Structural Barriers to Primary Care Among Sex Workers: Findings from a Community- Based Cohort in Vancouver, Canada (2014–2021)

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Given limited evidence on sex workers’ broader primary healthcare access, we aimed to examine structural factors associated with primary care access among sex workers over a 7-year period. Methods Data were derived from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women (cis and trans) sex workers in Metro Vancouver, from 2014 to 2021. Descriptive statistics were used to summarize the proportion of primary care use in the past six months and to assess primary care trends over time from 2014-2021. We used multivariate logistic regression with generalized estimating equations (GEE) to identify structural factors associated with primary care access (seeing a family doctor in the last six months), after adjusting for confounders. Results : Amongst 646 participants, most (87.4%) accessed primary care at some point during the study period, and primary care use in the in the last 6 months was relatively stable (ranging from 60-78%) across each follow-up period. At first available observation, participants faced a high burden of sexually transmitted and blood-borne infections (STBBIs) (48.0%, 11.5%, and 10.4% were HCV, HIV, or STI seropositive, respectively), 56.8% were diagnosed with a mental health disorder, 8.1% had recently overdosed, and 14.7% were recently hospitalized. In multivariable GEE analysis, exposure to intimate partner violence was associated with reduced access to primary care (Adjusted odds ratios (AOR) 0.63, 95% Confidence interval (CI): 0.49 - 0.82), and limited English fluency was marginally associated (AOR 0.76 CI: 0.51 - 1.14). Conclusions : This study characterized primary care access and its structural determinants among sex workers over 7-years. Participants faced a high burden of STBBIs and other health disparities, and a proportion faced gaps in primary care access. Scale-up of trauma-informed, culturally and linguistically tailored, sex worker-friendly primary care models are needed, alongside structural interventions to decriminalize and destigmatize sex work and substance use. women sex work primary care violence im/migration barriers facilitators Figures Figure 1 Introduction Due to structural marginalization and criminalization,x sex workers experience severe health inequities, including a high prevalence of sexually transmitted and blood-borne infections (STBBI), mental health disorders, trauma, and substance use ( 1 , 2 , 2 – 4 ). High-quality primary care that is accessible, timely, patient-focused, and comprehensive, is well positioned to address the unmet health care needs of sex workers ( 5 , 6 ). Primary care providers are ideally positioned to deliver wrap-around health services to patients with multiple and often complex and competing health and social priorities ( 7 , 8 ). Despite the promise of primary care for addressing sex workers’ unmet health needs, there is a paucity of studies assessing primary care engagement in this population, with most existing research focusing HIV, STIs, and substance use related services. Primary care plays a particularly critical role in settings like Canada, where the majority of Canadians report seeing their family doctor almost exclusively for their medical care ( 9 , 10 ). Primary care models that are community based, whose staff reflect the population they aim to serve (e.g., lived experiences, shared language), and are low barrier facilitate uptake among marginalized populations ( 11 – 14 ). Studies show that other marginalized populations, for example people living with HIV, are more likely to receive preventative health screening and have fewer hospitalizations when their medical care was predominately delivered by a family physician, compared to that of an HIV specialist ( 7 ). However, research on barriers and facilitators to health services among sex workers has largely focused on access to HIV and substances use services ( 3 , 15 , 16 ). Existing evidence suggests that structural factors such as criminalization, policing, violence, im/migration, stigma, housing instability are associated with barriers to HIV and substance use service prevention, treatment, and access to care ( 16 – 22 ), especially among sex workers who use criminalized substances or who have a mental health diagnosis ( 23 , 24 ). Given the high prevalence unmet health needs among sex workers and the potential for primary care to address these, it is important to examine determinants of primary care engagement among this population. Previous studies assessing HIV and substance use service use among sex workers demonstrate the significance of structural factors in heath service utilization however there is limited data on primary engagement. Therefore, this study aims to address this gap by assessing determents of primary care use amongst sex workers. Methods Aim We aimed to examine the association between structural factors with primary care use amongst a community-based cohort of sex workers from Vancouver, Canada over 7-years. Study design Data were derived from an open community-based cohort of women sex workers, An Evaluation of Sex Workers Health Access (AESHA), which initiated recruitment in 2010. As previously described (25), cis and trans women 1 who engaged in sex work (exchanging sex for money) in the past 30 days, aged 14 and older, who were able to provide informed consent were eligible to participate. AESHA activities were established in collaboration with community-based sex work agencies and continues to work with a Community Advisory Board, with representatives from more than 15 community agencies (26). Mapping of outdoor/public sex work locations and indoor sex work venues was used to facilitate time-location sampling to recruit participants through outreach across Metro Vancouver area, complemented by online outreach to sex workers working in online solicitation spaces. The recruitment rate was ~85% (primary reason for nonparticipation was a lack of active sex work engagement). All participants provided written informed consent prior to study enrollment. At enrolment and semi-annually, participants completed interviewer-administered questionnaires, conducted by a trained interviewer with extensive community and/or lived experience. After appropriate pretest counseling, Biolytical INSTI (Biolytical Laboratories Inc, Richmond, BC) rapid tests were offered for HIV screening. Reactive tests were confirmed by blood draw and Western blot testing at the British Columbia Centre for Disease Control. Urine samples were collected for gonorrhea and chlamydia, and blood samples for syphilis, hepatitis C virus (HCV) antibody, and HCV viremia testing. All participants received posttest counseling and those diagnosed with sexually transmitted infections (STIs) were provided treatment by an onsite study nurse and appropriate referrals were provided for new HIV and HCV diagnoses. The questionnaire captured demographic data, substance use patterns, social and interpersonal factors (e.g., condom use and negotiation, social cohesion), structural factors (e.g., experiences of violence, sex work environment, experiences of criminalization), and service utilization experiences (e.g., substance use, sexual health, and primary care). Participants received an honorarium of $65 CAD at each visit. The study holds ethical approvals from the Providence Health Care/University of British Columbia Research Ethics Board. The present analysis includes all AESHA participants who completed a baseline and at least one follow-up interview between 2014–2021 and who provided a valid response to the primary outcome variable (primary care use, last 6 months). The study was restricted to 2014 onwards as this is when the primary care and some structural factor questions were added to the AESHA questionnaire. Outcome variable The primary outcome variable of primary care use was defined as responding “yes” to the question “have you ever seen a family doctor in the last six months”. Primary care use was a time-updated variable with occurrences within the past six months measured at enrolment and each semi-annual study visit. In Canada, primary care is delivered almost exclusively by family medicine doctors and less commonly family medicine nurse practitioners (27). “Family doctor” is the terminology used by most Canadians in lay discussions and research in reference to primary care in the Canadian setting (28). Structural explanatory variables Several structural factors were selected as possible explanatory variables in our analyses. Structural variable selection was informed by existing literature on health service utilization among sex workers and other marginalized populations. Most structural variables were time-updated, measured semi-annually, save English fluency and immigration status which were time-fixed from baseline. To assess gender-based and workplace violence, we included exposure to intimate partner violence (measured as moderate to severe physical or sexual intimate partner violence using the World Health Organization standardized intimate partner violence scale (29), yes vs no/or no intimate partner), and violence when doing sex work (defined as being abducted/kidnapped, sexually assaulted or attempted sexual assault, raped, strangled, physically assaulted/beaten, locked/trapped in a car, thrown out of moving car, assaulted with weapon, drugged, or trapped in room/ hotel/ housing etc, yes vs no/or not doing sex work). To capture im/migration experiences we explored several variables including having limited English fluency (defined as being not very comfortable, uncomfortable, or very uncomfortable with speaking English), having precarious immigration status (defined as reporting being a temporary resident, a permanent resident, having no documents, expired documents, or other, yes vs no), and lacking health care coverage (yes vs no). To capture the impact of stigma we included health care stigma experiences, defined as reporting being denied health services or, maltreatment in health settings, or overhearing derogatory gossip about sex work in health settings (yes vs no). To capture housing, we included being unstably housed (defined as living in an single room occupancy hotel, staying with parents/family/relatives, supportive housing, or other, yes vs no). To capture factors related substance use and sex work criminalization we included incarceration (yes vs no), and experiencing policing harassment when doing sex work (defined as being told by police to move, stopped, searched, followed, being moved elsewhere to work, verbally harassed, repeatedly monitored, detained, physically assaulted, drug equipment taken, condoms taken, searched for condoms, other property taken, propositioned to exchange sex, or coerced into providing sexual favors by the police, yes vs no). Confounder variables Based on existing literature, potential confounders were selected that we hypothesized were related to primary care use and the above structural