Inconsistent Condom Use among Street-Based Transgender Sex Workers in Lahore, Pakistan: Socio-Ecological Analysis based on a Qualitative Study

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Therefore, this study examined the multi-level context of inconsistent condom use (ICU) in sexual interactions of transgender street-based workers (KSWs) with commercial and non-commercial sexual partners in Lahore. Methods: We conducted 20 in-depth interviews with street-based KSWs to investigate challenges to consistent condom utilization with sexual partners. The qualitative data was analyzed using thematic analysis to produce an initial set of codes during the first-level round. An essence-capturing strategy was utilized to identify broader themes through a heuristic exploration of the text. Results: Within a socio-ecological analysis we identified factors influencing ICU among KSWs at three levels. At the individual level, we identified knowledge and awareness, perceived characteristics of sexual partners, age and physical attributes, pleasure and pain, and mental health issues impacting on ICU. Gentrification of historical red-light district, discrimination, harassment and regular evictions, dynamics of cruising spots and places of sexual interactions, competition in sex trade, violence and lack of safety nets in street-based sex work, condom use with lovers, networks with non-governmental organizations were factors associated with ICU. Risk factors at community level were poverty, the influence of gurus, and Dera culture. Conclusions: Until now, HIV prevention efforts in Pakistan have primarily focused on HIV risk factors at the level of individual behaviors within specific networks of target populations. However, our study points towards both the effectiveness and the urgency of interventions that address macro-level risk factors specific to key populations in Pakistan, in addition to behavioral interventions. HIV sex work inconsistent condom use HIV risks barriers Introduction HIV remains an important global public health issue which has so far claimed approximately 36.3 million lives around the world [ 1 ]. In 2020, 65% of new HIV infections worldwide were observed amongst key populations which include commercial sex workers, men who have sex with men, people who inject drugs, transgender people and their respective sexual partners. Overall, 8% of new HIV infections among adult populations were detected in sex workers and transgender women, which were found to be at 34 times higher risk for acquisition of HIV [ 2 ]. Key populations in the Asia-Pacific region are more likely to report inconsistent condom use [ 3 ]. In addition, structural discrimination and societal stigma against transgender and sex worker populations, that take form of retributive laws, policies and practices, engender substantial disparities for these populations that hinder their abilities to prevent HIV-related harm [ 4 ]. Following global trends, the HIV epidemic in Pakistan is at present concentrated within key populations [ 5 ]. Pakistan has witnessed a sharp increase in new HIV infections from 1,400 in 2010 to 25,000 in 2019 [ 6 ]. Unprotected commercial sexual contacts, including those of homosexual nature, are recognized as a key risk for HIV [ 7 ]. Transgender sex workers, locally referred to as Khwaja sira or Hijra sex workers (KSWs) – sex workers identified as male at birth who frequently cross-dress in feminine clothing, with some having been born with intersex variations, or those who have obtained a surgical sex change [ 8 ] – currently comprise one of the most vulnerable populations to the acquisition of HIV in Pakistan. High rates of HIV among KSWs have been noted, and it was estimated that one out of every five KSWs in Pakistan would be living with HIV by the end of 2020 [ 9 ]. Despite targeted interventions, condom use and engagement with the HIV care system continues to be alarmingly low [ 5 ]. According to the most recent HIV surveillance data, the prevalence of HIV among KSWs was 5.4%, condom use at last sex was 27.7%, and only 15% utilized HIV prevention programs in the past year [ 10 ]. Research in South Asia and Pakistan has shown how social exclusion, structural discrimination, violation of human rights and everyday violence experienced by KSWs limit their access to key HIV prevention services [ 11 ]. Therefore, interventions that decrease violence and increase the capacity of KSWs to successfully negotiate condom use with clients are needed to control the rising incidence of HIV in sex-work networks [ 12 ]. This requires a better understanding of the socio-economic, occupational and legal context of street-based sex work and the specific risk factors that hinder condom use during commercial and personal sexual interactions. This paper aims to examine the socio-ecological context of inconsistent condom use (ICU) in sexual interactions of street-based KSWs with commercial and non-commercial sexual partners in Lahore. Khawaja sira sex work in Pakistan South Asia has a rich history of gender ambiguity whose contours have shifted with changing landscapes of authority in the region. In precolonial India, members of the khwaja sira community were viewed as pious individuals due to the ambiguity of their sexual corporeality. They upheld prestigious ranks in state and society, and distinguished themselves from hijras who cross-dressed, engaged in sex work and resided in impoverished neighborhoods. However, colonization of India by the British resulted in the establishment of policies that led to criminalization and regulation of transgender populations. The transgender bodies were pathologized as “diseased” and khwaja siras lost their high ranks within the society and the newly established government [ 13 ]. As a result of the loss of livelihood, khwaja siras found support in the hijra community which led to the assimilation of these two populations and to the marginalized position they are in today [ 14 ]. Recently, in an attempt to reclaim their historical respect and status, the term khwaja sira has been adopted and encouraged by transgender activists in place of the derogatory term hijra . This has been corresponded by granting of citizenship privileges and rights to khwaja siras through the Pakistani Supreme Court’s rulings in 2012 and the passing the Transgender Protection Bill in 2018 [ 13 ]. Sex work is not a recent phenomenon in Pakistan where 97% of the population is Muslim, and religious as well as social norms strongly prohibit extramarital sex. The contours of this work have shifted, however, from geographically located brothel-based arrangements for sexual activity to a more dispersed configuration of sexual transactions carried out across the country’s cities. This has largely been the result of Islamic Hudood laws, introduced by the military government in 1979, and the subsequent years of the criminalization and penalization of the sex-worker community and the shutting down of several brothels and red-light areas by the state. While the vast majority of street-based KSWs continue to survive and operate in the cities through “Deras” – strictly regimented, all-khwaja-sira residences, managed by a guru (group leader/network operator) that survive and function through the adoption of young boys abandoned by their families and communities [ 15 , 16 ] – the places used for sexual transactions have moved considerably outside their jurisdiction. During the last two decades, important shifts have occurred within commercial sex-work, which was historically organized around brothel-based patterns of sexual interaction. According to estimates, in 2010 only about 2–3% of KSWs were operating from brothels or red-light areas [ 11 ]. Street-based soliciting of clients among KSWs since then increased from 17.5% in 2007 to 33.3% in 2017 [ 10 ]. In Pakistan, where links have been found between consistent condom use in KSWs and dependence on gurus, the increasing trend towards street-based sex work has important implications for HIV prevention [ 17 ]. However, the emerging needs and vulnerabilities of occupationally mobile street-based sex workers within changing interactional sexual contexts remain inadequately addressed. The Modified Social Ecological Model and risk factors for inconsistent condom use Socio-cultural and economic contexts are paramount in shaping sexual behaviors including condom use among key populations. Condom use behaviors are also not fixed and evolve with changes in the environment that is shaped by gendered and hierarchical relations within the larger patriarchal society [ 18 ]. This paper examines ICU in KSWs within the context of street-based sex work in Lahore by applying the Modified Social Ecological Model (MSEM) [ 19 ]. Currently there is a dearth of research on ICU within the particular social, physical, and occupational contexts of street-based KSWs in Pakistan. Applying a social-ecological framework to ICU among KSWs can help to determine the way in which the multi-level socio-structural injustices and oppression experienced by street-based KSWs contribute to and reinforce barriers to condom use during commercial and non-commercial sexual interactions. The MSEM [ 19 ] examines HIV risk at five levels, ranging from the micro-level of the individual to meso-levels of network and community, and ultimately to the macro-level defined by public policy and the stage of HIV epidemic. This model emphasizes the identification of distinct factors for HIV risk at each level, where each level is understood as providing the context for examining risk factors at other levels through ongoing multilevel interactions between these factors. There are five level of risk factors: 1) individual level factors include biological or behavioral features related with susceptibility to acquisition or transmission of HIV infection, 2) social and sexual networks encompass interpersonal relationships ranging from family members, friends, neighbors, paid or unpaid sexual partners that impact on health related behaviors and wellbeing, 3) community environments commonly comprises of network links, associations among organizations, groups and geographical/political areas, 4) laws and policies of any government offer the wide-ranging context that determines the nature of HIV-related risk behaviors and coping strategies of marginalized populations, and 5) the stage of the epidemic refers to incidence and prevalence of HIV within the population. This paper asserts that a socio-ecological framework is useful in examining multi-level risk factors for ICU by KSWs in Pakistan for a number of reasons. Health policy in Pakistan tends to target HIV-related interventions at the individual level of risk behaviors [ 10 ], which constitute an important but not the only level of factors influencing the spread of HIV among vulnerable populations. The application of the socio-ecological framework to ICU among KSWs helps to illuminate that the HIV risk behaviors of KSWs, derived from processes at the social environment level as well as that of the individual, are an outcome of multiple causes, and are affected by multilevel combinations of intertwined factors [ 20 ]. As sex work for khwaja siras becomes increasingly violent, discriminatory, and risky, links with the changing nature of KSWs’ behaviors related to safe sex practices within the context of street-based sex work need to be explored. For this reason, the purpose of this study is to investigate the contextual determinants that influence ICU within street-based commercial and non-commercial sexual encounters by MSEM. Methods Study site The study was conducted between October 2017 and January 2018 with street-based KSWs in four neighborhoods of Lahore. Lahore is the capital city of the biggest province Punjab in Pakistan and has the one of the highest presences of KSWs. The study locations were chosen based on the known public presence of KSWs, and later through recommendations from already recruited respondents. Moreover, these neighborhoods represent different geographical areas of the city: Two neighborhoods are approximately 4.8 km apart in the old part of Lahore, one of it is associated with the historical red-light area of the city. Two further neighborhoods are located in the newly developed and relatively affluent sectors of the city, 36 km and 17.5 km away from the red-light district, respectively. Recruitment A multipronged approach was utilized to recruit 20 KSWs through purposive sampling. We partnered with a public health worker who had access to the KSW community and who hired as a research assistant. KSWs were recruited by this research assistant through street recruitment in the selected four neighborhoods of Lahore. Inclusion criteria required that the participants 1) were at least 18 years old, 2) were self-reported khwaja siras, 3) were voluntary sex workers who solicited clients primarily through walking the streets, 3) had reported participating in anal intercourse during the previous 12 months, 5) had lived in Lahore for at least 12 months, and 6) were able to provide informed consent of their own free will. KSWs who completed the interview received PKR 1,000 ( $ 7) compensation for their time which was not informed to them before the start of the interview. Data collection In total, 20 in-depth interviews with KSWs which lasted approximately 60 to 90 minutes were conducted. The interviews were conducted by the researcher and her research assistant in locations chosen by the respondents. These locations included their homes or the homes of their friends, street corners, markets, and sidewalks. A semi-structured interview guide was used during the interviews. It included questions relating to the nature, patterns, and dynamics of street-based sex work, as well as understandings, perceptions, and descriptions of the occupational, social, and residential neighborhoods. Additionally, questions were asked regarding conversations about sex and HIV risk behaviors within changing neighborhoods as well as in different transactional contexts, the development of sexual identity and behaviors, and the impact of social and sexual networks on condom utilization. All KSWs included in the study provided informed written consent before the start of the interview. The interviews were audio-recorded and examined for accuracy after professional transcription. Data analysis The qualitative data was analyzed using thematic analysis [ 21 ] to produce an initial set of codes during the first-level round. An essence-capturing strategy [ 22 ] was utilized to identify broader themes through a heuristic exploration of the text. For this, focused codes were developed by putting together phrases and passages from our data set that were suggestive of our research questions. These codes were then grouped together into larger unifying frameworks. These frameworks culminated in the following global themes [ 23 ]: (1) Individual level factors influencing ICU among KSWs, (2) social and sexual network level factors influencing ICU among KSWs, and (3) community level influences on sexual practices and identities. The analysis was carried out reflexively at all levels so that the uniqueness and validity of the codes could be maintained [ 24 ]. Results The sample characteristics are presented in Table 1 . The initial coding of interview data confirmed three levels of risk factors for ICU among KSWs: 1) individual level factors, 2) social and sexual network level factors, and 3) community level factors. The following open coding allowed to identify of sub-themes within each main theme. Table 2 lists the three main themes, the 16 sub-themes, descriptions of each sub-theme, and exemplary quotations reflecting the specific sub-theme. All sub-themes are described in detail in the following sections. Table 1 Sample characteristics of street-based KSWs in Lahore (n = 20) Sociodemographic variables n % Age 18–25 years 26–35 years 36–45 years 46 years and above 6 8 5 1 30 40 25 5 Education No education Primary level Secondary level 10 7 3 50 35 15 Living arrangement With the guru With family 20 0 100 0 Number of years in sex work Less than 5 years More than 5 years 8 12 40 60 Knowledge that HIV/AIDS is transmitted through sex Yes No 20 0 100 0 Consider yourself at risk of HIV/AIDS Yes No 14 6 70 30 Consistent condom use Yes No 3 17 85 15 Table 2 Summary of themes, descriptions, and exemplary quotations resulting from analysis of individual, network, and community level barriers to inconsistent condom use (n = 20) Theme Description Exemplary quotation Individual level risk factors Level of knowledge and awareness Discussion about their knowledge of practices of HIV/AIDS transmission and prevention • “We know HIV is spread through sex if you don’t use condoms.” • “HIV is spread through bed sharing with HIV positive men even if you are wearing condoms.” • “If you are regularly using condoms, occasional withdrawal method can protect you from HIV.” Perceived characteristics of sexual partners Descriptions of observable attributes of clients including social class, status, and physical attributes that were used to categorize clients as risky or safe for condomless sex. • “I look at their clothes to judge the status of clients. Middle class men are always in clean clothes. They also often prefer using condoms.” • “The drug addicts are always dirty and risky. I prefer to ignore them.” • “Skin is the best reflection of someone’s health. If a client has suspicious spots, pimples or wounds or if their skin is burnt and dark I know there is something wrong and at least I have to use condom. But sometimes at night if it is dark I can’t observe properly.” • “Clients don’t take my demands about condoms seriously because I am dark skinned.” Age and physical attributes Comments about age, skin color and other physical attributes of KSWs that impacted condom related decision making • “I am beautiful and young so I can demand my clients to use condoms or else they have to pay double.” • “If you are young you can charge higher rate for sex without condoms.” • “Now because I am older I am not that attractive to many clients. I cannot risk losing clients because of condoms.” Pleasure and pain Comments