs working on the street and in other high risk settings, and reduced access to prevention interventions, including condoms ATS and HIV/STI risk behavior among young FSWs in Phnom Penh

CONCLUSIONS Consistent condom use requires insistence by sex workers and acceptance by clients Clients seeking unprotected sex may be more likely to seek out women drug users or to offer women drugs in order to manipulate vulnerability Current prevention approaches focused on empowering FSWs to negotiate condom use fail to appreciate the complexities of transactions where ATS is involved ? role of interventions beyond condom use, including behavioral interventions and pharmacotherapy Current harm reduction interventions fail to account for gender-power relations and the social, cultural and economic factors that shape these relations and structure commercial transactions in different settings ATS and HIV/STI risk behavior among young FSWs in Phnom Penh

CONCLUSIONS Results highlight the escalating burden of ATS drug use in the sex/entertainment industry in Cambodia In a setting where 1/4 young FSWs are infected with HIV and HIV/STI incidence is high, widespread use of ATS may result in a reversal of downward trends in HIV Within this context, there is a clear and urgent need to: Increase awareness of the risks associated with ATS Provide young women with sustainable options for income generation Regulate the conditions of sex work Work with FSWs and their clients to develop and promote culturally appropriate harm reduction interventions. ATS and HIV/STI risk behavior among young FSWs in Phnom Penh

Acknowledgements Study participants and the CWDA interview team Funders: NIH grants U01AI , 1R21 DA025441, 1R01NR LM is supported by an NHMRC Senior Research Fellowship and MCC is supported by a CIHR Postdoctoral Fellowship. Young Women’s Health Study Collaborative: John Kaldor, Serey Phal Kien, Lisa Maher, Tooru Nemoto, Kimberly Page, Joel Palefsky, Vonthanak Sapphon, Mean Chhi Vun.