factors. These included time-fixed demographic variables of minority sexual orientation (defined as identifying as gay, lesbian, bisexual, asexual, queer, Indigenous two-spirit, and/or other non-heterosexual identities, yes vs no), gender minority (cis vs trans women, including transgender women, transexual women and other transfeminine identities) and racialization, defined as White, Indigenous (inclusive of First Nations, Inuit, Metis, or Inuit peoples), and Women of Colour (Asian, Black, Latinx) (30,31). Given the low proportion of participants who identified as Black in our sample (consistent with the Black population of British Columbia (<2%), we jointly examined Black and Women of Color to examine effects of racism among racialized women. Age, as continuous variable, was also included. HCV, HIV, STI serostatus were assessed based on lab test results. Other potential confounders included mental health diagnosis (time-varying, yes vs no), as well as time-varying measures of alcohol use (none vs less than daily vs daily), injection drug use (yes vs no), nonfatal overdose (yes vs no), and hospitalization (yes vs no) in the prior 6 months. Statistical analyses First, we stratified participant characteristics by primary care use in the last six months at their first available observation and reported these as counts and percentages for binary variables and medians and interquartile range for continuous variables. We used descriptive statistics to summarize the proportion of bi-annual interview visits where participates reported primary care use in the past six months during the study period. We assessed primary care use trends over time by calculating the proportion of the bi-annual interview visits involving primary care use during each calendar year from 2014 to 2021. To assess if there were any changes in primary care use over time we conducted a time-trend analysis. We used the Durbin-Watson test for autocorrelation to assess for any linear dependence between adjacent observations in our time series data. Existing literature was used to guide initial selection of structural exposure variables. Structural variables that had a high degree of collinearity were excluded. Logistic regression was used to examine the association between structural variables and confounders with primary care use over the study period. Generalized estimating equations (GEE) with a logit-link function and exchangeable correlation matrix were used to account for repeated measurements amongst participants over time (32,33). Missing and intermittent data were handled using a complete case approach. Hypothesized confounders identified a priori based on their known association with healthcare access in the literature were considered in multivariable analysis. All statistical analyses were performed in SAS version 9.4 (SAS, Cary, NC). We reported two-sided p-values and 95% confidence intervals. Results In total, 646 participants were included, who contributed 3881 observations over the seven-year period. The mean follow-up time was 6-study visits. Among the 646 included, there was missing primary care use data from three individuals. At first available observation of the 643 persons who reported primary care use, 562 (87.4%) reported using primary care at some point during the study. At participants’ first available observation, 387 (59.9%) used primary care at least once in the past six months. The median age was 39 years (IQR: 31.0-46.0), 31.9% identified as White, 43.0% as Indigenous, and 25.1% as Women of Colour (Table 1). Just under half (44.4%) reported a minority sexual orientation and 11.2% identified as a gender minority. Participants faced high prevalence of unmet healthcare needs: 48.0% were HCV seropositive, 11.5% were HIV seropositive, and 10.4% were STI positive based on lab data from the last 6 months. Mental health and substance use issues were also common. Over half (56.8%) of participants reported being diagnosed with a mental health disorder, and in the last six months 39.5% used alcohol, 41.5% reported injection drug use, 8.1% experienced a nonfatal overdose, and 14.7% had been hospitalized. Participants faced a high degree of structural marginalization (Table 1). Data from first available observation showed violence was common where in the last six-months 12.7% reported exposure to intimate partner violence and 7.6% reported some form of violence or harassment while working. Related to im/migration experiences, 10.2% reported limited English Fluency, 24.6% were im/migrants to Canada, and 24.6% lacked health insurance. Over two-thirds were unstably housed. Experiences related to stigma and criminalization were also common, with 8.8% reporting healthcare stigma, 5.1% had been incarcerated, and 7.1% reported exposure to police harassment while doing sex work all within the last six-months. [Insert Table 1] Figure 1 summarizes primary care use over time. Between 2014 to 2021 primary care use was documented to range from 60-79% at each follow-up period. Utilization was lowest (60.5%) in late 2014 and highest (78.6%) in the later part of 2016, though the time-trend analysis found no significant change in use over time. In total, 562/643 participants used primary care at some point during the study period. [Insert Figure 1] In unadjusted analyses (Table 2), structural factors associated with reduced odds of structural factors associated with reduced odds of primary care use included exposure to intimate partner violence and limited English fluency. Other covariates that were associated with increased odds of primary care use included increasing age, minority sexual orientation, identifying as a gender minority, having a mental health disorder, and being hospitalized in the last six months. In the adjusted multivariable GEE analysis, exposure to intimate partner violence was independently associated with a reduced odds of primary care use (AOR: 0.63, 95% CI: 0.49 - 0.82, p=0.002) after adjustment for key confounders (age, minority sexual orientation, gender identity, racialization, mental health diagnosis, hospitalization, and overdose). Additionally, having limited English fluency was marginally associated with a reduced odds (AOR: 0.76 CI: 0.51 - 1.14, p=0.182) of primary care use. [Insert Table 2] Discussion This study provides some of the first epidemiologic data characterizing primary care use among women sex workers globally. In this 7-year prospective cohort study, sex workers faced high prevalence of health inequities related to STBBIs, mental health and nonfatal overdose, accompanied by a lack of ever using primary care among a proportion (~ 12.6%) of participants. After adjusting for confounders, women experiencing recent intimate partner violence faced 37% reduced odds of recent primary care use, and im/migrant women facing language barriers faced a 24% reduced odds of primary use, though this was only marginally significant (p = 0.182). We found that most participants (87.4%) used primary care at least once throughout the study period. The study was conducted in a setting where provincially funded healthcare is provided to all residents without cost. However, health coverage is not extended to those with precarious im/migrants status and is thus not actually universal ( 34 , 35 ). To mitigate barriers to primary care experienced by marginalized communities, Vancouver has invested in low-barrier primary care services, such as drop-in clinics, mobile outreach, and care embedded within shelter and housing programs. This may have facilitated access for participants in the Metro Vancouver area ( 36 – 38 ). However, participants in our study still had a high burden of unmet health care needs including a high prevalence of STBBIs, and a high rate of hospitalization, an important indicator of unmet primary healthcare needs and serious illness ( 39 , 40 ). Findings from other studies suggest that such unmet health care needs may be related to barriers accessing needed health services within primary care due to service limitations, stigma, and language barriers ( 19 , 35 , 41 – 43 ). For example, women in our study had high rates of mental health diagnoses and substance use, but behavioral health and substance use services remain poorly integrated in primary care delivery ( 44 – 47 ). Criminalization of sex work and aspects of substance use, as well as internalized and institutional stigma, may also dimmish opportunities to address substance use and STBBIs within the context of primary care visits ( 19 , 48 – 50 ). Given the limitations of healthcare delivery for addressing broader structural drivers of the health inequities experienced by sex workers ( 16 , 21 , 51 ), structural interventions are crucially needed. Consistent with the literature, participants in our study experienced a high degree of structural marginalization, including intimate partner violence, housing instability, and criminalization. Violence against sex workers has been shown to be pervasive and rooted in both gender inequity and the criminalization of sex work and substance use ( 52 – 55 ). Importantly, we found that intimate-partner violence was associated with a reduced odds (AOR: 0.63, 95% CI: 0.49–0.82) of primary care use. This is consistent with research showing intimate-partner violence as a barrier to HIV and substance use services among sex workers and other structurally marginalized populations such as women who use substances ( 56 – 58 ). Unfortunately, primary care is also often insufficiently equipped to identify and address gender-based violence which may exacerbate barriers. A 2022 qualitative meta-synthesis showed that primary care providers lacked knowledge, time, and resources to address violence ( 59 ). Violence services remain siloed from other health services and often structurally discriminate against sex workers ( 60 ). Thus, systemic structural changes and changes in primary care delivery are needed to reduce barriers, integrate violence services within primary care, and overcome gaps created by silos. For example, decriminalizing sex work would enhance environmental safety and promote access to health services by reducing the normalization and justification of violence against sex workers which criminalization promotes ( 21 , 22 , 61 – 63 ). Violence services must dismantle policies that discriminate against sex workers, such as refusing to accept women who use drugs or women who view sex work as a legitimate way of financially supporting themselves and their families ( 60 ). Additionally, investment in training and supports that facilitate sex worker-friendly trauma-informed approaches inclusive of addressing violence within primary care settings could further reduce barriers. Multi-component violence reduction interventions used in some HIV prevention and treatment services for sex workers offer models to integrating violence services within primary care ( 64 – 66 ). Consistent with other studies, we found that limited English fluency was also associated with a reduced odds of primary care use. Though we found only marginal significance for this association