about the role of condoms in sexual arousal, sexual pleasure and experience of pain during anal intercourse with clients and its impact on condom related decision making. • “We all do it without condoms because honestly it is fun.” • “When I was new I was afraid of making my clients use condoms because other khwaja siras had told me it would be painful.” Mental health issues/psychological factors Discussions of psychosocial factors including feelings of isolation, loneliness, depression, anxiety among KSWs, and how they influence condom related decision making with sexual partners. • “They are always scaring us from HIV. But we all will get it one day so why live in constant fear. If sometimes I am worried about money I stop thinking about HIV and condoms.” • “At the end of the day I feel very lonely and depressed. I have trouble sleeping at night. If I am feeling too low I can get careless with clients.” • “Many KSWs these days are depressed and they get into habit of using alcohol with clients. Once you are under its influence you are not thinking about condoms or your safety.” Social and sexual network level risk factors Gentrification of historical red-light district Descriptions of changing dynamics of risk and safety in sex trade in red light district as a result of increasing tourism and presence of law enforcing agents. • “Now there are bus tours and walking tours around the red-light district. This place is not very workable for sex workers. We prefer to walk for hours to our spot where clients would be comfortable approaching us and there is less presence of police. But I prefer not to carry condoms because we have to pass police check posts and they often tease us.” • “I moved out of red-light district but the rent is higher here. Often I don’t have money to buy condoms.” Discrimination, harassment and regular evictions Comments about experiences of discrimination and harassment faced by KSWs in their residential neighborhoods and its impact on condom related decision making. • “There was an old man in my neighborhood who said I should come and take care of him. I told him I was a respectful khwaja sira. And he started calling me bad names and threatened to get me kicked out of the area. I never buy condoms from shops here just because of this reason.” • “Once men started beating at our door at night asking us to open the door. But we said we were not that kind of khwaja siras. We were very scared. This is why we don’t keep condoms at home.” • “The police hardly help us. They are just interested in sexual favors or getting money out of us. Who can dare ask a police man to use a condom?” Dynamics of cruising spots and places of sexual interactions Discussion of how spatial, temporal and cultural characteristics of cruising spots and venue of sexual exchange impact practices of condom utilization among KSWs and their partners. • “Everything happens very fast in our business. We and our clients are all in a hurry for our own reasons. There is no time for thinking about or using a condom.” • “If you insist on condoms too much sometimes the discussion can become heated. People here are just waiting for a show so they can gather around which is bad for clients.” • “Clients are scared of the police especially if they are younger. They don’t want their family to find out and our scared of police beating. So if you are too demanding or want to discuss matters like condoms they just move on quickly.” Competition in sex trade Description of presence of competition among larger sex trade industry that further includes Female sex workers and male sex workers and their impact on practices of condom utilization. • “The older KSWs are least in demand when you have young women, men and khwaja siras to choose from. Often our only appeal is that we can offer sex without condoms.” • “In this area there are all kinds of sex workers on the weekend nights. Many clients move on ahead the moment you mention the word condom.” Violence and lack of safety nets in street-based sex work Comments about the role of physical, social, sexual, and economic violence and absence of security for sex workers in sex trade in promoting ICU • “Once a man tied me to the tree after raping and beating me because I asked him to use a condom.” • “If I am with a group of clients I feel more insecure and just comply with their demands. If they want to use condoms I use them but if they don’t want to I will just agree.” • “No one comes to save us. Once these men raped me and left me unconscious in front of my house. My guru did nothing.” Condom use with lovers Discussion of risk evaluations and condom utilization practices with intimate partners • “I love him so why use a condom?” • “I don’t use it because he will think I am a sex worker.” • “I know he will leave eventually so why not enjoy while it lasts.” Networks with NGOs and CBOs Descriptions of role of existing private and government organizations in condom related decision making and practices • “They just want to do photoshoots with us. They call us to their office, give us biryani (cooked rice) and take pictures. They don’t give us condoms.” • “These khwaja siras in NGOs think they are better than us and look down on us. When they give us condoms they tell us to choose the right path and leave sex work. I don’t interact with these NGOs at all.” • “Most of the times they don’t have condoms and lubricants at the NGOs. Sometimes they tell us to buy from the shop which I don’t do.” Community level risk factors Poverty Discussion of role of socio-economic constraints and challenges within khwaja sira community on condom related decision making and practices among KSWs • “There is no job for us and we often don’t get paid by the client. We are always short of money. So condoms are not always my priority.” Influence of guru Descriptions of role of gurus on nature of sexual practices of their chelas • “My guru only cares about business. He does not want to deal with police so he discourages us from carrying condoms and insists that we demand our clients to get them. But it’s easier to convince clients if you have your own condom.” • “My guru is very kind and pious. He does not know I engage in sex work so I can’t bring condoms at the house. If someone is found with condoms she is fined or beaten up.” Dera culture Discussion of how traditional practices and customs influence condom related decision making and practices of KSWs • “We can only find clients in our guru’s area. So I can only choose from the clients that are in my area and there is not much choice on many days. The clients don’t take my demands for condoms seriously because they say we have done this before without it and nothing happened.” Individual-level risk factors Level of knowledge and awareness The level of knowledge and awareness about HIV/AIDS and further sexually transmitted infections (STIs) as well as safer sex practices among KSWs is critical in determining the consistency in condom use. Many respondents referred to HIV/AIDS as the “disease one gets from sharing bed”, referring to sexual intercourse. While all respondents in our study displayed awareness about HIV/AIDS, STIs and the necessity of condoms in protection against STIs, there were still important misconceptions that emerged as barriers to consistent condom utilization during sexual interactions. One major misconception among KSWs was that occasional non-usage of condoms did not pose a risk for contracting HIV to those sex workers who were otherwise regular users of condoms. For instance, a 25-year-old KSW said: I always use condoms. However, in some situations, I can’t negotiate to use it. Then I say it is not a problem. Perceived characteristics of sexual partners In situations where KSWs were in a position to negotiate condom use, the decision to not use condoms in a sexual interaction with clients was sometimes based on misconceptions about HIV and STIs in general. One important misconception that was reported among interviewed KSWs was the belief that another person’s HIV status could be ascertained through their physical appearance or observed social status. As a result, all of the KSWs had developed their own methods of profiling suitors as potentially HIV positive or negative. The drug addicts were mostly avoided because they never carried condoms with them, were unpredictable and often violent, but most importantly because they were self-identified by the sex workers as potentially HIV positive. For example, a 43-year-old KSW stated: We have been doing this for so long, you can almost tell from the appearance if someone has HIV or any disease like that. These drug addicts carry HIV around and it shows on their faces. The men who are healthy look clean. Some KSWs described that they analyze the overall condition of skin, or appearance of genitalia for any possible warning signs that could help them ascertain if the person is HIV positive. Some also reported not using condoms with middle-class appearing men because they were assumed to be less risky. HIV was here labelled as a disease of the wealthy or poor uneducated men, such as illustrated by a 30-year-old KSW: Middle class men have families and work and don’t have time to indulge in this so much. These men in big cars are the ones we are careful with. Who knows what they have been up to? Age and physical attributes Among the respondents of this study, age of KSWs emerged as an important barrier to consistent condom use during sexual interactions with clients. The KSWs between 18 to 25 years and those above 45 years of age reported most cases of ICU with clients as a result of their age. Young KSWs mentioned that the negotiation process for condom utilization was with clients overwhelming, especially with clients who were older in age as compared to them: I am still new and learning. I don’t always have the confidence to convince the clients. Two young sex workers believed that because they were less experienced as compared to other sex workers in the market, having sexual interaction with clients without condoms occasionally was also a way of getting more experience and understanding of their work: I am young and I am learning. So I sometimes don’t insist on condoms to see what difference does it make? One young respondent avoided condoms in order to deal with the lack of intimacy and feelings of alienation within street-based sex work. A 23-year-old respondent talking about young KSWs stated: They are young and easily heartbroken. They need love. So, when they don’t receive love, they don’t use condoms to feel love. Sex work is a competitive market and some respondents shared that ageing in their profession was a major drawback in securing clients. Therefore, HIV risk was not always the most salient health concern among ageing sex workers. As a result of the demand for younger sex workers, all of the KSWs aged more than 36 years reported being more compliant of their client’s demands. For example, a 43-year-old KSW mentioned: They say, if we have to use a condom why not go to the younger one? And we comply because at the end of the day we have to eat. One the other hand, most of the older KSWs also reported that street-based sex work was physically demanding. Four sex workers between 36 to 45 years of age spoke, for instance, of sex work as an economic necessity resulting from discrimination within employment practices in the city. As a result of ageing, their mobility had become restrained and restricted within familiar neighborhoods and with regular clients with whom condom use declined: “We’re too tired to negotiate. We stand or walk all day in this hot weather. We don’t have stamina for arguments now.” (38-year-old KSW) “They see us all the time, so they do not take us seriously when we ask them to use condoms. They [ clients ] say if nothing happened before, why would it happen now?” (36-year-old KSW) One respondent shared the fear of increasing health-related costs discourages them from demanding their clients to use condoms: “At this age, our body and pockets both can’t afford the beating.” (43-year-old KSW) In Pakistan there is a common preference for fair skin tones as a result of the country’s colonial past. The dominant beauty standards also create a social hierarchy among sex workers putting dark skinned KSWs at the bottom. For instance, four KSWs said that clients often ridiculed them for their dark skin and they had a harder time finding clients as compared to their fellow sex workers: When I say to use a condom, they say I should just should be glad they are with me. What can I say after that? Pleasure and pain Discussion of sexual pleasures and erotic desires is a taboo topic in Pakistan. However, sexual pleasure and erotic desires emerged as important considerations among KSWs in our discussions on condom use during sexual interactions. Condoms were believed to decrease the experience of pleasure: “I do not use condoms because I do not like them at all. If a person comes for anal sex then we use condoms. Otherwise, we do not want to. I don’t really enjoy using them either.” (23-year-old KSW) Sexual pleasure for these sex workers is complex and not solely restricted to anal penetration. However, anal penetration without condoms is a crucial element in the experience of pleasure and subsequently sexual identities: “How can you be one of us if you haven’t experienced it as it is? […] They will not admit it but all of us have done it without it sometimes or most of the time. That’s how you find your rooh [soul/identity].” (30-year-old KSW) In addition to concerns related to pleasure, some respondents found the use of condoms by their partners during penetration as painful or uncomfortable. In such cases, condoms were not used to avoid experiencing anal pain: “It hurts my back when they use condoms. I am sometimes afraid I will bleed.” (35-year-old KSW) Mental health issues/psychological factors The majority of KSW respondents in this study pointed out the significance of their mental state in determining their choices regarding condom utilization. For instance, a 39-year-old KSW stated that he often feels there is no reason to live. During such phases of depression, his concern for utilization of condom with clients or partners often declines: I think no one cares if I live or die. So why should I care? Another 25-year-old KSW shared how thinking about or using of condoms itself produced anxiety related to acquiring HIV/AIDS and affected decision making regarding its utilization: Sometimes we get exhausted by worrying so much about using condoms and getting HIV/AIDs all the time. At the end of the day this is our only bread and butter. Nowadays I am so worried that I don’t even want to talk about it with anyone. Debilitating mental states can also accrue financial costs by increasing dependence on medications and drugs. For instance, a 43-year-old respondent mentioned dependence on sleeping pills: I cannot sleep without the pills. And if I don’t sleep in the day I can’t work at night. So, I have to save money for the pills and I cannot always waste it on the condoms. Social and sexual network level risk factors Contextual factors, frequently disregarded in the discourse on condom utilization, have a huge impact on the capacity of street-based KSW to successfully negotiate and utilize condoms with their partners. The following section brings attention to issues highlighted by street-based KSW in the study. Gentrification of historical red-light district Street-based KSWs’ sexual and social networks is larger but dispersed as compared to those who engage in commercial sexual activities through brothels or deras. One drawback of increasing reliance on street-based sex work among KSWs is the loss of traditionally available safety nets within brothel-based sex work. For instance, two KSWs shared that there was comparatively more room for condom negotiation and less fear of violence from clients when sex workers were operating from brothels because of presence of pimps, local police officials with whom KSWs had established informal links, and the support of their own community or local community-based organizations (CBOs). According to respondents, the gentrification of the traditional red-light district has consequently increased the presence of urban tourists, vendors and law enforcing agents in the neighborhood. As a result, brothel-based sex workers are finding their work being forced onto the streets away from the red-light district. This is one of the reasons why most of the KSWs in this study were compelled to work on the streets: “Not many men come to the walled city for this [sex] anymore like in past because there are always tourists and families visiting and people don’t want to be publicly associated with us. Now we have to go looking out for men on the road. Those who are not on the streets do not have many clients.” (35-year-old KSW) Discrimination, harassment and regular evictions The closure and policing of the historic red-light area in Lahore has forced many KSWs to relocate in adjacent working-class neighborhoods in the city. However, over the years, KSWs have faced discrimination and regular evictions from their homes because of prejudice within larger society against their traditional practices. Therefore, many KSWs build izzat (respectability) by begging in morning and refraining from engaging in sex work within their neighborhoods. They engage in sex work mostly at night and through street-based soliciting of clients from cruising spots away from their places of residence. This adds costs related to transport, increases chances of exposure to violence and regular physical, verbal and monetary harassment by police officers. Most KSWs added that they avoided carrying condoms because of the fear of police harassment: “Every day we are stopped at police check-posts and we pay them to let us go so we can earn some money.” (20-year-old KSW) Another KSW mentioned the regular harassment they faced at hands of the law enforcing agents: “They often take us to the police station; especially if they find condoms and keep us there for a night or until my guru comes to get me.” (30-year-old KSW) Dynamics of cruising spots and places of sexual interactions