1. Amphetamine-type stimulant use increases HIV risk among young women engaged in sex work in Phnom Penh, Cambodia M-C Couture, N Sansothy, ES Stein, J Evans, K Sichan, L Maher, and K Page (Young Women’s Health Study)

2. HIV in Cambodia HIV prevalence (general population) : 2.7% (2001) to 0.9% (2007) Cambodia: one of the Asia’s most severe epidemic Contributing factors: Poverty High levels of STI Highly mobile workforce Patronage of female sex workers (FSWs) FSWs: a high risk population Brothel-based sex workers (direct) Entertainment/drinking establishments (indirect) Freelancers: parks, streets, private apartments

3. HIV prevalence in Cambodian FSWs

4. Amphetamine-Type Stimulants ATS use has been increasing dramatically throughout Southeast Asia, and Cambodia. Associated with increased risk behaviors and incidence of STI/HIV Main ATS observed in Cambodia: Methamphetamine in pills (yama) Methamphetamine in crystalline form (ice/crystal)  ATS use may lead to a reversal of the downward trend in HIV rates in Cambodia  No studies have examined the prevalence of ATS and its effect on sexual behaviors and HIV/STI infection in this population

5. Objective Examine the prevalence of ATS use and its effect on sexual behaviors and STI infection among young FSWs in Phnom Penh, Cambodia Institute of Global Health- UCSF Cambodia National Center for HIV, AIDS, Dermatology and STDs (NCHADS) Cambodian Women’s Development Agency (CWDA) National Centre for HIV Epidemiology and Clinical Research (NCHECR), UNSW Australia

6. Inclusion criteria: –Aged 15-29 years –Reporting >2 different sexual partners in the last month OR engaging in transactional sex within the last 3 months –Both HIV positive and negative women are enrolled Population: young at-risk women working in the sex and entertainment industry in Phnom Penh Recruitment: Convenience sample recruited in brothels, entertainment/drinking establishments, streets, parks and private apartments Young Women’s Health Study 1 Design: One year prospective cohort study

7. Data collection YWHS-1 (June 2007-2008) –Quarterly visits –Structured questionnaire –Blood samples: HIV –Urine samples: Chlamydia and Gonorrhea (3 and 12- month visits) –HIV referral and tracking

8. Statistical analysis - Bivariate analyses and multivariate models - Outcomes: 1. Number of partners -Negative binomial regression models (data from all visits) -Stratified by type of sex work venue 2. Inconsistent condom use -Generalized estimating equations (data from all visits) -Stratified by type of sex work venue 3. Incident STI (Chlamydia and Gonorrhea) -Logistic regression (data from 6-month visit for ATS use and 12- month visit for incident STI) Effect of recent ATS use (last 3 months)

9. Associations with prevalence of recent ATS use (last 3 months) of the YWHS-1 participants (N=160) Prevalence of characteristic (%) Prevalence of ATS use (%) p-value Overall 26.3 Age (median 25; IQR 21-27) 16-18 19-24 25-29 8.1 40.0 51.8 23.1 23.4 28.9 0.73 Education None Primary (1-6 years) Secondary (7+ years) 40 51.3 8.7 32.8 23.2 14.3 0.24 Type of sex venue (last month) Entertainment/drinking Brothels Freelance Multiple venues 31.9 9.2 39.3 16.9 17.7 34.7 35.6 14.8 0.06 Results

10. Associations between recent ATS use and high number of sexual partners by type of sex work venue Adjusted RR † 95% CI Entertainment/drinking ATS use (yes vs no) 2.51**1.59-3.70 Brothels ATS use (yes vs no) 1.57*1.09-2.28 Freelances ATS use (yes vs no) 0.900.70-1.22 Multiple venues ATS use (yes vs no) 1.770.86-3.67 Results ** p≤0.01; * p≤0.05 † Adjusted for age, education, condom use, # days drunk, HIV status Number of sex partners (last month)

11. Associations between recent ATS use and inconsistent condom use by type of sex work venue Adjusted OR † 95% CI Entertainment/drinking ATS use (yes vs no) 0.550.20-1.48 Brothels ATS use (yes vs no) 0.670.07-6.21 Freelances ATS use (yes vs no) 0.440.18-1.05 Multiple venues ATS use (yes vs no) 4.95*1.23-29.8 Results * p≤0.05 † Adjusted for age, education, # of sex partners, # days drunk, HIV status Inconsistent condom use (with last partner)

12. Associations between recent ATS use (last 3 months) and incident STI Adjusted OR † 95% CI ATS use No Yes 1.0 4.98*1.10-22.58 Results * p≤0.05 † Adjusted for age, education, # of sex partners, condom use, # days drunk, and working as freelance Incident STI

13. Conclusions ATS use is prevalent among young women engaged in sex work in Phnom Penh Recent ATS use was higher among women working in brothels and as freelance FSWs Associations with risky sexual behaviors and STI infection = urgency of addressing drug use issues among these young women Integration of drug use prevention interventions into HIV/STI programs

14. UCSF –Kimberly Page –Ellen Stein –Jennifer Evans –Joel Palefsky NCHADS –Vonthanak Sapphon –Mean Chi Vun –Neth San Sothy –TSP clinic staffs Acknowledgments CWDA –Serey Phal –Keo Sichan –Outreach workers UNSW –Lisa Maher –John Kaldor All participants Public Health Institute - Tooru Nemoto Couture MC, et al.. Young women engaged in sex work in Phnom Penh, Cambodia have high incidence of HIV and STI, and amphetamine-type stimulant use: new challenges to HIV prevention and risk. In Press in STD journal Maher L et al. “it makes us dare to do what we did not dare to do before”: amphetamine-type stimulants use and HIV/STI risk behaviors among young female sex workers in Phnom Penh Cambodia. Wednesday July 21 st 16:30 SR 5. Sansothy N et al: Poster TUPE0354 Tuesday July 20th Keo s. et al. : Poster TPHE1004 Thursday July 22nd