these findings are of important public health significance. Prior literature identified English language fluency as a barrier to health services, particularly among im/migrants ( 41 , 67 ). Language discordance between im/migrants and healthcare providers is identified as both a barrier to primary care access and diminished quality of care delivery, for example receiving lower rates of appropriate preventative health care services ( 5 , 67 ). In addition to language barriers, im/migrants are also more likely to lack health insurance, access to culturally-responsive services, and experience disrespectful treatment by providers ( 34 , 68 ). Such barriers and reduced health service quality can be exacerbated among sex workers due to the highly stigmatized and criminalized nature of sex work in Canada ( 69 , 70 ). In addition to integrating culturally responsive translation services, which have been shown to diminish language barriers, on-going investments in low-barrier, sex-worker lead services are needed to address the complex intersecting factors of limited-English fluency, im/migration, and stigma mitigating health service engagement among sex workers ( 36 , 71 , 72 ). Our findings must be interpreted within the study limitations. This study is based on observational data, and further research is needed to assess the pathways through which intimate partner violence and other structural factors influence primary care engagement for sex workers. There was missing longitudinal HIV, STI and HCV seropositivity data associated with interruptions in STBBI testing during COVID-19 research site closures. Further analyses examining intersectional impacts of marginalization related to gender minority status, sexual orientation, racialization, and im/migration status are also recommended. Our study relies on self-report data thus maybe subject to social desirability bias and underreporting of stigmatized issues and overreporting of positive health behaviors, such as our primary outcome of primary care use. However, the latter would attenuate our effect size towards the null. Additionally, our study looked at use alone, and did not explore quality of primary care experiences. Lastly, our study was focused on the experiences of sex workers who identified as women at baseline (cis or trans) in Vancouver, Canada, and thus did not sample for non-binary or male sex workers or those in other jurisdictions, limiting generalizability. While primary care is well positioned to address women sex workers unmet healthcare needs our study highlights persistent structural barriers mitigating primary care engagement, thereby suggesting the critical importance of multi-level interventions targeting both policy and health service delivery environments. Our findings underscore the need for ongoing scale-up of trauma-informed, culturally, and linguistically tailored low-barrier primary care models. Community-based, sex-worker led services that include comprehensive sexual reproductive health care, substance use treatment, trauma and mental health care, and violence services are approaches that could enhance primary care use among sex workers. Scale-up of such sex-worker responsive services requires investment in alternate-care models alongside broader structural interventions to decriminalize and destigmatize sex work and substance use. Abbreviations AESHA: An Evaluation of Sex Workers Health Access GEE: generalized estimating equations STBBI: sexually transmitted and blood-borne infection AOR: adjusted odds ratio CI: Confidence interval HCV: hepatitis C virus STI: sexually transmitted infection Declarations Ethics approval and consent to participate : The study holds ethical approvals from the Providence Health Care/University of British Columbia Research Ethics Board. All participants provided written informed consent prior to study enrollment. Consent for publication : Not applicable Availability of data and materials : The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests : The authors declare that they have no competing interests. Funding : This research is supported by the US National Institutes of Health, USA (NIDA R01DA028648) and the Canadian Institutes of Health Research, Canada (165855). Miriam Harris was supported by the International Collaborative Addiction Medicine Research Fellowship (NIDA R25-DA037756). Dr. Goldenberg was partially supported by NIH (R01DA028648) and a CIHR New Investigator Award. Drs. Shannon and Krusi were partially supported by NIH (R01DA028648). Authors' contributions: All authors have materially participated in the research and/or article preparation. Miriam T.H. Harris designed the research question, led the analysis design, and manuscript preparation. Haoxuan Zhou, MSc led data management, extraction, cleaning, and analyses and assisted with manuscript editing and review. Kate Shannon co-led the study, including funding, administration, and oversight of data collection, and assisted with manuscript editing and review. Andrea Krüsi co-led the study, including administration and oversight of data collection, and assisted with manuscript editing and review. Shira Goldenberg led the study, analysis design, data analysis development, and assisted with manuscript structure development, editing, and review. Acknowledgements We thank all those who contributed their time and expertise to this project, including participants, AESHA community advisory board members and partners, and the AESHA team including Emily Luba, Coco Merrison, Melody Wise, Natasha Feuchuk, Emma Chambers, Saetia James, Alex Martin, Alaina Ge, Grace Chong, Sophy Leung, Jennie Pearson, and Ran Hu. We also thank Melissa Braschel, Yuping Zhan, Portia Kuivi, and Peter Vann for statistical and administrative assistance. References Argento E, Goldenberg S, Shannon K. Preventing sexually transmitted and blood borne infections (STBBIs) among sex workers: a critical review of the evidence on determinants and interventions in high-income countries. BMC Infect Dis [Internet]. 2019 Mar 5 [cited 2020 Jul 28];19. 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A peer-led mobile outreach program and increased utilization of detoxification and residential drug treatment among female sex workers who use drugs in a Canadian setting. Drug Alcohol Depend. 2011 Jan 1;113(1):46–54. Kim SR, Goldenberg SM, Duff P, Nguyen P, Gibson K, Shannon K. Uptake of a women-only, sex-work-specific drop-in center and links with sexual and reproductive health care for sex workers. Int J Gynaecol Obstet. 2015 Mar;128(3):201–5. Machat S, Anonymous x 3, Noir C, João E, K8kyt, Tess, et al. By Us, For Us: A needs and risks assessment of sex workers in the Lower Mainland and Southern Vancouver Island. In Vancouver, BC; 2023. Available from: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://wish-vancouver.net/content/wp-content/uploads/2023/04/by_us_for_us_-_a_needs_and_risks_assessment_of_sex_workers_in_the_lower_mainland_and_southern_vancouver_island_-_web.pdf Anderson KE, Alexander GC, Niles L, Scholle SH, Saloner B, Dy SM. 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Health Disparities, Substance-Use Disorders, and Primary-Care. Prim Care. 2023 Mar;50(1):57–69. Goldenberg SM, Krüsi A, Zhang E, Chettiar J, Shannon K. Structural Determinants of Health among Im/Migrants in the Indoor Sex Industry: Experiences of Workers and Managers/Owners in Metropolitan Vancouver. PLOS ONE. 2017 Jan 31;12(1):e0170642. King EJ, Maman S, Bowling JM, Moracco KE, Dudina V. The Influence of Stigma and Discrimination on Female Sex Workers’ Access to HIV Services in St. Petersburg, Russia. AIDS Behav [Internet]. 2013 Oct [cited 2021 Mar 23];17(8). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3868674/ Goldenberg SM. Addressing Violence and Overdose Among Women Who Use Drugs-Need for Structural Interventions. JAMA Netw Open. 2020 Oct 1;3(10):e2021066. Bungay V, Johnson JL, Varcoe C, Boyd S. Women’s health and use of crack cocaine in context: Structural and ‘everyday’violence. International Journal of Drug Policy. 2010;21(4):321–9. 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Intimate partner violence, associations with perceived need for help and health care utilization: a population-based sample of women in Sweden. Scand J Public Health. 2021 May;49(3):268–76. Stone R, Rothman EF. Opioid Use and Intimate Partner Violence: a Systematic Review. Curr Epidemiol Rep. 2019 Jun 1;6(2):215–30. Hudspeth N, Cameron J, Baloch S, Tarzia L, Hegarty K. Health practitioners’ perceptions of structural barriers to the identification of intimate partner abuse: a qualitative meta-synthesis. BMC Health Serv Res. 2022 Jan 22;22(1):96. Schumacher JA, Holt DJ. Domestic violence shelter residents’ substance abuse treatment needs and options. Aggression and Violent Behavior. 2012 May 1;17(3):188–97. NSWP. NSWP Global Sex Worker Consultaion. In: Prevention and Treatment of HIV and Other Sexually Transmitted Infections for Sex Workers in Low- and Middle-Income Countries: Recommendations for a Public Health Approach [Internet]. World Health Organization; 2012 [cited 2024 May 1]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK304106/ UNAIDS. Save lives: decriminalize [Internet]. 2024 [cited 2024 May 1]. Available from: https://www.unaids.org/en/topic/decriminalization WHO. Sex workers [Internet]. 2024 [cited 2024 May 1]. Available from: https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/populations/sex-workers Beattie TS, Bhattacharjee P, Isac S, Mohan HL, Simic-Lawson M, Ramesh BM, et al. Declines in violence and police arrest among female sex workers in Karnataka state, south India, following a comprehensive HIV prevention programme. J Int AIDS Soc. 2015;18:20079. Reza-Paul S, Lorway R, O’Brien N, Lazarus L, Jain J, Bhagya M, et al. Sex worker-led structural interventions in India: a case study on addressing violence in HIV prevention through the Ashodaya Samithi collective in Mysore. Indian J Med Res. 2012;135:98–106. Ulibarri MD, Salazar M, Syvertsen JL, Bazzi AR, Rangel MG, Orozco HS, et al. Intimate Partner Violence Among Female Sex Workers and Their Noncommercial Male Partners in Mexico: A Mixed-Methods Study. Violence Against Women. 2019 Apr;25(5):549–71. DuBard CA, Gizlice Z. Language Spoken and Differences in Health Status, Access to Care, and Receipt of Preventive Services Among US Hispanics. Am J Public Health. 2008 Nov;98(11):2021–8. Caulford P, D’Andrade J. Health care for Canada’s medically uninsured immigrants and refugees: whose problem is it? Can Fam Physician. 2012 Jul;58(7):725–7, e362-364. Goldenberg SM, Chettiar J, Nguyen P, Dobrer S, Montaner J, Shannon K. Complexities of short-term mobility for sex work and migration among sex workers: violence and sexual risks, barriers to care, and enhanced social and economic opportunities. J Urban Health. 2014 Aug;91(4):736–51. Sou J, Goldenberg SM, Duff P, Nguyen P, Shoveller J, Shannon K. Recent im/migration to Canada linked to unmet health needs among sex workers in Vancouver, Canada: Findings of a longitudinal study. Health Care Women Int. 2017 May;38(5):492–506. Gagne CA, Finch WL, Myrick KJ, Davis LM. Peer Workers in the Behavioral and Integrated Health Workforce: Opportunities and Future Directions. American Journal of Preventive Medicine. 