The cruising spots and places of sexual interactions for KSWs in Lahore emerged as a key barrier to condom utilization. The cruising spots include traffic signals, bus stops or railway stations, commercial markets, and other accessible public venues. Engaging in transactional sex with a KSW is not only illegal but also considered disgraceful and downgrading for men in the heteronormative Pakistani society dominated by patriarchal values. For this reason, the exchange between KSW and clients is bound by time and the challenges of interacting in public spaces. The sex workers mostly receive resistance from clients on using condoms. Most respondents shared that successfully negotiating for condoms can be time-consuming and mostly discourages clients. Longer public interactions between men and KSW in public places tend to attract attention of the police or the bystanders: “The clients are in a hurry because they are worried for their reputation. If someone stops to talk to us, the others gather around to watch the show. They think it’s entertainment.” (25-year-old KSW) Three respondents reported that the clients of KSWs are also vulnerable to physical, verbal and monetary harassment by police or bystanders. As a result, the clients want to spend as little time at the cruising spot as possible. Competition in sex trade KSWs are territorial and mostly operate in groups of 4 to 5 or more at their designated cruising spots. This is a strategy to ensure safety and manage competition with other KSWs in the city. However, KSWs face competition from male and female sex workers in the vicinity. This competition negatively impacts condom negotiation and utilization between KSW and clients. Most of the respondents reported that they do not mention condoms on days when there are few clients or there are too many sex workers present at the same time. “On weekends, you have more sex workers around here. So, we are all competing for the clients. Demanding men to use condoms on these days is difficult because they have more options.” (19-year-old KSW) Some respondents reported that they themselves offer condom-less sex to secure a client quickly. KSWs aged between 18 to 25 years more often reported offering condom-less sex as a way of bargaining for a higher price. Violence and lack of safety nets in street-based sex work Cruising spots for KSWs and the places where sexual interaction takes place are often different. While the negotiations regarding price and condom utilization takes place at the cruising spot, the nature of sexual interaction is determined by the dynamics of the place where sexual interaction takes place. The payment is also made after the completion of the sexual exchange. These places as reported by KSWs ranged from public parks, motels, rented single rooms or deray (residence) in suburban areas or nearby villages adjacent to the city, private homes, and cars. The majority of respondents shared that in most cases KSWs cannot decide the place where sexual interaction will take place. This provides complete control over the nature of sexual exchange and the decision regarding utilization of condoms to the clients. Many KSWs reported that exposure to violence, extortion and varying degree of sexual assault including forced sex for KSWs was common. Many respondents reported instances where they were raped, faced physical violence, ended up fulfilling sexual demands of multiple men and/or were held at the venue for long periods of time. This usually happened when the client belonged to politically influential families, was under the influence of drugs, or if there were multiple men present at the place of sexual exchange. In such situations, KSWs reported that condoms were least of their concern because they focused on getting out alive without injuries as quickly as possible: “There is no use of discussing condoms when they are intoxicated. Once a client took me to the village. There were two or three men who were intoxicated and who sexually exploited me for two to three hours. When they were done with me, they gave me 500 rupees. I asked them for more but they didn’t give me. The man who picked me up, he accused me of stealing his phone. After that he started to beat me.” (27-year-old KSW) Condom use with lovers Many khwaja siras maintain short-term and long-term, monogamous sexual relationships with heterosexual men referred to as dost (friend, lover) or girya. These male partners are equated to husbands with whom khwaja siras adopt the role of receptive/passive sexual partners. Eight KSWs in the study mentioned that they did not regularly or occasionally use condoms with their giryas because they trusted and respected them and the nature of their relationship was different: “I use condoms with my clients not him. He will not like it if I asked him to do it.” (30-year-old KSW) Concurrently, the lovers are not seen as clients, often securing more trust of the khwaja sira who wants to make the most of these fleeting relationships. Therefore, khwaja siras are more likely to consent to the lover’s demands including engaging in condom-less sex. According to a respondent, these men are drawn to khwaja sira because they appear to be women without being women. This in many cases means that the accountability and responsibility within heterosexual relations that bound these men’s sexualities can be abandoned in their relationships with the khwaja sira. One respondent said that because khwaja siras cannot get pregnant they are assumed to not need condoms: “He often tells me he is likes spending time with me because there is no fear of pregnancy.” (39-year-old KSW) Networks with NGOs and CBOs Most of the respondents shared that they face harassment by shopkeepers if they directly try to buy condoms from the shop. Many respondents also added that they could not afford to buy condoms all the time and as a result relied on local healthcare workers, non-governmental organizations (NGOs) or CBOs for accessing condoms without a charge or at subsidized prices. However, there were a number of challenges that were reported in accessing free condoms. The public sector in Pakistan lacks the capacity to extend healthcare related services directly to high risk groups. This has resultantly increased the dependence of the state on NGOs for provision of HIV prevention services. Many local NGOs and CBOs hire or collaborate with KSWs to forge links with and develop trust within the KSW community. While this has proven to be an effective strategy, personal rifts between gurus or their servants ( chelas ) poses some serious challenges to the provision of condoms and other services. Many khwaja siras who work for NGOs do not engage in commercial sex work and often hold stigmatizing attitudes for KSWs. On the other hand, KSWs accused the NGO workers for being corrupt and allies of the West. As a result, five KSWs reported avoiding engaging with khwaja siras working with NGOs or disclosing their professional engagement in sex work: “These NGO workers come and throw condoms in our houses from outside. They have no respect for us. So, we throw their condoms back at them.” (27-year-old KSW) In addition, many KSWs found NGO workers as intrusive, insensitive and unreliable: “The NGO is corrupt. They only take care of their own people, the khwaja saras who work for them. But not us. We went for a checkup of our HIV status and for some condoms, but the females that worked there asked very private questions: How much sex do you have? How much does the penis go in? They were such personal questions that even we were embarrassed to answer them. Still they did not give me the results or condoms. It is totally corrupt… You see they earn from it. They get more money if they can interview more transgender people.” (39-year-old KSW) Furthermore, HIV prevention and treatment endeavors have slowed down in Pakistan as a result of unsteady policies and dwindling donations from donor agencies. Many KSWs complained that there was an absence of stable prevention efforts in their localities including provision of free condoms and lubricants among KSWs: “Sometimes they have condoms, and at other times we have to manage on our own.” (23-year-old KSW) Community level risk factors Experiences of marginality and violence originating from gender variance drives many gender non-normative persons into the khwaja sira communities in Pakistan. These communities provide structured care within strictly regimented, hierarchical peer networks. These peer networks are regulated through the traditional Guru-chela (master-apprentice) relationship. Many khwaja siras live in conditions of poverty after being abandoned by their families and joining khwaja sira communities. The young novices are trained and disciplined into khwaja sira livelihood and lifestyle under the guidance of their guru who acts both as a parent and a mentor. Gurus hold immense influence within the khwaja sira universe and often act as pimps or network operators for KSWs by offering their deras as safe spaces for sexual exchange. Therefore, they play a critical role in fostering safe or risky sexual behaviors among their chelas. KSWs reported that ensuring sexual health and safety of chelas was not a priority of many gurus. The gurus enforced their will through financial penalties, physical and verbal abuse, and complete social boycott: “I work in this area; our guru doesn’t allow us to go anywhere else. He doesn’t care about our protection. He hurts us, physically abuses us, and calls us names. If we don’t share our money with him, he will cut our hair, tear our clothes and blacken our faces. He will even kick us out. Do you think he cares if we use condoms?” (23-year-old KSW) Some respondents also highlighted the prevalence of discrimination between chelas by gurus as a common challenge for consistent condom use. For instance, some respondents said that gurus often imposed financial penalties on their chelas as a result of some violation: “My previous guru was very strict. If I ever disagreed with him he would confiscate all my belongings. Once, I said that at least give me my condoms before I leave for work. But you could never change his mind.” (35-year-old KSW) Only chelas of gurus are allowed to engage in traditional khwaja sira sources of income within their designated areas. The majority of KSWs spoke how violation of community codes of conduct could increase their risks for ICU. For instance, some KSWs mentioned that soliciting clients in the designated area of another guru often entailed episodes of violence and abuse from other KSWs: “If I go to another guru’s area and if other KSWs catch us, they beat us up, cut our hair, take our belongings and throwaway our condoms. Whatever they want, they do.” (25-year-old KSW) In addition, gurus act as protectors of their chelas and are responsible for their conduct within the community and the city at large. Most khwaja sira communities manage societal stigma and avoid police harassment by maintaining an image of piety, retaining ambiguity about their corporeality, hiding their sexualized lifestyles, and publicly engaging in begging only. A threat to this public image is seen as a threat to the survival of the community. In this situation, KSWs reported that condoms utilization is an important threat to this collective image and makes it difficult for them to buy condoms from shops in their neighborhoods. Purchasing of condoms is discouraged by the gurus who also become a barrier to accessing condoms provided by NGOs: “My guru is a kind soul and doesn’t believe in sin [implying sex]. The social workers come to our houses with condoms and our guru throws them away so the police will not bother us, or those kinds of men would not find their way to our dera .” (35-year-old KSW) Discussion Khwaja sira respondents in Lahore displayed knowledge of HIV prevention methods, especially the use of condoms. The study participants described street-based sex work as a dangerous and uncertain occupation, because multiple risks associated with places of sexual exchange and clients could not be ascertained beforehand. This uncertainty was seen as an outcome of their occupational mobility, which took them away from the familiar context of the brothel/community-based sex work. Similar findings have been reported by a study conducted among female sex workers in India which has found an association between high HIV risk and small-scale mobility of sex workers [ 25 ]. Furthermore, safety concerns within short-lived places of sexual exchange with gay men have been observed in the United State of America [ 26 ]. More research is needed in the context of street-based sex work in Pakistan to ascertain the changing dynamics of HIV risk for KSWs as a result of their occupational mobility. Research on sexual and cultural practices of Khawaja sira community is just beginning to emerge in Pakistan. Our findings depart from some important findings on khwaja sira sexual practices related to safe sex. For instance, studies in Pakistan have found that gurus acting as network operators have a protective effect on KSWs sexual practices including consistent use of condoms. High rates of consistent condom use among KSWs were found in cities including Karachi and Lahore when gurus were acting as network operators for their chelas [ 8 , 17 ]. This has been followed by government initiatives that now provide options of granting citizenship status to khwaja siras in name of their gurus instead of their biological fathers. Such initiatives offer the potential to consolidate the authority of gurus over their chelas. Contrary to these findings, our study suggests that gurus play an important role in exposing KSWs to conditions of unsafe sex, violence and promoting ICU during commercial sexual interactions. In addition, predictors of HIV risk behaviors among KSWs have included alcohol and substance use prior to or during sexual interaction, the absence of support within social networks, and identity-related marginalization and internalized transphobia [ 16 , 27 ]. The narratives of KSWs included these factors as reasons for ICU during sexual interactions. According to a study on the clients of KSWs in Karachi, drug and alcohol use were not predictive of condom use in sexual interactions [ 15 ]. However, in our respondents’ narratives, alcohol and drug use by clients was frequently linked with ICU in the context of street-based sex work. Therefore, more nuanced research is required to substantiate the links between substance and alcohol use, and the role of gurus as network operators with ICU in sex-worker networks across Pakistan. We derive several important considerations from the narratives of study participants. Firstly, the results suggest a mutual and multidirectional interaction between risk factors for ICU situated at multiple levels within the individual context of street-based sex workers in Lahore. These risks factors result in systematic harm to KSWs’ safety via the normalization of unprotected transactional sex and sexual abuse throughout the sex-worker community, as suggested in the literature on HIV risk behaviors [ 28 , 29 ]. Moreover, our study also reflects the usefulness of utilizing a socio-ecological framework for describing ICU for key populations. Secondly, it is evident that condom utilization varies based not only on city-specific characteristics but also through more nuanced distinctions based on the occupational and neighborhood contexts of sex workers. The findings of this study suggest that risk factors producing risk environments for ICU and/or presenting social barriers to protected sexual contact may vary considerably, not only from one city to another but also among neighborhoods and occupational contexts within the same city, such as in Lahore. In this regard, caution is suggested when generalizing these findings across urban localities, with increasing attention required to contextualized analyses of the lives of KSWs and key populations in Pakistan. Finally, despite our study’s focus on the barriers of condom use and the structural deficiencies within street-based commercial sex work, resilience-focused community interventions may profit from the findings. For example, the absence of family or social support in addition to a lack of positive role models was identified as a key factor in the HIV-risk-exposing mobility of young khwaja siras. HIV interventions in Pakistan should, therefore, focus on the identification of possible avenues of support, including but not limited to the traditional support networks of family or deras . The development of social support within commercial sex networks may have the potential to positively impact upon a range of interlinked risk factors, including substance use and ICU. Limitations The present study has a number of limitations. Firstly, the findings are derived from self-reported data through in-depth interviews with street-based KSWs. Our estimates of high-risk and protective behaviors are prone to social-response-related reporting bias and, therefore, may be underestimates or overestimates, respectively. Secondly, data collection with our respondents was made possible through the provision of incentives. Although this was not communicated beforehand, it may have led to bias and collusion. However, in this sociocultural setting, there were ethical considerations involved since a high monetary cost as well as a social and health cost is attached to the utilization of sex workers’ time during working hours. Lastly, the data was collected before COVID-19 and as a result does not include information about how ICU is impacted by the pandemic and subsequent nationwide lockdowns. Conclusion In this paper, we have adopted a socio-ecological framework to investigate ICU within the risk contexts for HIV transmission among transgender street-based sex worker in Lahore, Pakistan. The results of this study are exploratory in nature but offer nuanced and first-hand evidence for condom utilization patterns of at-risk, street-based KSWs in Lahore. In doing so, our findings support the central role that HIV risk contexts play in exposing KSWs to the risk of contracting HIV by creating barriers to the access and utilization of condoms during commercial and non-commercial sexual interactions. Until now, HIV prevention efforts in Pakistan have primarily focused on HIV risk factors at the level of individual behaviors within specific networks of target populations. However, our study points towards both the effectiveness and the urgency of interventions that address macro-level risk factors specific to key populations in Pakistan, in addition to behavioral interventions. The socio-ecological approach taken in this paper helps us to situate KSWs’ HIV risk behaviors within the wider social and physical environment, broadening the focus to include the social conditions and processes affecting sex workers’ life choices, experiences and health behaviors. Abbreviations AIDS: Acquired immunodeficiency syndrome CBO: Community-based organizations HIV: Human immunodeficiency virus ICU: Inconsistent utilization of condoms KSW: Khwaja sira sex workers MSEM: Modified Social Ecological Model NGO: Non-governmental organization Declarations Ethics approval and consent to participate The study has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. All KSWs included in the study provided informed written consent before the start of the interview. Illiterate persons were informed in detail verbally before the study started and provided their sign afterwards. This procedure was reviewed and approved by the Departmental Ethical Review Committee, University of the Punjab (201/DERC/ISCS/PU, September 18, 2017). Consent for publication Not applicable. Availability of data and materials The qualitative datasets generated and/or analysed during the current study are not publicly available due to the data containing information that could compromise research participant privacy/consent but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. FF serves as Academic Editor for BMC Public Health. Funding None. Authors’ contributions SB and RR conceptualized the study. SB was responsible for data collection and data analysis, RR supervised this process. SB drafted the first version of the manuscript, RR and FF revised it critically for important intellectual content. All authors read and approved the final version of this manuscript. Acknowledgements We would like to thank all Khwaja sira sex workers that participated in the study, who generously took the time to share with us their opinions, thoughts and insights. We acknowledge financial support from the Open Access Publication Fund of Charité – Universitätsmedizin Berlin and the German Research Foundation (DFG). References WHO. Global HIV & AIDS statistics – Fact sheet 2021. World Health Organization. 