2018 Jun 1;54(6):S258–66. Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007 Apr;42(2):727–54. Footnotes Eligibility was inclusive of cis women and other self-reported transfeminine identities at enrolment. As gender identity is fluid, some participants’ gender presentation differed throughout various times and aspects of their lives. For example, a participant may present as a woman/femme while interacting with sex work clients but identify as non-binary outside of work environments. Tables Table 1. Baseline sample characteristics of sex workers in Metro Vancouver, Canada, stratified by primary care use, 2014–2021 (N = 646) Characteristic Total N (%) Primary care use a N (%) 646 Yes 387 (59.9%) No 249 (38.5%) Demographic Age (med, interquartile range) a 39 (31.0-46.0) 40 (32.0-46.0) 38 (30.0-46.0) Minority sexual orientation b 287(44.4%) 176 (45.5%) 107 (43.0%) Gender minority b 72 (11.1%) 47 (12.1%) 23 (9.2%) Racialization b White Indigenous Black/Women of Color 206 (31.9%) 278 (43.0%) 162 (25.1%) 120 (31.0%) 177 (45.7%) 90 (23.3%) 86 (34.5%) 94 (37.8%) 69 (27.7%) Health HCV seropositivity c 310 (48.0%) 210 (54.3%) 96 (38.6%) HIV seropositivity c 74 (11.5%) 67 (17.3%) 7 (2.8%) STI positivity c 67 (10.4%) 39 (10.8%) 26 (10.4%) Mental health diagnosis b 367 (56.8%) 231 (59.7%) 131 (52.6%) Alcohol use a None Less than daily Daily 384 (59.4%) 219 (33.9%) 36 (5.6%) 243 (62.8%) 126 (32.6%) 13 (3.4%) 133 (53.4%) 91 (36.6%) 23 (9.24%) Injection drug use a 268 (41.5%) 160 (41.3%) 106 (42.6%) Overdose a 52 (8.1%) 24 (6.2%) 26 (10.4%) Hospitalized a 95 (14.7%) 63 (16.3%) 29 (11.7%) Structural Intimate partner violence a 54 (8.4%) 24 (6.2%) 29 (11.7%) Violence while working a 49 (7.6%) 24 (6.2%) 24 (9.6%) Limited English Fluency a 66 (10.2%) 33 (8.5%) 32 (12.9%) Im/migrant to Canada a 159 (24.6%) 85 (22.0%) 71 (28.5%) No health insurance a 159 (24.6%) 90 (23.3%) 65 (26.1%) Health care stigma a 57 (8.8%) 35 (9.0%) 21 (8.4%) Unstably housed a 515 (79.7%) 312 (80.6) 197 (79.1) Incarcerated a 33 (5.1%) 19 (4.9%) 13 (5.2%) Police harassment while working a 46 (7.1%) 25 (6.4%) 20 (8.0%) HCV; hepatitis C virus, HIV; human immunodeficiency virus, STI; sexually transmitted infection Minority sexual orientation includes those who identified as lesbian, gay, bisexual, queer, and/or asexual Gender minority included transgender women, transexual women and other transfeminine identities Indigenous racial identities included First Nations, Inuit, & Metis. Women of Color included Black, Chinese/Taiwanese, Vietnamese, Korean, Japanese, Thai, Filipina, Indian, Pakistani, Bangladeshi, Sri Lankan, Latin American, Middle Eastern, or African a In the last 6 months. b In lifetime. c Based on first available observation, there was 11% missing data for HCV serostatus, 20% for STI serostatus, and 9% for HIV serostatus There was less than 5% missing data for all other characteristics. Table 2. Unadjusted and adjusted generalized estimating equation (GEE) models of structural factors associated with primary care use in a cohort of women sex workers in Metro Vancouver, Canada, 2010–2021 (N = 646) Unadjusted odds ratio (95% CI) Adjusted odds ratio (95% CI) Structural variables Intimate partner violence a 0.78 (0.65 - 0.95) 0.64 (0.49 - 0.82) Violence while working a 0.94 (0.70 - 1.25) Experienced health care stigma a 1.04 (0.81 - 1.35) Limited English fluency a 0.59 (0.42 - 0.83) 0.76 (0.51 - 1.14) Unstably housed a 1.10 (0.90 - 1.33) Incarcerated a 1.09 (0.75 - 1.57) Police harassment while working a 0.85 (0.61 - 1.18) Confounder variables Demographic Age a 1.03 (1.02 – 1.04) 1.03 (1.02 - 1.04) Minority sexual orientation b 1.26 (1.00 - 1.59) 1.11 (0.87 - 1.42) Gender minority b 1.60 (1.12 - 2.30) 1.45 (0.98 - 2.15) Racalization b White Indigenous Women of Color -ref- 1.04 (0.80 - 1.35) 0.70 (0.51 - 0.95) -ref- 1.12 (0.87 - 1.46) 0.83 (0.57 - 1.22) Health Mental health disorder b 1.33 (1.04 - 1.70) 1.22 (0.93 - 1.60) Hospitalized a 1.34 (1.13 - 1.59) 1.26 (1.04 - 1.54) Alcohol use a None Less than daily Daily -ref- 1.06 (0.90 - 1.24) 1.09 (0.83 - 1.42) Injection drug use a 0.90 (0.75 - 1.08) Overdose a 0.84 (0.68 – 1.05) 0.79 (0.62 - 1.01) CI, confidence interval Minority sexual orientation includes those who identified as lesbian, gay, bisexual, queer, and/or asexual Indigenous racial identities included First Nations, Inuit, & Metis. Women of Color included Black, Chinese/Taiwanese, Vietnamese, Korean, Japanese, Thai, Filipina, Indian, Pakistani, Bangladeshi, Sri Lankan, Latin American, Middle Eastern, or African a Time updated measure in the last six months. b Time updated lifetime measure. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Jan, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 31 Jul, 2024 Editor assigned by journal 26 Jul, 2024 Submission checks completed at journal 26 Jul, 2024 First submitted to journal 25 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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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-4802645","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":334204952,"identity":"7e36fcc5-ebc3-4d69-92c1-d54c22f7e96e","order_by":0,"name":"Miriam TH Harris","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYBACg8MMDAeAdAKIc4Ch4gBhLZaoWs4QocUeqgashYGxjQgtZsd5Hx74mcOQxz/77MODP+fdieZvYD728Qs+LYfZDQ72bmMoljiXbnCYd9uz3BkH2JJny+DVwsZwgHcbQ2LDGTaGw4zbDuduYOAxZpbAo8UAqOXgX6CW+UAtB3/OIVLLYZAtG86ArGuAaGH8QEiL7DaJxI0gh/EcA/rlMFsyMx4dDAbnjzF/fLvNJnHeGTbmjz9q7uT2tzcfZvyBTw8EILsdaAUzD2EtaIAYW0bBKBgFo2DkAAAg0FV0L8HrVQAAAABJRU5ErkJggg==","orcid":"","institution":"Boston Medical Center, One Boston Medical Center Place","correspondingAuthor":true,"prefix":"","firstName":"Miriam","middleName":"TH","lastName":"Harris","suffix":""},{"id":334204953,"identity":"e19f7c3b-ff81-473a-ab4e-14149b066733","order_by":1,"name":"Kate Shannon","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Kate","middleName":"","lastName":"Shannon","suffix":""},{"id":334204954,"identity":"3b256c13-1d5f-4533-9eb9-696fd17945c3","order_by":2,"name":"Andrea Krüsi","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Krüsi","suffix":""},{"id":334204955,"identity":"24d6dbd6-2105-42d6-9ad8-81ad2cb2adf1","order_by":3,"name":"Haoxuan Zhou","email":"","orcid":"","institution":"University of British Columbia","correspondingAuthor":false,"prefix":"","firstName":"Haoxuan","middleName":"","lastName":"Zhou","suffix":""},{"id":334204956,"identity":"8ac02a35-01f0-4a1f-858b-22d25a80299e","order_by":4,"name":"Shira M Goldenberg","email":"","orcid":"","institution":"San Diego State University","correspondingAuthor":false,"prefix":"","firstName":"Shira","middleName":"M","lastName":"Goldenberg","suffix":""}],"badges":[],"createdAt":"2024-07-25 14:46:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4802645/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4802645/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-12275-x","type":"published","date":"2025-01-24T15:57:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63421069,"identity":"d08433d6-3f45-4625-97a5-3c1c8d23a04a","added_by":"auto","created_at":"2024-08-28 02:43:49","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":206419,"visible":true,"origin":"","legend":"\u003cp\u003ePeriod prevalence of primary care use at each six-month study period amongst a community-based cohort of women sex workers in Metro Vancouver, Canada, 2014–2021 (N = 646)\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4802645/v1/07620fcedfd9a7b9ca497f99.jpeg"},{"id":74858307,"identity":"bfbfc4c2-fdaa-4b7d-805e-b114f99ad9e8","added_by":"auto","created_at":"2025-01-27 16:07:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":930992,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4802645/v1/dce8a8f5-3158-4d28-8b26-6d3658b96181.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Structural Barriers to Primary Care Among Sex Workers: Findings from a Community- Based Cohort in Vancouver, Canada (2014–2021)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDue to structural marginalization and criminalization,x sex workers experience severe health inequities, including a high prevalence of sexually transmitted and blood-borne infections (STBBI), mental health disorders, trauma, and substance use (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). High-quality primary care that is accessible, timely, patient-focused, and comprehensive, is well positioned to address the unmet health care needs of sex workers (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Primary care providers are ideally positioned to deliver wrap-around health services to patients with multiple and often complex and competing health and social priorities (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Despite the promise of primary care for addressing sex workers\u0026rsquo; unmet health needs, there is a paucity of studies assessing primary care engagement in this population, with most existing research focusing HIV, STIs, and substance use related services.\u003c/p\u003e \u003cp\u003ePrimary care plays a particularly critical role in settings like Canada, where the majority of Canadians report seeing their family doctor almost exclusively for their medical care (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Primary care models that are community based, whose staff reflect the population they aim to serve (e.g., lived experiences, shared language), and are low barrier facilitate uptake among marginalized populations (\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Studies show that other marginalized populations, for example people living with HIV, are more likely to receive preventative health screening and have fewer hospitalizations when their medical care was predominately delivered by a family physician, compared to that of an HIV specialist (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). However, research on barriers and facilitators to health services among sex workers has largely focused on access to HIV and substances use services (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Existing evidence suggests that structural factors such as criminalization, policing, violence, im/migration, stigma, housing instability are associated with barriers to HIV and substance use service prevention, treatment, and access to care (\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20 CR21\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), especially among sex workers who use criminalized substances or who have a mental health diagnosis (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the high prevalence unmet health needs among sex workers and the potential for primary care to address these, it is important to examine determinants of primary care engagement among this population. Previous studies assessing HIV and substance use service use among sex workers demonstrate the significance of structural factors in heath service utilization however there is limited data on primary engagement. Therefore, this study aims to address this gap by assessing determents of primary care use amongst sex workers.