2021. https://www.who.int/news-room/fact-sheets/detail/hiv-aids . Accessed 18 April 2022. UNAIDS . Global HIV & AIDS statistics – Fact sheet . The Joint United Nations Programme on HIV / AIDS . 2020. https://www.unaids.org/en/resources/fact-sheet. Accessed 18 April 2022 . Deuba K, Kohlbrenner V, Koirala S. Condom use behaviour among people living with HIV: a seven-country community-based participatory research in the Asia-Pacific region . Sexually Transmitted Infections. 2017; 94 ( 3 ):2005. UNAIDS . Human Right Fact Sheet Series ; HIV and sex work . The Joint United Nations Programme on HIV / AIDS . 2021. https://www.unaids.org/en/resources/documents/2021/05-hiv-human-rights-factsheet-sex-work. Accessed 18 April 2022 . Ahmed A, Hashmi FK, Khan GM. HIV outbreaks in Pakistan . Lancet HIV. 2019; 6 ( 7 ):e418. HIV and AIDS Data Hub for Asia Pacific . Pakistan country data 2020 . HIV and AIDS Data Hub for Asia Pacific . 2020. https://www.aidsdatahub.org/resource/pakistan-country-data-2020. Accessed 18 April 2022 . Bokhari A, Nizamani NM, Jackson DJ, Rehan NE, Rahman M, Muzaffar R, Mansoor S, Raza H, Qayum K, Girault P, Pisani E, Thaver I. HIV risk in Karachi and Lahore, Pakistan: An Emerging Epidemic in Injecting and Commercial Sex Networks. International Journal of STD and AIDS. 2007;18(7):486–92. Thompson LH, Salim M, Baloch CR, Musa N, Reza T, Dar N, Arian S, Blanchard JF, Emmanuel F. Heterogeneity of characteristics, structure, and dynamics of male and hijra sex workers in selected cities of Pakistan. Sexually Transmitted Infections. 2013;89(Suppl. 2):43–7. Melesse DY, Shafer LA, Emmanuel F, Reza T, Achakzai BK, Furqan S, Blanchard JF. Heterogeneity in geographical trends of HIV epidemics among key populations in Pakistan: a mathematical modeling study of survey data. Journal of Global Health. 2018;8(1):010412. National AIDS Control Program. Integrated biological and behavioral surveillance in Pakistan 2016–17, Round 5 Report. National AIDS Control Program; 2017. Khan AA, Khan A. The HIV epidemic in Pakistan . Journal of Pakistan Medical Association. 2010; 60 ( 4 ):300–7. Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT, McFall A, Fonner VA, Butler J. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up. Lancet. 2015;385(9963):172–85. Khan FA. Khwaja sira activism and the politics of gender ambiguity in Pakistan . Transgender Studies Quarterly . 2016; 3 ( 1 – 2 ): 158 – 64 . Khan S. What is in a name? Khwaja sara , hijra and eunuchs in Pakistan . Indian Journal of Gender Studies . 2016; 23 ( 2 ): 218 – 42 . Siddiqui AUR, Qian HZ, Altaf A, Cassell H, Shah SA, Vermund SH. Condom use during commercial sex among clients of hijra sex workers in Karachi, Pakistan (cross-sectional study). BMJ Open. 2011;1(2):e000154. Collumbien M, Qureshi AA, Mayhew SH, Rizvi N, Rabbani A, Rolfe B, Verma RK, Rehman H, Naveed-i-Rahat. Understanding the context of male and transgender sex work using peer ethnography. Sexually Transmitted Infections. 2009;85(Suppl. 2):3–7. Khalid H, Martin EG. Relationship between network operators and risky sex behaviors among female versus transgender commercial sex workers in Pakistan. AIDS Care: Psychological and Socio-Medical Aspects of AIDS/HIV. 2019;31(6):767–76. Parker R, Barbosa RM, Aggleton P. Framing the sexual subject . In :Parker R, Barbosa RM, Aggleton P, editors . The politics of gender, sexuality, and power . University of California Press; 2000. p . 1–29. Baral S, Logie CH, Grosso A, Wirtz AL, Beyrer C. Modified social ecological model: a tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health. 2013;13:482. Lounsbury DW, Mitchell SG. Introduction to special issue on social ecological approaches to community health research and action . American Journal of Community Psychology. 2009; 44 ( 3–4 ):213–20. Ryan GW, Bernard HR. Techniques to identify themes. Field Methods. 2003;15(1):85–109. Saldana J. The coding manual for qualitative researchers. SAGE Publications Ltd.; 2013. Attride-Stirling J. Thematic networks: an analytic tool for qualitative research. Qualitative Research. 2001;1(3):385–405. Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. SAGE Publications Ltd.; 1994. Saggurti N, Jain AK, Sebastian MP, Singh R, Modugu HR, Halli SS, Verma RK. Indicators of mobility, socio-economic vulnerabilities and HIV risk behaviours among mobile female sex workers in India. AIDS and Behavior. 2012;16(4):952–9. Stillwagon R, Ghaziani A. Queer pop-ups: a cultural innovation in urban life. City Community. 2019;18(3):874–95. Ashraf R, Khan N. Internalized transphobia, copying strategies and common mental disorders in transgender. European Journal of Research in Social Sciences. 2019;7(1):13–26. Parsons JT, Antebi-Gruszka N, Millar BM, Cain D, Gurung S. Syndemic conditions, HIV transmission risk behavior, and transactional sex among transgender women. AIDS and Behavior. 2018;22(7):2056–67. Chakrapani V, Newman PA, Shunmugam M, Logie CH, Samuel M. Syndemics of depression, alcohol use, and victimisation, and their association with HIV-related sexual risk among men who have sex with men and transgender women in India. Global Public Health. 2015;12(2):250–65. Additional Declarations Competing interest reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1568313","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":108976238,"identity":"c38d3894-3e5a-460a-a216-a833fd48b1db","order_by":0,"name":"Shermeen Bano","email":"","orcid":"","institution":"University of the Punjab","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shermeen","middleName":"","lastName":"Bano","suffix":""},{"id":108976241,"identity":"d79bd23a-484e-47fd-8d09-8e9fdb7d2924","order_by":1,"name":"Rahla Rahat","email":"","orcid":"","institution":"University of the Punjab","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rahla","middleName":"","lastName":"Rahat","suffix":""},{"id":108976242,"identity":"dc1a1e06-c966-46da-9c80-ddb68d98afc6","order_by":2,"name":"Florian Fischer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIie2PsWrDMBCGrwis5YxXmxb3Fa4IDIVCXkXGq2kDXTIEIgg4W2c/jovAWdy9hVKSxXPAUFoIoZKbTnE8d9A36H5O+jgdgMPxD+Erc0gblgDMVAwATSE49k9BfbyywSpXkeoVGlf6UP0qd1RZBUYUxurdZv4OyPm2m84+UKxfnrvZdB8Dz6phxctKWbcmoLgsm0dMmvssaogEYDs4ZmJegvS0DR7zC4nJK1KkiFIV5jQ8xSoHbQJvmX+QKEoU30ZZqPBhd1ZJC6tAwnwlkUJM7BQJYX5mfS+D9EljvwvWEsMmT24ViZsC2+GP8aW++PrUMQbrbYdzOQlWjXhT+/g64NlmcMyfetryxt47HA6HY5QfsvhOLaVQ1DcAAAAASUVORK5CYII=","orcid":"","institution":"Institute of Public Health, Charité – Universitätsmedizin Berlin","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Florian","middleName":"","lastName":"Fischer","suffix":""}],"badges":[],"createdAt":"2022-04-18 08:44:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1568313/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1568313/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-023-15550-w","type":"published","date":"2023-04-03T20:23:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44724469,"identity":"c752df3f-feda-4597-b23f-01899c62b42c","added_by":"auto","created_at":"2023-10-16 20:30:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":762070,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1568313/v1/ae09545c-dcd5-4393-bce5-fa3b9c77ea64.pdf"}],"financialInterests":"Competing interest reported. The authors declare that they have no competing interests. FF serves as Academic Editor for BMC Public Health.","formattedTitle":"Inconsistent Condom Use among Street-Based Transgender Sex Workers in Lahore, Pakistan: Socio-Ecological Analysis based on a Qualitative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHIV remains an important global public health issue which has so far claimed approximately 36.3\u0026nbsp;million lives around the world [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In 2020, 65% of new HIV infections worldwide were observed amongst key populations which include commercial sex workers, men who have sex with men, people who inject drugs, transgender people and their respective sexual partners. Overall, 8% of new HIV infections among adult populations were detected in sex workers and transgender women, which were found to be at 34 times higher risk for acquisition of HIV [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Key populations in the Asia-Pacific region are more likely to report inconsistent condom use [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In addition, structural discrimination and societal stigma against transgender and sex worker populations, that take form of retributive laws, policies and practices, engender substantial disparities for these populations that hinder their abilities to prevent HIV-related harm [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFollowing global trends, the HIV epidemic in Pakistan is at present concentrated within key populations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Pakistan has witnessed a sharp increase in new HIV infections from 1,400 in 2010 to 25,000 in 2019 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Unprotected commercial sexual contacts, including those of homosexual nature, are recognized as a key risk for HIV [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Transgender sex workers, locally referred to as \u003cem\u003eKhwaja sira\u003c/em\u003e or \u003cem\u003eHijra sex workers\u003c/em\u003e (KSWs) \u0026ndash; sex workers identified as male at birth who frequently cross-dress in feminine clothing, with some having been born with intersex variations, or those who have obtained a surgical sex change [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] \u0026ndash; currently comprise one of the most vulnerable populations to the acquisition of HIV in Pakistan. High rates of HIV among KSWs have been noted, and it was estimated that one out of every five KSWs in Pakistan would be living with HIV by the end of 2020 [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Despite targeted interventions, condom use and engagement with the HIV care system continues to be alarmingly low [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. According to the most recent HIV surveillance data, the prevalence of HIV among KSWs was 5.4%, condom use at last sex was 27.7%, and only 15% utilized HIV prevention programs in the past year [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResearch in South Asia and Pakistan has shown how social exclusion, structural discrimination, violation of human rights and everyday violence experienced by KSWs limit their access to key HIV prevention services [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Therefore, interventions that decrease violence and increase the capacity of KSWs to successfully negotiate condom use with clients are needed to control the rising incidence of HIV in sex-work networks [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. This requires a better understanding of the socio-economic, occupational and legal context of street-based sex work and the specific risk factors that hinder condom use during commercial and personal sexual interactions. This paper aims to examine the socio-ecological context of inconsistent condom use (ICU) in sexual interactions of street-based KSWs with commercial and non-commercial sexual partners in Lahore.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eKhawaja sira sex work in Pakistan\u003c/h2\u003e \u003cp\u003eSouth Asia has a rich history of gender ambiguity whose contours have shifted with changing landscapes of authority in the region. In precolonial India, members of the khwaja sira community were viewed as pious individuals due to the ambiguity of their sexual corporeality. They upheld prestigious ranks in state and society, and distinguished themselves from \u003cem\u003ehijras\u003c/em\u003e who cross-dressed, engaged in sex work and resided in impoverished neighborhoods. However, colonization of India by the British resulted in the establishment of policies that led to criminalization and regulation of transgender populations. The transgender bodies were pathologized as \u0026ldquo;diseased\u0026rdquo; and khwaja siras lost their high ranks within the society and the newly established government [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. As a result of the loss of livelihood, khwaja siras found support in the hijra community which led to the assimilation of these two populations and to the marginalized position they are in today [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Recently, in an attempt to reclaim their historical respect and status, the term \u003cem\u003ekhwaja sira\u003c/em\u003e has been adopted and encouraged by transgender activists in place of the derogatory term \u003cem\u003ehijra\u003c/em\u003e. This has been corresponded by granting of citizenship privileges and rights to khwaja siras through the Pakistani Supreme Court\u0026rsquo;s rulings in 2012 and the passing the Transgender Protection Bill in 2018 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSex work is not a recent phenomenon in Pakistan where 97% of the population is Muslim, and religious as well as social norms strongly prohibit extramarital sex. The contours of this work have shifted, however, from geographically located brothel-based arrangements for sexual activity to a more dispersed configuration of sexual transactions carried out across the country\u0026rsquo;s cities. This has largely been the result of Islamic Hudood laws, introduced by the military government in 1979, and the subsequent years of the criminalization and penalization of the sex-worker community and the shutting down of several brothels and red-light areas by the state. While the vast majority of street-based KSWs continue to survive and operate in the cities through \u0026ldquo;Deras\u0026rdquo; \u0026ndash; strictly regimented, all-khwaja-sira residences, managed by a guru (group leader/network operator) that survive and function through the adoption of young boys abandoned by their families and communities [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] \u0026ndash; the places used for sexual transactions have moved considerably outside their jurisdiction.\u003c/p\u003e \u003cp\u003eDuring the last two decades, important shifts have occurred within commercial sex-work, which was historically organized around brothel-based patterns of sexual interaction. According to estimates, in 2010 only about 2\u0026ndash;3% of KSWs were operating from brothels or red-light areas [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Street-based soliciting of clients among KSWs since then increased from 17.5% in 2007 to 33.3% in 2017 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In Pakistan, where links have been found between consistent condom use in KSWs and dependence on gurus, the increasing trend towards street-based sex work has important implications for HIV prevention [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. However, the emerging needs and vulnerabilities of occupationally mobile street-based sex workers within changing interactional sexual contexts remain inadequately addressed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eThe Modified Social Ecological Model and risk factors for inconsistent condom use\u003c/h2\u003e \u003cp\u003eSocio-cultural and economic contexts are paramount in shaping sexual behaviors including condom use among key populations. Condom use behaviors are also not fixed and evolve with changes in the environment that is shaped by gendered and hierarchical relations within the larger patriarchal society [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This paper examines ICU in KSWs within the context of street-based sex work in Lahore by applying the Modified Social Ecological Model (MSEM) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Currently there is a dearth of research on ICU within the particular social, physical, and occupational contexts of street-based KSWs in Pakistan. Applying a social-ecological framework to ICU among KSWs can help to determine the way in which the multi-level socio-structural injustices and oppression experienced by street-based KSWs contribute to and reinforce barriers to condom use during commercial and non-commercial sexual interactions.