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAim\u003c/p\u003e\n\u003cp\u003eWe aimed to examine the association between structural factors with primary care use amongst a community-based cohort of sex workers from Vancouver, Canada over 7-years.\u003c/p\u003e\n\u003cp\u003eStudy design\u003c/p\u003e\n\u003cp\u003eData were derived from an open community-based cohort of women sex workers, An Evaluation of Sex Workers Health Access (AESHA), which initiated recruitment in 2010. As previously described (25), cis and trans women\u003csup\u003e1\u003c/sup\u003e who engaged in sex work (exchanging sex for money) in the past 30 days, aged 14 and older, who were able to provide informed consent were eligible to participate. AESHA activities were established in collaboration with community-based sex work agencies and continues to work with a Community Advisory Board, with representatives from more than 15 community agencies (26). Mapping of outdoor/public sex work locations and indoor sex work venues was used to facilitate time-location sampling to recruit participants through outreach across Metro Vancouver area, complemented by online outreach to sex workers working in online solicitation spaces. The recruitment rate was ~85% (primary reason for nonparticipation was a lack of active sex work engagement). All participants provided written informed consent prior to study enrollment.\u003c/p\u003e\n\u003cp\u003eAt enrolment and semi-annually, participants completed interviewer-administered questionnaires, conducted by a trained interviewer with extensive community and/or lived experience. After appropriate pretest counseling, Biolytical INSTI (Biolytical Laboratories Inc, Richmond, BC) rapid tests were offered for HIV screening. Reactive tests were confirmed by blood draw and Western blot testing at the British Columbia Centre for Disease Control. Urine samples were collected for gonorrhea and chlamydia, and blood samples for syphilis, hepatitis C virus (HCV) antibody, and HCV viremia testing. All participants received posttest counseling and those diagnosed with sexually transmitted infections (STIs) were provided treatment by an onsite study nurse and appropriate referrals were provided for new HIV and HCV diagnoses. The questionnaire captured demographic data, substance use patterns, social and interpersonal factors (e.g., condom use and negotiation, social cohesion), structural factors (e.g., experiences of violence, sex work environment, experiences of criminalization), and service utilization experiences (e.g., substance use, sexual health, and primary care). Participants received an honorarium of $65 CAD at each visit. The study holds ethical approvals from the Providence Health Care/University of British Columbia Research Ethics Board. The present analysis includes all AESHA participants who completed a baseline and at least one follow-up interview between 2014\u0026ndash;2021 and who provided a valid response to the primary outcome variable (primary care use, last 6 months). The study was restricted to 2014 onwards as this is when the primary care and some structural factor questions were added to the AESHA questionnaire.\u003c/p\u003e\n\u003cp\u003eOutcome variable\u003c/p\u003e\n\u003cp\u003eThe primary outcome variable of primary care use was defined as responding \u0026ldquo;yes\u0026rdquo; to the question \u0026ldquo;have you ever seen a family doctor in the last six months\u0026rdquo;. Primary care use was a time-updated variable with occurrences within the past six months measured at enrolment and each semi-annual study visit. In Canada, primary care is delivered almost exclusively by family medicine doctors and less commonly family medicine nurse practitioners (27). \u0026ldquo;Family doctor\u0026rdquo; is the terminology used by most Canadians in lay discussions and research in reference to primary care in the Canadian setting (28).\u003c/p\u003e\n\u003cp\u003eStructural explanatory variables\u003c/p\u003e\n\u003cp\u003eSeveral structural factors were selected as possible explanatory variables in our analyses. Structural variable selection was informed by existing literature on health service utilization among sex workers and other marginalized populations. Most structural variables were time-updated, measured semi-annually, save English fluency and immigration status which were time-fixed from baseline.\u003c/p\u003e\n\u003cp\u003eTo assess gender-based and workplace violence, we included exposure to intimate partner violence (measured as moderate to severe physical or sexual intimate partner violence using the World Health Organization standardized intimate partner violence scale (29), yes vs no/or no intimate partner), and violence when doing sex work (defined as being abducted/kidnapped, sexually assaulted or attempted sexual assault, raped, strangled, physically assaulted/beaten, locked/trapped in a car, thrown out of moving car, assaulted with weapon, drugged, or trapped in room/ hotel/ housing etc, yes vs no/or not doing sex work). To capture im/migration experiences we explored several variables including having limited English fluency (defined as being not very comfortable, uncomfortable, or very uncomfortable with speaking English), having precarious immigration status (defined as reporting being a temporary resident, a permanent resident, having no documents, expired documents, or other, yes vs no), and lacking health care coverage (yes vs no). To capture the impact of stigma we included health care stigma experiences, defined as reporting being denied health services or, maltreatment in health settings, or overhearing derogatory gossip about sex work in health settings (yes vs no). To capture housing, we included being unstably housed (defined as living in an single room occupancy hotel, staying with parents/family/relatives, supportive housing, or other, yes vs no). To capture factors related substance use and sex work criminalization we included incarceration (yes vs no), and experiencing policing harassment when doing sex work (defined as being told by police to move, stopped, searched, followed, being moved elsewhere to work, verbally harassed, repeatedly monitored, detained, physically assaulted, drug equipment taken, condoms taken, searched for condoms, other property taken, propositioned to exchange sex, or coerced into providing sexual favors by the police, yes vs no).\u003c/p\u003e\n\u003cp\u003eConfounder variables\u003c/p\u003e\n\u003cp\u003eBased on existing literature, potential confounders were selected that we hypothesized were related to primary care use and the above structural factors. These included time-fixed demographic variables of minority sexual orientation (defined as identifying as gay, lesbian, bisexual, asexual, queer, Indigenous two-spirit, and/or other non-heterosexual identities, yes vs no), gender minority (cis vs trans women, including transgender women, transexual women and other transfeminine identities) and racialization, defined as White, Indigenous (inclusive of First Nations, Inuit, Metis, or Inuit peoples), and Women of Colour (Asian, Black, Latinx) (30,31). Given the low proportion of participants who identified as Black in our sample (consistent with the Black population of British Columbia (\u0026lt;2%), we jointly examined Black and Women of Color to examine effects of racism among racialized women. Age, as continuous variable, was also included. HCV, HIV, STI serostatus were assessed based on lab test results. Other potential confounders included mental health diagnosis (time-varying, yes vs no), as well as time-varying measures of alcohol use (none vs less than daily vs daily), injection drug use (yes vs no), nonfatal overdose (yes vs no), and hospitalization (yes vs no) in the prior 6 months.\u003c/p\u003e\n\u003cp\u003eStatistical analyses\u003c/p\u003e\n\u003cp\u003eFirst, we stratified participant characteristics by primary care use in the last six months at their first available observation and reported these as counts and percentages for binary variables and medians and interquartile range for continuous variables.\u003c/p\u003e\n\u003cp\u003eWe used descriptive statistics to summarize the proportion of bi-annual interview visits where participates reported primary care use in the past six months during the study period. We assessed primary care use trends over time by calculating the proportion of the bi-annual interview visits involving primary care use during each calendar year from 2014 to 2021. To assess if there were any changes in primary care use over time we conducted a time-trend analysis. We used the Durbin-Watson test for autocorrelation to assess for any linear dependence between adjacent observations in our time series data.\u003c/p\u003e\n\u003cp\u003eExisting literature was used to guide initial selection of structural exposure variables. Structural variables that had a high degree of collinearity were excluded. Logistic regression was used to examine the association between structural variables and confounders with primary care use over the study period. Generalized estimating equations (GEE) with a logit-link function and exchangeable correlation matrix were used to account for repeated measurements amongst participants over time (32,33). Missing and intermittent data were handled using a complete case approach. Hypothesized confounders identified a priori based on their known association with healthcare access in the literature were considered in multivariable analysis. All statistical analyses were performed in SAS version 9.4 (SAS, Cary, NC). We reported two-sided p-values and 95% confidence intervals.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 646 participants were included, who contributed 3881 observations over the seven-year period. The mean follow-up time was 6-study visits. Among the 646 included, there was missing primary care use data from three individuals. At first available observation of the 643 persons who reported primary care use, 562 (87.4%) reported using primary care at some point during the study. At participants\u0026rsquo; first available observation, 387 (59.9%) used primary care at least once in the past six months. The median age was 39 years (IQR: 31.0-46.0), 31.9% identified as White, 43.0% as Indigenous, and 25.1% as Women of Colour (Table 1). Just under half (44.4%) reported a minority sexual orientation and 11.2% identified as a gender minority. Participants faced high prevalence of unmet healthcare needs: 48.0% were HCV seropositive, 11.5% were HIV seropositive, and 10.4% were STI positive based on lab data from the last 6 months. Mental health and substance use issues were also common. Over half (56.8%) of participants reported being diagnosed with a mental health disorder, and in the last six months 39.5% used alcohol, 41.5% reported injection drug use, 8.1% experienced a nonfatal overdose, and 14.7% had been hospitalized.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants faced a high degree of structural marginalization (Table 1). Data from first available observation showed violence was common where in the last six-months 12.7% reported exposure to intimate partner violence and 7.6% reported some form of violence or harassment while working. Related to im/migration experiences, 10.2% reported limited English Fluency, 24.6% were im/migrants to Canada, and 24.6% lacked health insurance. Over two-thirds were unstably housed. Experiences related to stigma and criminalization were also common, with 8.8% reporting healthcare stigma, 5.1% had been incarcerated, and 7.1% reported exposure to police harassment while doing sex work all within the last six-months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Insert Table 1]\u003c/p\u003e\n\u003cp\u003eFigure 1 summarizes primary care use over time. Between 2014 to 2021 primary care use was documented to range from 60-79% at each follow-up period. Utilization was lowest (60.5%) in late 2014 and highest (78.6%) in the later part of 2016, though the time-trend analysis found no significant change in use over time. In total, 562/643 participants used primary care at some point during the study period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Insert Figure 1]\u003c/p\u003e\n\u003cp\u003eIn unadjusted analyses (Table 2), structural factors associated with reduced odds of structural factors associated with reduced odds of primary care use included exposure to intimate partner violence and limited English fluency. Other covariates that were associated with increased odds of primary care use included increasing age, minority sexual orientation, identifying as a gender minority, having a mental health disorder, and being hospitalized in the last six months. In the adjusted multivariable GEE analysis, exposure to intimate partner violence was independently associated with a reduced odds of primary care use (AOR: 0.63, 95% CI: 0.49 - 0.82, p=0.002) after adjustment for key confounders (age, minority sexual orientation,\u003csup\u003e\u0026nbsp;\u003c/sup\u003egender identity, racialization, mental health diagnosis, hospitalization, and overdose). Additionally, having limited English fluency was marginally associated with a reduced odds (AOR: 0.76 CI: 0.51 - 1.14, p=0.182) of primary care use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[Insert Table 2]\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides some of the first epidemiologic data characterizing primary care use among women sex workers globally. In this 7-year prospective cohort study, sex workers faced high prevalence of health inequities related to STBBIs, mental health and nonfatal overdose, accompanied by a lack of ever using primary care among a proportion (~\u0026thinsp;12.6%) of participants. After adjusting for confounders, women experiencing recent intimate partner violence faced 37% reduced odds of recent primary care use, and im/migrant women facing language barriers faced a 24% reduced odds of primary use, though this was only marginally significant (p\u0026thinsp;=\u0026thinsp;0.182).\u003c/p\u003e \u003cp\u003eWe found that most participants (87.4%) used primary care at least once throughout the study period. The study was conducted in a setting where provincially funded healthcare is provided to all residents without cost. However, health coverage is not extended to those with precarious im/migrants status and is thus not actually universal (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). To mitigate barriers to primary care experienced by marginalized communities, Vancouver has invested in low-barrier primary care services, such as drop-in clinics, mobile outreach, and care embedded within shelter and housing programs. This may have facilitated access for participants in the Metro Vancouver area (\u003cspan additionalcitationids=\"CR37\" citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). However, participants in our study still had a high burden of unmet health care needs including a high prevalence of STBBIs, and a high rate of hospitalization, an important indicator of unmet primary healthcare needs and serious illness (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Findings from other studies suggest that such unmet health care needs may be related to barriers accessing needed health services within primary care due to service limitations, stigma, and language barriers (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). For example, women in our study had high rates of mental health diagnoses and substance use, but behavioral health and substance use services remain poorly integrated in primary care delivery (\u003cspan additionalcitationids=\"CR45 CR46\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Criminalization of sex work and aspects of substance use, as well as internalized and institutional stigma, may also dimmish opportunities to address substance use and STBBIs within the context of primary care visits (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the limitations of healthcare delivery for addressing broader structural drivers of the health inequities experienced by sex workers (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e), structural interventions are crucially needed. Consistent with the literature, participants in our study experienced a high degree of structural marginalization, including intimate partner violence, housing instability, and criminalization. Violence against sex workers has been shown to be pervasive and rooted in both gender inequity and the criminalization of sex work and substance use (\u003cspan additionalcitationids=\"CR53 CR54\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Importantly, we found that intimate-partner violence was associated with a reduced odds (AOR: 0.63, 95% CI: 0.49\u0026ndash;0.82) of primary care use. This is consistent with research showing intimate-partner violence as a barrier to HIV and substance use services among sex workers and other structurally marginalized populations such as women who use substances (\u003cspan additionalcitationids=\"CR57\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnfortunately, primary care is also often insufficiently equipped to identify and address gender-based violence which may exacerbate barriers. A 2022 qualitative meta-synthesis showed that primary care providers lacked knowledge, time, and resources to address violence (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Violence services remain siloed from other health services and often structurally discriminate against sex workers (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Thus, systemic structural changes and changes in primary care delivery are needed to reduce barriers, integrate violence services within primary care, and overcome gaps created by silos. For example, decriminalizing sex work would enhance environmental safety and promote access to health services by reducing the normalization and justification of violence against sex workers which criminalization promotes (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan additionalcitationids=\"CR62\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). Violence services must dismantle policies that discriminate against sex workers, such as refusing to accept women who use drugs or women who view sex work as a legitimate way of financially supporting themselves and their families (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Additionally, investment in training and supports that facilitate sex worker-friendly trauma-informed approaches inclusive of addressing violence within primary care settings could further reduce barriers. Multi-component violence reduction interventions used in some HIV prevention and treatment services for sex workers offer models to integrating violence services within primary care (\u003cspan additionalcitationids=\"CR65\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsistent with other studies, we found that limited English fluency was also associated with a reduced odds of primary care use. Though we found only marginal significance for this association these findings are of important public health significance. Prior literature identified English language fluency as a barrier to health services, particularly among im/migrants (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e). Language discordance between im/migrants and healthcare providers is identified as both a barrier to primary care access and diminished quality of care delivery, for example receiving lower rates of appropriate preventative health care services (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e). In addition to language barriers, im/migrants are also more likely to lack health insurance, access to culturally-responsive services, and experience disrespectful treatment by providers (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). Such barriers and reduced health service quality can be exacerbated among sex workers due to the highly stigmatized and criminalized nature of sex work in Canada (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e, \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). In addition to integrating culturally responsive translation services, which have been shown to diminish language barriers, on-going investments in low-barrier, sex-worker lead services are needed to address the complex intersecting factors of limited-English fluency, im/migration, and stigma mitigating health service engagement among sex workers (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur findings must be interpreted within the study limitations. This study is based on observational data, and further research is needed to assess the pathways through which intimate partner violence and other structural factors influence primary care engagement for sex workers. There was missing longitudinal HIV, STI and HCV seropositivity data associated with interruptions in STBBI testing during COVID-19 research site closures. Further analyses examining intersectional impacts of marginalization related to gender minority status, sexual orientation, racialization, and im/migration status are also recommended. Our study relies on self-report data thus maybe subject to social desirability bias and underreporting of stigmatized issues and overreporting of positive health behaviors, such as our primary outcome of primary care use. However, the latter would attenuate our effect size towards the null. Additionally, our study looked at use alone, and did not explore quality of primary care experiences. Lastly, our study was focused on the experiences of sex workers who identified as women at baseline (cis or trans) in Vancouver, Canada, and thus did not sample for non-binary or male sex workers or those in other jurisdictions, limiting generalizability.