\u003c/p\u003e \u003cp\u003eThe MSEM [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] examines HIV risk at five levels, ranging from the micro-level of the individual to meso-levels of network and community, and ultimately to the macro-level defined by public policy and the stage of HIV epidemic. This model emphasizes the identification of distinct factors for HIV risk at each level, where each level is understood as providing the context for examining risk factors at other levels through ongoing multilevel interactions between these factors. There are five level of risk factors: 1) \u003cem\u003eindividual level factors\u003c/em\u003e include biological or behavioral features related with susceptibility to acquisition or transmission of HIV infection, 2) \u003cem\u003esocial and sexual networks\u003c/em\u003e encompass interpersonal relationships ranging from family members, friends, neighbors, paid or unpaid sexual partners that impact on health related behaviors and wellbeing, 3) \u003cem\u003ecommunity environments\u003c/em\u003e commonly comprises of network links, associations among organizations, groups and geographical/political areas, 4) \u003cem\u003elaws and policies\u003c/em\u003e of any government offer the wide-ranging context that determines the nature of HIV-related risk behaviors and coping strategies of marginalized populations, and 5) the \u003cem\u003estage of the epidemic\u003c/em\u003e refers to incidence and prevalence of HIV within the population.\u003c/p\u003e \u003cp\u003eThis paper asserts that a socio-ecological framework is useful in examining multi-level risk factors for ICU by KSWs in Pakistan for a number of reasons. Health policy in Pakistan tends to target HIV-related interventions at the individual level of risk behaviors [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], which constitute an important but not the only level of factors influencing the spread of HIV among vulnerable populations. The application of the socio-ecological framework to ICU among KSWs helps to illuminate that the HIV risk behaviors of KSWs, derived from processes at the social environment level as well as that of the individual, are an outcome of multiple causes, and are affected by multilevel combinations of intertwined factors [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs sex work for khwaja siras becomes increasingly violent, discriminatory, and risky, links with the changing nature of KSWs\u0026rsquo; behaviors related to safe sex practices within the context of street-based sex work need to be explored. For this reason, the purpose of this study is to investigate the contextual determinants that influence ICU within street-based commercial and non-commercial sexual encounters by MSEM.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy site\u003c/h2\u003e \u003cp\u003eThe study was conducted between October 2017 and January 2018 with street-based KSWs in four neighborhoods of Lahore. Lahore is the capital city of the biggest province Punjab in Pakistan and has the one of the highest presences of KSWs. The study locations were chosen based on the known public presence of KSWs, and later through recommendations from already recruited respondents. Moreover, these neighborhoods represent different geographical areas of the city: Two neighborhoods are approximately 4.8 km apart in the old part of Lahore, one of it is associated with the historical red-light area of the city. Two further neighborhoods are located in the newly developed and relatively affluent sectors of the city, 36 km and 17.5 km away from the red-light district, respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment\u003c/h2\u003e \u003cp\u003e A multipronged approach was utilized to recruit 20 KSWs through purposive sampling. We partnered with a public health worker who had access to the KSW community and who hired as a research assistant. KSWs were recruited by this research assistant through street recruitment in the selected four neighborhoods of Lahore. Inclusion criteria required that the participants 1) were at least 18 years old, 2) were self-reported khwaja siras, 3) were voluntary sex workers who solicited clients primarily through walking the streets, 3) had reported participating in anal intercourse during the previous 12 months, 5) had lived in Lahore for at least 12 months, and 6) were able to provide informed consent of their own free will. KSWs who completed the interview received PKR 1,000 (\u003cspan\u003e$\u003c/span\u003e7) compensation for their time which was not informed to them before the start of the interview.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eIn total, 20 in-depth interviews with KSWs which lasted approximately 60 to 90 minutes were conducted. The interviews were conducted by the researcher and her research assistant in locations chosen by the respondents. These locations included their homes or the homes of their friends, street corners, markets, and sidewalks. A semi-structured interview guide was used during the interviews. It included questions relating to the nature, patterns, and dynamics of street-based sex work, as well as understandings, perceptions, and descriptions of the occupational, social, and residential neighborhoods. Additionally, questions were asked regarding conversations about sex and HIV risk behaviors within changing neighborhoods as well as in different transactional contexts, the development of sexual identity and behaviors, and the impact of social and sexual networks on condom utilization. All KSWs included in the study provided informed written consent before the start of the interview. The interviews were audio-recorded and examined for accuracy after professional transcription.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe qualitative data was analyzed using thematic analysis [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] to produce an initial set of codes during the first-level round. An essence-capturing strategy [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] was utilized to identify broader themes through a heuristic exploration of the text. For this, focused codes were developed by putting together phrases and passages from our data set that were suggestive of our research questions. These codes were then grouped together into larger unifying frameworks. These frameworks culminated in the following global themes [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]: (1) Individual level factors influencing ICU among KSWs, (2) social and sexual network level factors influencing ICU among KSWs, and (3) community level influences on sexual practices and identities. The analysis was carried out reflexively at all levels so that the uniqueness and validity of the codes could be maintained [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe sample characteristics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The initial coding of interview data confirmed three levels of risk factors for ICU among KSWs: 1) individual level factors, 2) social and sexual network level factors, and 3) community level factors. The following open coding allowed to identify of sub-themes within each main theme. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e lists the three main themes, the 16 sub-themes, descriptions of each sub-theme, and exemplary quotations reflecting the specific sub-theme. All sub-themes are described in detail in the following sections.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSample characteristics of street-based KSWs in Lahore (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSociodemographic variables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003cp\u003e18\u0026ndash;25 years\u003c/p\u003e \u003cp\u003e26\u0026ndash;35 years\u003c/p\u003e \u003cp\u003e36\u0026ndash;45 years\u003c/p\u003e \u003cp\u003e46 years and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e40\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003cp\u003eNo education\u003c/p\u003e \u003cp\u003ePrimary level\u003c/p\u003e \u003cp\u003eSecondary level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003cp\u003e35\u003c/p\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLiving arrangement\u003c/b\u003e\u003c/p\u003e \u003cp\u003eWith the guru\u003c/p\u003e \u003cp\u003eWith family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of years in sex work\u003c/b\u003e\u003c/p\u003e \u003cp\u003eLess than 5 years\u003c/p\u003e \u003cp\u003eMore than 5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge that HIV/AIDS is transmitted through sex\u003c/b\u003e\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConsider yourself at risk of HIV/AIDS\u003c/b\u003e\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConsistent condom use\u003c/b\u003e\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85\u003c/p\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of themes, descriptions, and exemplary quotations resulting from analysis of individual, network, and community level barriers to inconsistent condom use (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExemplary quotation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eIndividual level risk factors\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of knowledge and awareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscussion about their knowledge of practices of HIV/AIDS transmission and prevention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;We know HIV is spread through sex if you don\u0026rsquo;t use condoms.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;HIV is spread through bed sharing with HIV positive men even if you are wearing condoms.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;If you are regularly using condoms, occasional withdrawal method can protect you from HIV.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived characteristics of sexual partners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptions of observable attributes of clients including social class, status, and physical attributes that were used to categorize clients as risky or safe for condomless sex.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;I look at their clothes to judge the status of clients. Middle class men are always in clean clothes. They also often prefer using condoms.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;The drug addicts are always dirty and risky. I prefer to ignore them.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Skin is the best reflection of someone\u0026rsquo;s health. If a client has suspicious spots, pimples or wounds or if their skin is burnt and dark I know there is something wrong and at least I have to use condom. But sometimes at night if it is dark I can\u0026rsquo;t observe properly.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Clients don\u0026rsquo;t take my demands about condoms seriously because I am dark skinned.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge and physical attributes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComments about age, skin color and other physical attributes of KSWs that impacted condom related decision making\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;I am beautiful and young so I can demand my clients to use condoms or else they have to pay double.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;If you are young you can charge higher rate for sex without condoms.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Now because I am older I am not that attractive to many clients. I cannot risk losing clients because of condoms.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleasure and pain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComments about the role of condoms in sexual arousal, sexual pleasure and experience of pain during anal intercourse with clients and its impact on condom related decision making.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;We all do it without condoms because honestly it is fun.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;When I was new I was afraid of making my clients use condoms because other khwaja siras had told me it would be painful.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental health issues/psychological factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscussions of psychosocial factors including feelings of isolation, loneliness, depression, anxiety among KSWs, and how they influence condom related decision making with sexual partners.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;They are always scaring us from HIV. But we all will get it one day so why live in constant fear. If sometimes I am worried about money I stop thinking about HIV and condoms.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;At the end of the day I feel very lonely and depressed. I have trouble sleeping at night. If I am feeling too low I can get careless with clients.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Many KSWs these days are depressed and they get into habit of using alcohol with clients. Once you are under its influence you are not thinking about condoms or your safety.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eSocial and sexual network level risk factors\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGentrification of historical red-light district\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptions of changing dynamics of risk and safety in sex trade in red light district as a result of increasing tourism and presence of law enforcing agents.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Now there are bus tours and walking tours around the red-light district. This place is not very workable for sex workers. We prefer to walk for hours to our spot where clients would be comfortable approaching us and there is less presence of police. But I prefer not to carry condoms because we have to pass police check posts and they often tease us.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;I moved out of red-light district but the rent is higher here. Often I don\u0026rsquo;t have money to buy condoms.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscrimination, harassment and regular evictions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComments about experiences of discrimination and harassment faced by KSWs in their residential neighborhoods and its impact on condom related decision making.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;There was an old man in my neighborhood who said I should come and take care of him. I told him I was a respectful khwaja sira. And he started calling me bad names and threatened to get me kicked out of the area. I never buy condoms from shops here just because of this reason.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Once men started beating at our door at night asking us to open the door. But we said we were not that kind of khwaja siras. We were very scared. This is why we don\u0026rsquo;t keep condoms at home.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;The police hardly help us. They are just interested in sexual favors or getting money out of us. Who can dare ask a police man to use a condom?\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDynamics of cruising spots and places of sexual interactions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscussion of how spatial, temporal and cultural characteristics of cruising spots and venue of sexual exchange impact practices of condom utilization among KSWs and their partners.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Everything happens very fast in our business. We and our clients are all in a hurry for our own reasons. There is no time for thinking about or using a condom.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;If you insist on condoms too much sometimes the discussion can become heated. People here are just waiting for a show so they can gather around which is bad for clients.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Clients are scared of the police especially if they are younger. They don\u0026rsquo;t want their family to find out and our scared of police beating. So if you are too demanding or want to discuss matters like condoms they just move on quickly.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompetition in sex trade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription of presence of competition among larger sex trade industry that further includes Female sex workers and male sex workers and their impact on practices of condom utilization.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;The older KSWs are least in demand when you have young women, men and khwaja siras to choose from. Often our only appeal is that we can offer sex without condoms.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;In this area there are all kinds of sex workers on the weekend nights. Many clients move on ahead the moment you mention the word condom.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eViolence and lack of safety nets in street-based sex work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eComments about the role of physical, social, sexual, and economic violence and absence of security for sex workers in sex trade in promoting ICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Once a man tied me to the tree after raping and beating me because I asked him to use a condom.