\u003c/p\u003e \u003cp\u003eWhile primary care is well positioned to address women sex workers unmet healthcare needs our study highlights persistent structural barriers mitigating primary care engagement, thereby suggesting the critical importance of multi-level interventions targeting both policy and health service delivery environments. Our findings underscore the need for ongoing scale-up of trauma-informed, culturally, and linguistically tailored low-barrier primary care models. Community-based, sex-worker led services that include comprehensive sexual reproductive health care, substance use treatment, trauma and mental health care, and violence services are approaches that could enhance primary care use among sex workers. Scale-up of such sex-worker responsive services requires investment in alternate-care models alongside broader structural interventions to decriminalize and destigmatize sex work and substance use.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAESHA: An Evaluation of Sex Workers Health Access\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGEE: generalized estimating equations\u003c/p\u003e\n\u003cp\u003eSTBBI: sexually transmitted and blood-borne infection\u003c/p\u003e\n\u003cp\u003eAOR: adjusted odds ratio\u003c/p\u003e\n\u003cp\u003eCI: Confidence interval\u003c/p\u003e\n\u003cp\u003eHCV: hepatitis C virus\u003c/p\u003e\n\u003cp\u003eSTI: sexually transmitted infection\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: The study holds ethical approvals from the Providence Health Care/University of British Columbia Research Ethics Board. All participants provided written informed consent prior to study enrollment. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This research is supported by the US National Institutes of Health, USA (NIDA R01DA028648) and the Canadian Institutes of Health Research, Canada (165855). Miriam Harris was supported by the International Collaborative Addiction Medicine Research Fellowship (NIDA R25-DA037756). Dr. Goldenberg was partially supported by NIH (R01DA028648) and a CIHR New Investigator Award. Drs. Shannon and Krusi were partially supported by NIH (R01DA028648). \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eAll authors have materially participated in the research and/or article preparation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMiriam T.H. Harris designed the research question, led the analysis design, and manuscript preparation.\u003c/p\u003e\n\u003cp\u003eHaoxuan\u0026nbsp;Zhou, MSc led data management, extraction, cleaning, and analyses and assisted with manuscript editing and review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKate Shannon co-led the study, including funding, administration, and oversight of data collection, and assisted with manuscript editing and review.\u003c/p\u003e\n\u003cp\u003eAndrea Kr\u0026uuml;si\u0026nbsp;co-led the study, including administration and oversight of data collection, and assisted with manuscript editing and review.\u003c/p\u003e\n\u003cp\u003eShira Goldenberg led the study, analysis design, data analysis development, and assisted with manuscript structure development, editing, and review.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all those who contributed their time and expertise to this project, including participants, AESHA community advisory board members and partners, and the AESHA team including Emily Luba, Coco Merrison, Melody Wise, Natasha Feuchuk, Emma Chambers, Saetia James, Alex Martin, Alaina Ge, Grace Chong, Sophy Leung, Jennie Pearson, and Ran Hu. We also thank Melissa Braschel, Yuping Zhan, Portia Kuivi, and Peter Vann for statistical and administrative assistance.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eArgento E, Goldenberg S, Shannon K. Preventing sexually transmitted and blood borne infections (STBBIs) among sex workers: a critical review of the evidence on determinants and interventions in high-income countries. BMC Infect Dis [Internet]. 2019 Mar 5 [cited 2020 Jul 28];19. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6399876/\u003c/li\u003e\n\u003cli\u003eGoldenberg SM, Pearson J, Moreheart S, Nazaroff H, Kr\u0026uuml;si A, Braschel M, et al. Prevalence and structural correlates of HIV and STI testing among a community-based cohort of women sex workers in Vancouver Canada. PLoS One. 2023 Mar 30;18(3):e0283729.\u003c/li\u003e\n\u003cli\u003eStrathdee SA, West BS, Reed E, Moazen B, Moazan B, Azim T, et al. 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Peer Workers in the Behavioral and Integrated Health Workforce: Opportunities and Future Directions. American Journal of Preventive Medicine. 2018 Jun 1;54(6):S258\u0026ndash;66.\u003c/li\u003e\n\u003cli\u003eKarliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007 Apr;42(2):727\u0026ndash;54.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Eligibility was inclusive of cis women and other self-reported transfeminine identities at enrolment. As gender identity is fluid, some participants\u0026rsquo; gender presentation differed throughout various times and aspects of their lives. For example, a participant may present as a woman/femme while interacting with sex work clients but identify as non-binary outside of work environments.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1.\u0026nbsp;Baseline sample characteristics of sex workers in Metro Vancouver, Canada, stratified by primary care use, 2014\u0026ndash;2021 (N = 646)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.38383838383838%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary care use\u003c/strong\u003e\u003csup\u003ea\u003c/sup\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e646\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e387 (59.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e249 (38.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eAge (med, interquartile range)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e39 (31.0-46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e40 (32.0-46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e38 (30.0-46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eMinority sexual orientation\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e287(44.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e176 (45.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e107 (43.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eGender minority\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e72 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e47 (12.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e23 (9.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eRacialization\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003cp\u003eIndigenous\u003c/p\u003e\n \u003cp\u003eBlack/Women of Color\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e206 (31.9%)\u003c/p\u003e\n \u003cp\u003e278 (43.0%)\u003c/p\u003e\n \u003cp\u003e162 (25.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e120 (31.0%)\u003c/p\u003e\n \u003cp\u003e177 (45.7%)\u003c/p\u003e\n \u003cp\u003e90 (23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e86 (34.5%)\u003c/p\u003e\n \u003cp\u003e94 (37.8%)\u003c/p\u003e\n \u003cp\u003e69 (27.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eHCV seropositivity\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e310 (48.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e210 (54.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e96 (38.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eHIV seropositivity\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e74 (11.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e67 (17.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e7 (2.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eSTI positivity\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e67 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e39 (10.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e26 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eMental health diagnosis\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e367 (56.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e231 (59.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e131 (52.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eAlcohol use\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eLess than daily\u003c/p\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e384 (59.4%)\u003c/p\u003e\n \u003cp\u003e219 (33.9%)\u003c/p\u003e\n \u003cp\u003e36 (5.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e243 (62.8%)\u003c/p\u003e\n \u003cp\u003e126 (32.6%)\u003c/p\u003e\n \u003cp\u003e13 (3.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e133 (53.4%)\u003c/p\u003e\n \u003cp\u003e91 (36.6%)\u003c/p\u003e\n \u003cp\u003e23 (9.24%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eInjection drug use\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e268 (41.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e160 (41.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e106 (42.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eOverdose\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e52 (8.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e24 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e26 (10.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eHospitalized\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e95 (14.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e63 (16.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e29 (11.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStructural\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eIntimate partner violence\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e54 (8.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e24 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e29 (11.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eViolence while working\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e49 (7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e24 (6.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e24 (9.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eLimited English Fluency\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e66 (10.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e33 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e32 (12.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eIm/migrant to Canada\u003csup\u003ea\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e159 (24.6%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e85 (22.0%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e71 (28.5%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eNo health insurance\u003csup\u003ea\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e159 (24.6%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e90 (23.3%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e65 (26.1%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eHealth care stigma\u003csup\u003ea\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e57 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e35 (9.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e21 (8.