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;If I am with a group of clients I feel more insecure and just comply with their demands. If they want to use condoms I use them but if they don\u0026rsquo;t want to I will just agree.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;No one comes to save us. Once these men raped me and left me unconscious in front of my house. My guru did nothing.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCondom use with lovers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscussion of risk evaluations and condom utilization practices with intimate partners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;I love him so why use a condom?\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;I don\u0026rsquo;t use it because he will think I am a sex worker.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;I know he will leave eventually so why not enjoy while it lasts.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNetworks with NGOs and CBOs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptions of role of existing private and government organizations in condom related decision making and practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;They just want to do photoshoots with us. They call us to their office, give us biryani (cooked rice) and take pictures. They don\u0026rsquo;t give us condoms.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;These khwaja siras in NGOs think they are better than us and look down on us. When they give us condoms they tell us to choose the right path and leave sex work. I don\u0026rsquo;t interact with these NGOs at all.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;Most of the times they don\u0026rsquo;t have condoms and lubricants at the NGOs. Sometimes they tell us to buy from the shop which I don\u0026rsquo;t do.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eCommunity level risk factors\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePoverty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscussion of role of socio-economic constraints and challenges within khwaja sira community on condom related decision making and practices among KSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;There is no job for us and we often don\u0026rsquo;t get paid by the client. We are always short of money. So condoms are not always my priority.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfluence of guru\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescriptions of role of gurus on nature of sexual practices of their chelas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;My guru only cares about business. He does not want to deal with police so he discourages us from carrying condoms and insists that we demand our clients to get them. But it\u0026rsquo;s easier to convince clients if you have your own condom.\u0026rdquo;\u003c/p\u003e \u003cp\u003e\u0026bull; \u0026ldquo;My guru is very kind and pious. He does not know I engage in sex work so I can\u0026rsquo;t bring condoms at the house. If someone is found with condoms she is fined or beaten up.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDera culture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiscussion of how traditional practices and customs influence condom related decision making and practices of KSWs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; \u0026ldquo;We can only find clients in our guru\u0026rsquo;s area. So I can only choose from the clients that are in my area and there is not much choice on many days. The clients don\u0026rsquo;t take my demands for condoms seriously because they say we have done this before without it and nothing happened.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eIndividual-level risk factors\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003eLevel of knowledge and awareness\u003c/h2\u003e \u003cp\u003eThe level of knowledge and awareness about HIV/AIDS and further sexually transmitted infections (STIs) as well as safer sex practices among KSWs is critical in determining the consistency in condom use. Many respondents referred to HIV/AIDS as the \u0026ldquo;disease one gets from sharing bed\u0026rdquo;, referring to sexual intercourse. While all respondents in our study displayed awareness about HIV/AIDS, STIs and the necessity of condoms in protection against STIs, there were still important misconceptions that emerged as barriers to consistent condom utilization during sexual interactions.\u003c/p\u003e \u003cp\u003eOne major misconception among KSWs was that occasional non-usage of condoms did not pose a risk for contracting HIV to those sex workers who were otherwise regular users of condoms. For instance, a 25-year-old KSW said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI always use condoms. However, in some situations, I can\u0026rsquo;t negotiate to use it. Then I say it is not a problem.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003ePerceived characteristics of sexual partners\u003c/h2\u003e \u003cp\u003eIn situations where KSWs were in a position to negotiate condom use, the decision to not use condoms in a sexual interaction with clients was sometimes based on misconceptions about HIV and STIs in general. One important misconception that was reported among interviewed KSWs was the belief that another person\u0026rsquo;s HIV status could be ascertained through their physical appearance or observed social status. As a result, all of the KSWs had developed their own methods of profiling suitors as potentially HIV positive or negative. The drug addicts were mostly avoided because they never carried condoms with them, were unpredictable and often violent, but most importantly because they were self-identified by the sex workers as potentially HIV positive. For example, a 43-year-old KSW stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe have been doing this for so long, you can almost tell from the appearance if someone has HIV or any disease like that. These drug addicts carry HIV around and it shows on their faces. The men who are healthy look clean.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome KSWs described that they analyze the overall condition of skin, or appearance of genitalia for any possible warning signs that could help them ascertain if the person is HIV positive. Some also reported not using condoms with middle-class appearing men because they were assumed to be less risky. HIV was here labelled as a disease of the wealthy or poor uneducated men, such as illustrated by a 30-year-old KSW:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eMiddle class men have families and work and don\u0026rsquo;t have time to indulge in this so much. These men in big cars are the ones we are careful with. Who knows what they have been up to?\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eAge and physical attributes\u003c/h2\u003e \u003cp\u003eAmong the respondents of this study, age of KSWs emerged as an important barrier to consistent condom use during sexual interactions with clients. The KSWs between 18 to 25 years and those above 45 years of age reported most cases of ICU with clients as a result of their age. Young KSWs mentioned that the negotiation process for condom utilization was with clients overwhelming, especially with clients who were older in age as compared to them:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI am still new and learning. I don\u0026rsquo;t always have the confidence to convince the clients.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTwo young sex workers believed that because they were less experienced as compared to other sex workers in the market, having sexual interaction with clients without condoms occasionally was also a way of getting more experience and understanding of their work:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI am young and I am learning. So I sometimes don\u0026rsquo;t insist on condoms to see what difference does it make?\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne young respondent avoided condoms in order to deal with the lack of intimacy and feelings of alienation within street-based sex work. A 23-year-old respondent talking about young KSWs stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey are young and easily heartbroken. They need love. So, when they don\u0026rsquo;t receive love, they don\u0026rsquo;t use condoms to feel love.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSex work is a competitive market and some respondents shared that ageing in their profession was a major drawback in securing clients. Therefore, HIV risk was not always the most salient health concern among ageing sex workers. As a result of the demand for younger sex workers, all of the KSWs aged more than 36 years reported being more compliant of their client\u0026rsquo;s demands. For example, a 43-year-old KSW mentioned:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThey say, if we have to use a condom why not go to the younger one? And we comply because at the end of the day we have to eat.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne the other hand, most of the older KSWs also reported that street-based sex work was physically demanding. Four sex workers between 36 to 45 years of age spoke, for instance, of sex work as an economic necessity resulting from discrimination within employment practices in the city. As a result of ageing, their mobility had become restrained and restricted within familiar neighborhoods and with regular clients with whom condom use declined:\u003c/p\u003e \u003cp\u003e\u0026ldquo;We\u0026rsquo;re too tired to negotiate. We stand or walk all day in this hot weather. We don\u0026rsquo;t have stamina for arguments now.\u0026rdquo; (38-year-old KSW)\u003c/p\u003e \u003cp\u003e\u0026ldquo;They see us all the time, so they do not take us seriously when we ask them to use condoms. They [\u003cem\u003eclients\u003c/em\u003e] say if nothing happened before, why would it happen now?\u0026rdquo; (36-year-old KSW)\u003c/p\u003e \u003cp\u003eOne respondent shared the fear of increasing health-related costs discourages them from demanding their clients to use condoms:\u003c/p\u003e \u003cp\u003e\u0026ldquo;At this age, our body and pockets both can\u0026rsquo;t afford the beating.\u0026rdquo; (43-year-old KSW)\u003c/p\u003e \u003cp\u003eIn Pakistan there is a common preference for fair skin tones as a result of the country\u0026rsquo;s colonial past. The dominant beauty standards also create a social hierarchy among sex workers putting dark skinned KSWs at the bottom. For instance, four KSWs said that clients often ridiculed them for their dark skin and they had a harder time finding clients as compared to their fellow sex workers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen I say to use a condom, they say I should just should be glad they are with me. What can I say after that?\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003ePleasure and pain\u003c/h2\u003e \u003cp\u003eDiscussion of sexual pleasures and erotic desires is a taboo topic in Pakistan. However, sexual pleasure and erotic desires emerged as important considerations among KSWs in our discussions on condom use during sexual interactions. Condoms were believed to decrease the experience of pleasure:\u003c/p\u003e \u003cp\u003e\u0026ldquo;I do not use condoms because I do not like them at all. If a person comes for anal sex then we use condoms. Otherwise, we do not \u003cem\u003ewant\u003c/em\u003e to. I don\u0026rsquo;t really \u003cem\u003eenjoy\u003c/em\u003e using them either.\u0026rdquo; (23-year-old KSW)\u003c/p\u003e \u003cp\u003eSexual pleasure for these sex workers is complex and not solely restricted to anal penetration. However, anal penetration without condoms is a crucial element in the experience of pleasure and subsequently sexual identities:\u003c/p\u003e \u003cp\u003e\u0026ldquo;How can you be one of \u003cem\u003eus\u003c/em\u003e if you haven\u0026rsquo;t experienced it as it is? [\u0026hellip;] They will not admit it but all of us have done it without it sometimes or most of the time. That\u0026rsquo;s how you find your \u003cem\u003erooh\u003c/em\u003e [soul/identity].\u0026rdquo; (30-year-old KSW)\u003c/p\u003e \u003cp\u003eIn addition to concerns related to pleasure, some respondents found the use of condoms by their partners during penetration as painful or uncomfortable. In such cases, condoms were not used to avoid experiencing anal pain:\u003c/p\u003e \u003cp\u003e\u0026ldquo;It hurts my back when they use condoms. I am sometimes afraid I will bleed.\u0026rdquo; (35-year-old KSW)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eMental health issues/psychological factors\u003c/h2\u003e \u003cp\u003eThe majority of KSW respondents in this study pointed out the significance of their mental state in determining their choices regarding condom utilization. For instance, a 39-year-old KSW stated that he often feels there is no reason to live. During such phases of depression, his concern for utilization of condom with clients or partners often declines:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think no one cares if I live or die. So why should I care?\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother 25-year-old KSW shared how thinking about or using of condoms itself produced anxiety related to acquiring HIV/AIDS and affected decision making regarding its utilization:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSometimes we get exhausted by worrying so much about using condoms and getting HIV/AIDs all the time. At the end of the day this is our only bread and butter. Nowadays I am so worried that I don\u0026rsquo;t even want to talk about it with anyone.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDebilitating mental states can also accrue financial costs by increasing dependence on medications and drugs. For instance, a 43-year-old respondent mentioned dependence on sleeping pills:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI cannot sleep without the pills. And if I don\u0026rsquo;t sleep in the day I can\u0026rsquo;t work at night. So, I have to save money for the pills and I cannot always waste it on the condoms.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSocial and sexual network level risk factors\u003c/h2\u003e \u003cp\u003eContextual factors, frequently disregarded in the discourse on condom utilization, have a huge impact on the capacity of street-based KSW to successfully negotiate and utilize condoms with their partners. The following section brings attention to issues highlighted by street-based KSW in the study.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003eGentrification of historical red-light district\u003c/h2\u003e \u003cp\u003eStreet-based KSWs\u0026rsquo; sexual and social networks is larger but dispersed as compared to those who engage in commercial sexual activities through brothels or deras. One drawback of increasing reliance on street-based sex work among KSWs is the loss of traditionally available safety nets within brothel-based sex work. For instance, two KSWs shared that there was comparatively more room for condom negotiation and less fear of violence from clients when sex workers were operating from brothels because of presence of pimps, local police officials with whom KSWs had established informal links, and the support of their own community or local community-based organizations (CBOs).\u003c/p\u003e \u003cp\u003eAccording to respondents, the gentrification of the traditional red-light district has consequently increased the presence of urban tourists, vendors and law enforcing agents in the neighborhood. As a result, brothel-based sex workers are finding their work being forced onto the streets away from the red-light district. This is one of the reasons why most of the KSWs in this study were compelled to work on the streets:\u003c/p\u003e \u003cp\u003e\u0026ldquo;Not many men come to the walled city for this [sex] anymore like in past because there are always tourists and families visiting and people don\u0026rsquo;t want to be publicly associated with us. Now we have to go looking out for men on the road. Those who are not on the streets do not have many clients.\u0026rdquo; (35-year-old KSW)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eDiscrimination, harassment and regular evictions\u003c/h2\u003e \u003cp\u003eThe closure and policing of the historic red-light area in Lahore has forced many KSWs to relocate in adjacent working-class neighborhoods in the city. However, over the years, KSWs have faced discrimination and regular evictions from their homes because of prejudice within larger society against their traditional practices. Therefore, many KSWs build \u003cem\u003eizzat\u003c/em\u003e (respectability) by begging in morning and refraining from engaging in sex work within their neighborhoods. They engage in sex work mostly at night and through street-based soliciting of clients from cruising spots away from their places of residence. This adds costs related to transport, increases chances of exposure to violence and regular physical, verbal and monetary harassment by police officers. Most KSWs added that they avoided carrying condoms because of the fear of police harassment:\u003c/p\u003e \u003cp\u003e\u0026ldquo;Every day we are stopped at police check-posts and we pay them to let us go so we can earn some money.\u0026rdquo; (20-year-old KSW)\u003c/p\u003e \u003cp\u003eAnother KSW mentioned the regular harassment they faced at hands of the law enforcing agents:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;They often take us to the police station; especially if they find condoms and keep us there for a night or until my guru comes to get me.\u0026rdquo; (30-year-old KSW)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eDynamics of cruising spots and places of sexual interactions\u003c/h2\u003e \u003cp\u003eThe cruising spots and places of sexual interactions for KSWs in Lahore emerged as a key barrier to condom utilization. The cruising spots include traffic signals, bus stops or railway stations, commercial markets, and other accessible public venues. Engaging in transactional sex with a KSW is not only illegal but also considered disgraceful and downgrading for men in the heteronormative Pakistani society dominated by patriarchal values. For this reason, the exchange between KSW and clients is bound by time and the challenges of interacting in public spaces. The sex workers mostly receive resistance from clients on using condoms. Most respondents shared that successfully negotiating for condoms can be time-consuming and mostly discourages clients. Longer public interactions between men and KSW in public places tend to attract attention of the police or the bystanders:\u003c/p\u003e \u003cp\u003e\u0026ldquo;The clients are in a hurry because they are worried for their reputation. If someone stops to talk to us, the others gather around to watch the show. They think it\u0026rsquo;s entertainment.\u0026rdquo; (25-year-old KSW)\u003c/p\u003e \u003cp\u003e Three respondents reported that the clients of KSWs are also vulnerable to physical, verbal and monetary harassment by police or bystanders. As a result, the clients want to spend as little time at the cruising spot as possible.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003eCompetition in sex trade\u003c/h2\u003e \u003cp\u003eKSWs are territorial and mostly operate in groups of 4 to 5 or more at their designated cruising spots. This is a strategy to ensure safety and manage competition with other KSWs in the city. However, KSWs face competition from male and female sex workers in the vicinity. This competition negatively impacts condom negotiation and utilization between KSW and clients. Most of the respondents reported that they do not mention condoms on days when there are few clients or there are too many sex workers present at the same time.\u003c/p\u003e \u003cp\u003e\u0026ldquo;On weekends, you have more sex workers around here. So, we are all competing for the clients. Demanding men to use condoms on these days is difficult because they have more options.\u0026rdquo; (19-year-old KSW)\u003c/p\u003e \u003cp\u003eSome respondents reported that they themselves offer condom-less sex to secure a client quickly. KSWs aged between 18 to 25 years more often reported offering condom-less sex as a way of bargaining for a higher price.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eViolence and lack of safety nets in street-based sex work\u003c/h2\u003e \u003cp\u003eCruising spots for KSWs and the places where sexual interaction takes place are often different. While the negotiations regarding price and condom utilization takes place at the cruising spot, the nature of sexual interaction is determined by the dynamics of the place where sexual interaction takes place. The payment is also made after the completion of the sexual exchange. These places as reported by KSWs ranged from public parks, motels, rented single rooms or \u003cem\u003ederay\u003c/em\u003e (residence) in suburban areas or nearby villages adjacent to the city, private homes, and cars. The majority of respondents shared that in most cases KSWs cannot decide the place where sexual interaction will take place. This provides complete control over the nature of sexual exchange and the decision regarding utilization of condoms to the clients. Many KSWs reported that exposure to violence, extortion and varying degree of sexual assault including forced sex for KSWs was common. Many respondents reported instances where they were raped, faced physical violence, ended up fulfilling sexual demands of multiple men and/or were held at the venue for long periods of time. This usually happened when the client belonged to politically influential families, was under the influence of drugs, or if there were multiple men present at the place of sexual exchange. In such situations, KSWs reported that condoms were least of their concern because they focused on getting out alive without injuries as quickly as possible:\u003c/p\u003e \u003cp\u003e\u0026ldquo;There is no use of discussing condoms when they are intoxicated. Once a client took me to the village. There were two or three men who were intoxicated and who sexually exploited me for two to three hours. When they were done with me, they gave me 500 rupees. I asked them for more but they didn\u0026rsquo;t give me. The man who picked me up, he accused me of stealing his phone. After that he started to beat me.\u0026rdquo; (27-year-old KSW)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003eCondom use with lovers\u003c/h2\u003e \u003cp\u003eMany khwaja siras maintain short-term and long-term, monogamous sexual relationships with heterosexual men referred to as \u003cem\u003edost\u003c/em\u003e (friend, lover) or \u003cem\u003egirya.\u003c/em\u003e These male partners are equated to husbands with whom khwaja siras adopt the role of receptive/passive sexual partners. Eight KSWs in the study mentioned that they did not regularly or occasionally use condoms with their \u003cem\u003egiryas\u003c/em\u003e because they trusted and respected them and the nature of their relationship was different:\u003c/p\u003e \u003cp\u003e\u0026ldquo;I use condoms with my clients not him. He will not like it if I asked him to do it.\u0026rdquo; (30-year-old KSW)\u003c/p\u003e \u003cp\u003eConcurrently, the lovers are not seen as clients, often securing more trust of the khwaja sira who wants to make the most of these fleeting relationships. Therefore, khwaja siras are more likely to consent to the lover\u0026rsquo;s demands including engaging in condom-less sex. According to a respondent, these men are drawn to khwaja sira because they appear to be women without being women. This in many cases means that the accountability and responsibility within heterosexual relations that bound these men\u0026rsquo;s sexualities can be abandoned in their relationships with the khwaja sira. One respondent said that because khwaja siras cannot get pregnant they are assumed to not need condoms:\u003c/p\u003e \u003cp\u003e\u0026ldquo;He often tells me he is likes spending time with me because there is no fear of pregnancy.\u0026rdquo; (39-year-old KSW)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eNetworks with NGOs and CBOs\u003c/h2\u003e \u003cp\u003eMost of the respondents shared that they face harassment by shopkeepers if they directly try to buy condoms from the shop. Many respondents also added that they could not afford to buy condoms all the time and as a result relied on local healthcare workers, non-governmental organizations (NGOs) or CBOs for accessing condoms without a charge or at subsidized prices. However, there were a number of challenges that were reported in accessing free condoms.\u003c/p\u003e \u003cp\u003eThe public sector in Pakistan lacks the capacity to extend healthcare related services directly to high risk groups. This has resultantly increased the dependence of the state on NGOs for provision of HIV prevention services. Many local NGOs and CBOs hire or collaborate with KSWs to forge links with and develop trust within the KSW community. While this has proven to be an effective strategy, personal rifts between gurus or their servants (\u003cem\u003echelas\u003c/em\u003e) poses some serious challenges to the provision of condoms and other services. Many khwaja siras who work for NGOs do not engage in commercial sex work and often hold stigmatizing attitudes for KSWs. On the other hand, KSWs accused the NGO workers for being corrupt and allies of the West. As a result, five KSWs reported avoiding engaging with khwaja siras working with NGOs or disclosing their professional engagement in sex work:\u003c/p\u003e \u003cp\u003e\u0026ldquo;These NGO workers come and throw condoms in our houses from outside. They have no respect for us. So, we throw their condoms back at them.\u0026rdquo; (27-year-old KSW)\u003c/p\u003e \u003cp\u003eIn addition, many KSWs found NGO workers as intrusive, insensitive and unreliable:\u003c/p\u003e \u003cp\u003e\u0026ldquo;The NGO is corrupt. They only take care of their own people, the khwaja saras who work for them. But not us. We went for a checkup of our HIV status and for some condoms, but the females that worked there asked very private questions: How much sex do you have? How much does the penis go in? They were such personal questions that even we were embarrassed to answer them. Still they did not give me the results or condoms. It is totally corrupt\u0026hellip; You see they earn from it. They get more money if they can interview more transgender people.\u0026rdquo; (39-year-old KSW)\u003c/p\u003e \u003cp\u003eFurthermore, HIV prevention and treatment endeavors have slowed down in Pakistan as a result of unsteady policies and dwindling donations from donor agencies. Many KSWs complained that there was an absence of stable prevention efforts in their localities including provision of free condoms and lubricants among KSWs:\u003c/p\u003e \u003cp\u003e\u0026ldquo;Sometimes they have condoms, and at other times we have to manage on our own.\u0026rdquo; (23-year-old KSW)\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eCommunity level risk factors\u003c/h2\u003e \u003cp\u003eExperiences of marginality and violence originating from gender variance drives many gender non-normative persons into the khwaja sira communities in Pakistan. These communities provide structured care within strictly regimented, hierarchical peer networks. These peer networks are regulated through the traditional \u003cem\u003eGuru-chela\u003c/em\u003e (master-apprentice) \u003cem\u003erelationship.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eMany khwaja siras live in conditions of poverty after being abandoned by their families and joining khwaja sira communities. The young novices are trained and disciplined into khwaja sira livelihood and lifestyle under the guidance of their guru who acts both as a parent and a mentor. Gurus hold immense influence within the khwaja sira universe and often act as pimps or network operators for KSWs by offering their \u003cem\u003ederas\u003c/em\u003e as safe spaces for sexual exchange. Therefore, they play a critical role in fostering safe or risky sexual behaviors among their chelas. KSWs reported that ensuring sexual health and safety of chelas was not a priority of many gurus. The gurus enforced their will through financial penalties, physical and verbal abuse, and complete social boycott:\u003c/p\u003e \u003cp\u003e\u0026ldquo;I work in this area; our guru doesn\u0026rsquo;t allow us to go anywhere else. He doesn\u0026rsquo;t care about our protection. He hurts us, physically abuses us, and calls us names. If we don\u0026rsquo;t share our money with him, he will cut our hair, tear our clothes and blacken our faces. He will even kick us out. Do you think he cares if we use condoms?\u0026rdquo; (23-year-old KSW)\u003c/p\u003e \u003cp\u003eSome respondents also highlighted the prevalence of discrimination between chelas by gurus as a common challenge for consistent condom use. For instance, some respondents said that gurus often imposed financial penalties on their chelas as a result of some violation:\u003c/p\u003e \u003cp\u003e\u0026ldquo;My previous guru was very strict. If I ever disagreed with him he would confiscate all my belongings. Once, I said that at least give me my condoms before I leave for work. But you could never change his mind.\u0026rdquo; (35-year-old KSW)\u003c/p\u003e \u003cp\u003eOnly chelas of gurus are allowed to engage in traditional khwaja sira sources of income within their designated areas. The majority of KSWs spoke how violation of community codes of conduct could increase their risks for ICU. For instance, some KSWs mentioned that soliciting clients in the designated area of another guru often entailed episodes of violence and abuse from other KSWs:\u003c/p\u003e \u003cp\u003e\u0026ldquo;If I go to another guru\u0026rsquo;s area and if other KSWs catch us, they beat us up, cut our hair, take our belongings and throwaway our condoms. Whatever they want, they do.\u0026rdquo; (25-year-old KSW)\u003c/p\u003e \u003cp\u003eIn addition, gurus act as protectors of their chelas and are responsible for their conduct within the community and the city at large. Most khwaja sira communities manage societal stigma and avoid police harassment by maintaining an image of piety, retaining ambiguity about their corporeality, hiding their sexualized lifestyles, and publicly engaging in begging only. A threat to this public image is seen as a threat to the survival of the community. In this situation, KSWs reported that condoms utilization is an important threat to this collective image and makes it difficult for them to buy condoms from shops in their neighborhoods. Purchasing of condoms is discouraged by the gurus who also become a barrier to accessing condoms provided by NGOs:\u003c/p\u003e \u003cp\u003e\u0026ldquo;My guru is a kind soul and doesn\u0026rsquo;t believe in sin [implying sex]. The social workers come to our houses with condoms and our guru throws them away so the police will not bother us, or those kinds of men would not find their way to our \u003cem\u003edera\u003c/em\u003e.\u0026rdquo; (35-year-old KSW)\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eKhwaja sira respondents in Lahore displayed knowledge of HIV prevention methods, especially the use of condoms. The study participants described street-based sex work as a dangerous and uncertain occupation, because multiple risks associated with places of sexual exchange and clients could not be ascertained beforehand. This uncertainty was seen as an outcome of their occupational mobility, which took them away from the familiar context of the brothel/community-based sex work. Similar findings have been reported by a study conducted among female sex workers in India which has found an association between high HIV risk and small-scale mobility of sex workers [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Furthermore, safety concerns within short-lived places of sexual exchange with gay men have been observed in the United State of America [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. More research is needed in the context of street-based sex work in Pakistan to ascertain the changing dynamics of HIV risk for KSWs as a result of their occupational mobility.\u003c/p\u003e \u003cp\u003eResearch on sexual and cultural practices of Khawaja sira community is just beginning to emerge in Pakistan. Our findings depart from some important findings on khwaja sira sexual practices related to safe sex. For instance, studies in Pakistan have found that gurus acting as network operators have a protective effect on KSWs sexual practices including consistent use of condoms. High rates of consistent condom use among KSWs were found in cities including Karachi and Lahore when gurus were acting as network operators for their chelas [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This has been followed by government initiatives that now provide options of granting citizenship status to khwaja siras in name of their gurus instead of their biological fathers. Such initiatives offer the potential to consolidate the authority of gurus over their chelas. Contrary to these findings, our study suggests that gurus play an important role in exposing KSWs to conditions of unsafe sex, violence and promoting ICU during commercial sexual interactions.\u003c/p\u003e \u003cp\u003eIn addition, predictors of HIV risk behaviors among KSWs have included alcohol and substance use prior to or during sexual interaction, the absence of support within social networks, and identity-related marginalization and internalized transphobia [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The narratives of KSWs included these factors as reasons for ICU during sexual interactions. According to a study on the clients of KSWs in Karachi, drug and alcohol use were not predictive of condom use in sexual interactions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, in our respondents\u0026rsquo; narratives, alcohol and drug use by clients was frequently linked with ICU in the context of street-based sex work. Therefore, more nuanced research is required to substantiate the links between substance and alcohol use, and the role of gurus as network operators with ICU in sex-worker networks across Pakistan.\u003c/p\u003e \u003cp\u003eWe derive several important considerations from the narratives of study participants. Firstly, the results suggest a mutual and multidirectional interaction between risk factors for ICU situated at multiple levels within the individual context of street-based sex workers in Lahore. These risks factors result in systematic harm to KSWs\u0026rsquo; safety via the normalization of unprotected transactional sex and sexual abuse throughout the sex-worker community, as suggested in the literature on HIV risk behaviors [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Moreover, our study also reflects the usefulness of utilizing a socio-ecological framework for describing ICU for key populations.\u003c/p\u003e \u003cp\u003eSecondly, it is evident that condom utilization varies based not only on city-specific characteristics but also through more nuanced distinctions based on the occupational and neighborhood contexts of sex workers. The findings of this study suggest that risk factors producing risk environments for ICU and/or presenting social barriers to protected sexual contact may vary considerably, not only from one city to another but also among neighborhoods and occupational contexts within the same city, such as in Lahore. In this regard, caution is suggested when generalizing these findings across urban localities, with increasing attention required to contextualized analyses of the lives of KSWs and key populations in Pakistan.\u003c/p\u003e \u003cp\u003eFinally, despite our study\u0026rsquo;s focus on the barriers of condom use and the structural deficiencies within street-based commercial sex work, resilience-focused community interventions may profit from the findings. For example, the absence of family or social support in addition to a lack of positive role models was identified as a key factor in the HIV-risk-exposing mobility of young khwaja siras. HIV interventions in Pakistan should, therefore, focus on the identification of possible avenues of support, including but not limited to the traditional support networks of family or \u003cem\u003ederas\u003c/em\u003e. The development of social support within commercial sex networks may have the potential to positively impact upon a range of interlinked risk factors, including substance use and ICU.