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eUnstably housed\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e515 (79.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e312 (80.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e197 (79.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003eIncarcerated\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e33 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e19 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e13 (5.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.42424242424242%\" valign=\"top\"\u003e\n \u003cp\u003ePolice harassment while working\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e46 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e25 (6.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.19191919191919%\" valign=\"top\"\u003e\n \u003cp\u003e20 (8.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHCV; hepatitis C virus, HIV; human immunodeficiency virus, STI; sexually transmitted infection\u003c/p\u003e\n\u003cp\u003eMinority sexual orientation includes those who identified as lesbian, gay, bisexual, queer, and/or asexual\u003c/p\u003e\n\u003cp\u003eGender minority included transgender women, transexual women and other transfeminine identities\u003c/p\u003e\n\u003cp\u003eIndigenous racial identities included First Nations, Inuit, \u0026amp; Metis. Women of Color included Black, Chinese/Taiwanese, Vietnamese, Korean, Japanese, Thai, Filipina, Indian, Pakistani, Bangladeshi, Sri Lankan, Latin American, Middle Eastern, or African\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eIn the last 6 months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003eIn lifetime.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u003c/sup\u003eBased on first available observation, there was 11% missing data for HCV serostatus, 20% for STI serostatus, and 9% for HIV serostatus\u003c/p\u003e\n\u003cp\u003eThere was less than 5% missing data for all other characteristics.\u003c/p\u003e\n\u003cp\u003eTable 2. Unadjusted and adjusted generalized estimating equation (GEE) models of structural factors associated with primary care use in a cohort of women sex workers in Metro Vancouver, Canada, 2010\u0026ndash;2021 (N = 646)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eUnadjusted odds ratio\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003eAdjusted odds ratio\u003c/p\u003e\n \u003cp\u003e(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStructural variables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eIntimate partner violence\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.78 (0.65 - 0.95)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.64\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(0.49\u0026nbsp;- 0.82)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eViolence while working\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0.94 (0.70 - 1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eExperienced health care stigma\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1.04 (0.81 - 1.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eLimited English fluency\u003csup\u003ea\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.59 (0.42 - 0.83)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.76\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(0.51 - 1.14)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eUnstably housed\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1.10 (0.90 - 1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eIncarcerated\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e1.09 (0.75 - 1.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003ePolice harassment while working\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0.85 (0.61 - 1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eConfounder variables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eAge\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.03\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(1.02 \u0026ndash; 1.04)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e1.03 (1.02 - 1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eMinority sexual orientation\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.26 (1.00 - 1.59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e1.11 (0.87 - 1.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eGender minority\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.60 (1.12 - 2.30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e1.45 (0.98 - 2.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eRacalization\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003cp\u003eIndigenous\u003c/p\u003e\n \u003cp\u003eWomen of Color\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-ref-\u003c/p\u003e\n \u003cp\u003e1.04 (0.80 - 1.35)\u003c/p\u003e\n \u003cp\u003e0.70 (0.51 - 0.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-ref-\u003c/p\u003e\n \u003cp\u003e1.12 (0.87 - 1.46)\u003c/p\u003e\n \u003cp\u003e0.83 (0.57 - 1.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHealth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eMental health disorder\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.33 (1.04 - 1.70)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e1.22 (0.93 - 1.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eHospitalized\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.34 (1.13 - 1.59)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e1.26\u0026nbsp;(1.04 - 1.54)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eAlcohol use\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003cp\u003eLess than daily\u003c/p\u003e\n \u003cp\u003eDaily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e-ref-\u003c/p\u003e\n \u003cp\u003e1.06 (0.90 - 1.24)\u003c/p\u003e\n \u003cp\u003e1.09 (0.83 - 1.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eInjection drug use\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0.90 (0.75 - 1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.86538461538461%\" valign=\"top\"\u003e\n \u003cp\u003eOverdose\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.333333333333336%\" valign=\"top\"\u003e\n \u003cp\u003e0.84 (0.68 \u0026ndash; 1.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.80128205128205%\" valign=\"top\"\u003e\n \u003cp\u003e0.79 (0.62 - 1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCI, confidence interval\u003c/p\u003e\n\u003cp\u003eMinority sexual orientation includes those who identified as lesbian, gay, bisexual, queer, and/or asexual\u003c/p\u003e\n\u003cp\u003eIndigenous racial identities included First Nations, Inuit, \u0026amp; Metis. Women of Color included Black, Chinese/Taiwanese, Vietnamese, Korean, Japanese, Thai, Filipina, Indian, Pakistani, Bangladeshi, Sri Lankan, Latin American, Middle Eastern, or African\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eTime updated measure in the last six months.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003eTime updated lifetime measure.\u0026nbsp;\u003c/p\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-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"women, sex work, primary care, violence, im/migration, barriers, facilitators ","lastPublishedDoi":"10.21203/rs.3.rs-4802645/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4802645/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Due to structural marginalization, sex workers experience health inequities including a high prevalence of sexually transmitted and blood-borne infections, mental health disorders, trauma, and substance use, alongside a multitude of barriers to HIV and substance use services. Given limited evidence on sex workers’ broader primary healthcare access, we aimed to examine structural factors associated with primary care access among sex workers over a 7-year period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e Data were derived from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women (cis and trans) sex workers in Metro Vancouver, from 2014 to 2021. Descriptive statistics were used to summarize the proportion of primary care use in the past six months and to assess primary care trends over time from 2014-2021. We used multivariate logistic regression with generalized estimating equations (GEE) to identify structural factors associated with primary care access (seeing a family doctor in the last six months), after adjusting for confounders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Amongst 646 participants, most (87.4%) accessed primary care at some point during the study period, and primary care use in the in the last 6 months was relatively stable (ranging from 60-78%) across each follow-up period. \u0026nbsp;At first available observation, participants faced a high burden of sexually transmitted and blood-borne infections (STBBIs) (48.0%, 11.5%, and 10.4% were HCV, HIV, or STI seropositive, respectively), 56.8% were diagnosed with a mental health disorder, 8.1% had recently overdosed, and 14.7% were recently hospitalized. In multivariable GEE analysis, exposure to intimate partner violence was associated with reduced access to primary care (Adjusted odds ratios (AOR) 0.63, 95% Confidence interval (CI): 0.49 - 0.82), and limited English fluency was marginally associated (AOR 0.76 CI: 0.51 - 1.14).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: \u0026nbsp;This study characterized primary care access and its structural determinants among sex workers over 7-years. Participants faced a high burden of STBBIs and other health disparities, and a proportion faced gaps in primary care access. Scale-up of trauma-informed, culturally and linguistically tailored, sex worker-friendly primary care models are needed, alongside structural interventions to decriminalize and destigmatize sex work and substance use.\u003c/p\u003e","manuscriptTitle":"Structural Barriers to Primary Care Among Sex Workers: Findings from a Community- Based Cohort in Vancouver, Canada (2014–2021)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-28 02:43:44","doi":"10.21203/rs.3.rs-4802645/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-31T11:07:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-26T12:47:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-26T12:47:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-07-25T14:45:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d07e3e0-cc10-4f68-80c8-548ac2e70d98","owner":[],"postedDate":"August 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-27T15:59:41+00:00","versionOfRecord":{"articleIdentity":"rs-4802645","link":"https://doi.org/10.1186/s12913-025-12275-x","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-01-24 15:57:05","publishedOnDateReadable":"January 24th, 2025"},"versionCreatedAt":"2024-08-28 02:43:44","video":"","vorDoi":"10.1186/s12913-025-12275-x","vorDoiUrl":"https://doi.org/10.1186/s12913-025-12275-x","workflowStages":[]},"version":"v1","identity":"rs-4802645","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4802645","identity":"rs-4802645","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}