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe present study has a number of limitations. Firstly, the findings are derived from self-reported data through in-depth interviews with street-based KSWs. Our estimates of high-risk and protective behaviors are prone to social-response-related reporting bias and, therefore, may be underestimates or overestimates, respectively. Secondly, data collection with our respondents was made possible through the provision of incentives. Although this was not communicated beforehand, it may have led to bias and collusion. However, in this sociocultural setting, there were ethical considerations involved since a high monetary cost as well as a social and health cost is attached to the utilization of sex workers\u0026rsquo; time during working hours. Lastly, the data was collected before COVID-19 and as a result does not include information about how ICU is impacted by the pandemic and subsequent nationwide lockdowns.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this paper, we have adopted a socio-ecological framework to investigate ICU within the risk contexts for HIV transmission among transgender street-based sex worker in Lahore, Pakistan. The results of this study are exploratory in nature but offer nuanced and first-hand evidence for condom utilization patterns of at-risk, street-based KSWs in Lahore. In doing so, our findings support the central role that HIV risk contexts play in exposing KSWs to the risk of contracting HIV by creating barriers to the access and utilization of condoms during commercial and non-commercial sexual interactions.\u003c/p\u003e \u003cp\u003eUntil now, HIV prevention efforts in Pakistan have primarily focused on HIV risk factors at the level of individual behaviors within specific networks of target populations. However, our study points towards both the effectiveness and the urgency of interventions that address macro-level risk factors specific to key populations in Pakistan, in addition to behavioral interventions. The socio-ecological approach taken in this paper helps us to situate KSWs\u0026rsquo; HIV risk behaviors within the wider social and physical environment, broadening the focus to include the social conditions and processes affecting sex workers\u0026rsquo; life choices, experiences and health behaviors.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eAIDS: \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eAcquired immunodeficiency syndrome\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCBO:\u003c/strong\u003e \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Community-based organizations\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHIV:\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eHuman immunodeficiency virus\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICU: \u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003eInconsistent utilization of condoms\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKSW:\u003c/strong\u003e \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Khwaja sira sex workers\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMSEM:\u003c/strong\u003e \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Modified Social Ecological Model\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNGO:\u003c/strong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Non-governmental organization\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. All KSWs included in the study provided informed written consent before the start of the interview. Illiterate persons were informed in detail verbally before the study started and provided their sign afterwards.\u0026nbsp;This procedure was reviewed and approved by the Departmental Ethical Review Committee, University of the Punjab (201/DERC/ISCS/PU, September 18, 2017).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative datasets generated and/or analysed during the current study are not publicly available due to the data containing information that could compromise research participant privacy/consent but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests. FF serves as Academic Editor for BMC Public Health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSB and RR conceptualized the study. SB was responsible for data collection and data analysis, RR supervised this process. SB drafted the first version of the manuscript, RR and FF revised it critically for important intellectual content. All authors read and approved the final version of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all Khwaja sira sex workers that participated in the study, who generously took the time to share with us their opinions, thoughts and insights.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe acknowledge financial support from the Open Access Publication Fund of Charit\u0026eacute; \u0026ndash; Universit\u0026auml;tsmedizin Berlin and the German Research Foundation (DFG).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eWHO. Global HIV \u0026amp; AIDS statistics \u0026ndash; Fact sheet 2021. World Health Organization. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/hiv-aids\u003c/span\u003e\u003c/span\u003e. Accessed 18 April 2022.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e\u003cstrong\u003eUNAIDS\u003c/strong\u003e. Global \u003cstrong\u003eHIV\u003c/strong\u003e \u0026amp; \u003cstrong\u003eAIDS statistics\u003c/strong\u003e \u0026ndash; \u003cstrong\u003eFact sheet\u003c/strong\u003e. \u003cstrong\u003eThe Joint United Nations Programme on HIV\u003c/strong\u003e/\u003cstrong\u003eAIDS\u003c/strong\u003e. 2020. \u0026lt;background-color:#FF3300;bu\u0026gt;https://www.unaids.org/en/resources/fact-sheet\u0026lt;/background-color:#FF3300;bu\u0026gt;. \u003cstrong\u003eAccessed 18 April 2022\u003c/strong\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDeuba K, Kohlbrenner V, Koirala S. \u003cstrong\u003eCondom use behaviour among people living with HIV: a seven-country community-based participatory research in the Asia-Pacific region\u003c/strong\u003e. Sexually Transmitted Infections. 2017;\u003cstrong\u003e94\u003c/strong\u003e(\u003cstrong\u003e3\u003c/strong\u003e):2005.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e\u003cstrong\u003eUNAIDS\u003c/strong\u003e. \u003cstrong\u003eHuman Right Fact Sheet Series\u003c/strong\u003e; \u003cstrong\u003eHIV and sex work\u003c/strong\u003e. \u003cstrong\u003eThe Joint United Nations Programme on HIV\u003c/strong\u003e/\u003cstrong\u003eAIDS\u003c/strong\u003e. 2021. \u0026lt;background-color:#FF3300;bu\u0026gt;https://www.unaids.org/en/resources/documents/2021/05-hiv-human-rights-factsheet-sex-work\u0026lt;/background-color:#FF3300;bu\u0026gt;. \u003cstrong\u003eAccessed 18 April 2022\u003c/strong\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAhmed A, Hashmi FK, Khan GM. \u003cstrong\u003eHIV outbreaks in Pakistan\u003c/strong\u003e. Lancet HIV. 2019;\u003cstrong\u003e6\u003c/strong\u003e(\u003cstrong\u003e7\u003c/strong\u003e):e418.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003e\u003cstrong\u003eHIV and AIDS Data Hub for Asia Pacific\u003c/strong\u003e. \u003cstrong\u003ePakistan country data 2020\u003c/strong\u003e. \u003cstrong\u003eHIV and AIDS Data Hub for Asia Pacific\u003c/strong\u003e. 2020. \u0026lt;background-color:#FF3300;bu\u0026gt;https://www.aidsdatahub.org/resource/pakistan-country-data-2020\u0026lt;/background-color:#FF3300;bu\u0026gt;. \u003cstrong\u003eAccessed 18 April 2022\u003c/strong\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBokhari A, Nizamani NM, Jackson DJ, Rehan NE, Rahman M, Muzaffar R, Mansoor S, Raza H, Qayum K, Girault P, Pisani E, Thaver I. HIV risk in Karachi and Lahore, Pakistan: An Emerging Epidemic in Injecting and Commercial Sex Networks. International Journal of STD and AIDS. 2007;18(7):486\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eThompson LH, Salim M, Baloch CR, Musa N, Reza T, Dar N, Arian S, Blanchard JF, Emmanuel F. Heterogeneity of characteristics, structure, and dynamics of male and hijra sex workers in selected cities of Pakistan. Sexually Transmitted Infections. 2013;89(Suppl. 2):43\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMelesse DY, Shafer LA, Emmanuel F, Reza T, Achakzai BK, Furqan S, Blanchard JF. Heterogeneity in geographical trends of HIV epidemics among key populations in Pakistan: a mathematical modeling study of survey data. Journal of Global Health. 2018;8(1):010412.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNational AIDS Control Program. Integrated biological and behavioral surveillance in Pakistan 2016\u0026ndash;17, Round 5 Report. National AIDS Control Program; 2017.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKhan AA, Khan A. \u003cstrong\u003eThe HIV epidemic in Pakistan\u003c/strong\u003e. Journal of Pakistan Medical Association. 2010;\u003cstrong\u003e60\u003c/strong\u003e(\u003cstrong\u003e4\u003c/strong\u003e):300\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT, McFall A, Fonner VA, Butler J. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up. Lancet. 2015;385(9963):172\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKhan FA. \u003cstrong\u003eKhwaja sira activism and the politics of gender ambiguity in Pakistan\u003c/strong\u003e. \u003cstrong\u003eTransgender Studies Quarterly\u003c/strong\u003e. 2016;\u003cstrong\u003e3\u003c/strong\u003e(\u003cstrong\u003e1\u003c/strong\u003e\u0026ndash;\u003cstrong\u003e2\u003c/strong\u003e):\u003cstrong\u003e158\u003c/strong\u003e \u0026ndash; \u003cstrong\u003e64\u003c/strong\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKhan S. \u003cstrong\u003eWhat is in a name? Khwaja sara\u003c/strong\u003e, \u003cstrong\u003ehijra and eunuchs in Pakistan\u003c/strong\u003e. \u003cstrong\u003eIndian Journal of Gender Studies\u003c/strong\u003e. 2016;\u003cstrong\u003e23\u003c/strong\u003e(\u003cstrong\u003e2\u003c/strong\u003e):\u003cstrong\u003e218\u003c/strong\u003e \u0026ndash; \u003cstrong\u003e42\u003c/strong\u003e.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSiddiqui AUR, Qian HZ, Altaf A, Cassell H, Shah SA, Vermund SH. Condom use during commercial sex among clients of hijra sex workers in Karachi, Pakistan (cross-sectional study). BMJ Open. 2011;1(2):e000154.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCollumbien M, Qureshi AA, Mayhew SH, Rizvi N, Rabbani A, Rolfe B, Verma RK, Rehman H, Naveed-i-Rahat. Understanding the context of male and transgender sex work using peer ethnography. Sexually Transmitted Infections. 2009;85(Suppl. 2):3\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKhalid H, Martin EG. Relationship between network operators and risky sex behaviors among female versus transgender commercial sex workers in Pakistan. AIDS Care: Psychological and Socio-Medical Aspects of AIDS/HIV. 2019;31(6):767\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eParker R, Barbosa RM, Aggleton P. \u003cstrong\u003eFraming the sexual subject\u003c/strong\u003e. \u003cstrong\u003eIn\u003c/strong\u003e:Parker R, Barbosa RM, Aggleton P, \u003cstrong\u003eeditors\u003c/strong\u003e. \u003cstrong\u003eThe politics of gender, sexuality, and power\u003c/strong\u003e. University of California Press; 2000. \u003cstrong\u003ep\u003c/strong\u003e. 1\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBaral S, Logie CH, Grosso A, Wirtz AL, Beyrer C. Modified social ecological model: a tool to guide the assessment of the risks and risk contexts of HIV epidemics. BMC Public Health. 2013;13:482.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLounsbury DW, Mitchell SG. \u003cstrong\u003eIntroduction to special issue on social ecological approaches to community health research and action\u003c/strong\u003e. American Journal of Community Psychology. 2009;\u003cstrong\u003e44\u003c/strong\u003e(\u003cstrong\u003e3\u0026ndash;4\u003c/strong\u003e):213\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRyan GW, Bernard HR. Techniques to identify themes. Field Methods. 2003;15(1):85\u0026ndash;109.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSaldana J. The coding manual for qualitative researchers. SAGE Publications Ltd.; 2013.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAttride-Stirling J. Thematic networks: an analytic tool for qualitative research. Qualitative Research. 2001;1(3):385\u0026ndash;405.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMiles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook. SAGE Publications Ltd.; 1994.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSaggurti N, Jain AK, Sebastian MP, Singh R, Modugu HR, Halli SS, Verma RK. Indicators of mobility, socio-economic vulnerabilities and HIV risk behaviours among mobile female sex workers in India. AIDS and Behavior. 2012;16(4):952\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStillwagon R, Ghaziani A. Queer pop-ups: a cultural innovation in urban life. City Community. 2019;18(3):874\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAshraf R, Khan N. Internalized transphobia, copying strategies and common mental disorders in transgender. European Journal of Research in Social Sciences. 2019;7(1):13\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eParsons JT, Antebi-Gruszka N, Millar BM, Cain D, Gurung S. Syndemic conditions, HIV transmission risk behavior, and transactional sex among transgender women. AIDS and Behavior. 2018;22(7):2056\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChakrapani V, Newman PA, Shunmugam M, Logie CH, Samuel M. Syndemics of depression, alcohol use, and victimisation, and their association with HIV-related sexual risk among men who have sex with men and transgender women in India. Global Public Health. 2015;12(2):250\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HIV, sex work, inconsistent condom use, HIV risks, barriers","lastPublishedDoi":"10.21203/rs.3.rs-1568313/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1568313/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eBackground:\u003c/em\u003e\u003c/strong\u003e A large amount of new HIV infections worldwide is observed amongst key populations which include e.g. commercial sex workers or transgender people and their respective sexual partners. Therefore, this study examined the multi-level context of inconsistent condom use (ICU) in sexual interactions of transgender street-based workers (KSWs) with commercial and non-commercial sexual partners in Lahore. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eMethods:\u003c/em\u003e\u003c/strong\u003e We conducted 20 in-depth interviews with street-based KSWs to investigate challenges to consistent condom utilization with sexual partners. The qualitative data was analyzed using thematic analysis to produce an initial set of codes during the first-level round. An essence-capturing strategy was utilized to identify broader themes through a heuristic exploration of the text. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eResults:\u003c/em\u003e\u003c/strong\u003e Within a socio-ecological analysis we identified factors influencing ICU among KSWs at three levels. At the individual level, we identified knowledge and awareness, perceived characteristics of sexual partners, age and physical attributes, pleasure and pain, and mental health issues impacting on ICU. Gentrification of historical red-light district, discrimination, harassment and regular evictions, dynamics of cruising spots and places of sexual interactions, competition in sex trade, violence and lack of safety nets in street-based sex work, condom use with lovers, networks with non-governmental organizations were factors associated with ICU. Risk factors at community level were poverty, the influence of gurus, and Dera culture.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConclusions:\u003c/em\u003e\u003c/strong\u003e Until now, HIV prevention efforts in Pakistan have primarily focused on HIV risk factors at the level of individual behaviors within specific networks of target populations. However, our study points towards both the effectiveness and the urgency of interventions that address macro-level risk factors specific to key populations in Pakistan, in addition to behavioral interventions.\u003c/p\u003e","manuscriptTitle":"Inconsistent Condom Use among Street-Based Transgender Sex Workers in Lahore, Pakistan: Socio-Ecological Analysis based on a Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-05-27 16:58:39","doi":"10.21203/rs.3.rs-1568313/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2022-07-13T07:36:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-06-08T17:42:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"8d50e2ae-8566-483a-b0a3-4015ac9dd541","date":"2022-05-29T02:06:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-05-26T23:39:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-05-26T23:25:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-05-26T11:46:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-05-26T11:41:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2022-04-18T08:30:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6a2f8b23-0c75-4990-acfe-f12742a2bb3d","owner":[],"postedDate":"May 27th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:28:05+00:00","versionOfRecord":{"articleIdentity":"rs-1568313","link":"https://doi.org/10.1186/s12889-023-15550-w","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2023-04-03 20:23:37","publishedOnDateReadable":"April 3rd, 2023"},"versionCreatedAt":"2022-05-27 16:58:39","video":"","vorDoi":"10.1186/s12889-023-15550-w","vorDoiUrl":"https://doi.org/10.1186/s12889-023-15550-w","workflowStages":[]},"version":"v1","identity":"rs-1568313","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1568313","identity":"rs-1568313","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}