This study is one of few that examines the prevalence and correlates of homelessness among street-based FSWs. The results demonstrate a staggering prevalence of both lifetime and recent homelessness among street-based FSWs, with a median age of first sleeping on the street during adolescence. Of particular concern, after adjusting for individual and interpersonal risks, homeless street-based FSWs were more likely to be younger, to experience sexual violence by non-commercial partners, to service a higher volume of weekly clients, to report intensive, daily crack smoking, and to exchange sex in outdoor spaces (as compared to indoor settings).
These findings collectively highlight the intersecting social and physical contexts of place in shaping health inequities among street-based FSWs. In our study, homeless street-based FSWs were 68% more likely to service a high number of clients (10+) per week compared to their housed counterparts, pointing to increased economic dependence on sex work for survival among impoverished women. This finding persisted even after adjustment for frequency and intensity of drug use, suggesting that lack of a basic necessity such as housing combined with the immediacy of sleeping on the street may confer additional need to exchange sex for basic resource needs, such as shelter or food. Our results extend earlier studies among homeless and marginally housed youth and IDU that found higher number of sexual partnerships than their more stably housed counterparts [10, 12], perhaps through commercial sex exchanges. Similarly, Surratt and Inciardi (2004) found significantly more frequent vaginal and oral sex acts among homeless FSWs compared to their housed counterparts. Sexual violence by non-commercial partners is higher among homeless street-based FSWs suggesting that lack of access to safe, affordable spaces may reduce street-based FSWs' capacity to negotiate safety and elevate their risk for exploitation and abuse by intimate partners and other sexual partners. Other studies in North America have observed heightened risk of physical and sexual violence among homeless women . Qualitative studies have highlighted that women immersed in the street economy occupy a subordinate role in the male-centred street ideology, and are often the victims of exploitation, physical and symbolic violence . Street-entrenched women often enter intimate partnerships as a strategy for protection from structural, symbolic and interpersonal violence intrinsic to life on the street, however the power imbalances arising from these partnerships sometimes trap women in abusive relationships .
Importantly, contrary to a recent study among homeless and unstably housed male and female IDUs that found increased risk of unprotected sex compared to their stably housed counterparts , there were no differences in condom use among homeless and housed street-based FSWs. Instead, in our study, homeless street-based FSWs were more likely to work in public spaces, a context previously shown to be correlated with geographic 'hotspots' for increased coercive unprotected sex by clients in this setting . These findings suggest that factors relating to unsafe sex work environments may be more important in the context of condom use negotiation and violence among street-based FSWs. However, the social and physical context of the lack of availability of safe places to sleep for street-based FSWs may play a more distal role on the causal pathway to unprotected sex by removing options to service clients indoors, within a setting where criminalization and enforcement are already displacing much of the street-based sex market to outlying areas.
Finally, unlike earlier investigations that have focused exclusively on IDUs, slightly less than half of our sample of street based FSWs were injectors while the majority smoked crack cocaine. In our study we found that being homeless was significantly associated with intensive, daily crack smoking. Our findings suggest that the pressures of living on the street may contribute to heightened levels of crack use among homeless street-based FSWs. Since many of the women in our sample live in Vancouver's downtown eastside, an area characterized by homelessness, poverty and high levels of drug use, this setting may increase street-based FSWs' exposure to high-risk environments such as crack houses, public drug markets, and shooting galleries that may elevate their crack consumption. Furthermore, living on the streets may also facilitate the creation of social ties with other drug users, encouraging and/or exacerbating intensive daily crack use among homeless street-based FSWs. Given that drug use is often an antecedent of homelessness and exchanging sex for survival , increased drug use among homeless street-based FSWs in our study was not unexpected. However, given the growing concern that crack cocaine smoking has emerged as a risk factor for HIV acquisition among IDUs in our setting , replacing cocaine injection in the earlier phases of the epidemic, our results have important public health implications. Further exploration of the contexts of homeless FSWs who smoke crack but do not inject is needed, combined with increased safer environment interventions targeting this population.
Collectively, our findings suggest that physical and social contexts of homelessness may contribute to or exacerbate violence, sexual- and drug- related risks and point towards the need for safer environment interventions that mitigate homelessness and associated risks. Safer environment interventions aimed at improving access and availability of safe, stable low-income housing for women in street-based sex work is particularly important in Vancouver, given the high costs of rental units and steady decreases in low income housing stock . At the macro-level, policies that support expanding the continuum of safe, secure housing options for women are warranted, from low-threshold transitional shelters to supportive housing models. These housing options need to be coupled with higher rental subsidies and rental assistance programs that have proven effective elsewhere . Furthermore, our results suggest that women- and sex work-only housing options need to be piloted and evaluated to reduce exposure to violence by intimate partners, strangers and mitigate sexual risks among street-based FSWs. These types of interventions should be supported by removal of criminal sanctions targeting sex work, given growing evidence of the links between enforcement of criminalized policies and displacement of street-based FSWs away from health and support services [9, 24]. At the micro-level, other safer environment interventions that have proven effective in modifying the immediate risk environment and should be scaled up include peer-led outreach strategies . Mobile health and support outreach services continue to be a critical, low-threshold model of connecting street-involved women with health and support services, and should be expanded to isolated sex work spaces.
This study has a number of limitations that should be noted. The findings from this study may not be generalizable to off-street sex workers (e.g. exotic dance, escort) or male sex workers. Given the observational nature of this research, we cannot determine causality, though some potential temporal bias may be reduced due to the use of generalized estimating equations that account for repeated responses by the same respondent. This study used self-report data, and women's responses may be subject to social desirability bias. However, a number of studies have found sex workers and drug users to provide truthful accounts of their sex and drug use activities when questioned in a non-threatening environment . Due to a low prevalence of transgender women (6.3%), we were unable to tease out differences in homelessness by sexual identity in our current analysis. Finally, due to a recall period of 6 months, our results may be susceptible to recall bias. To reduce this bias, strategies such as using an individual event six months prior were used to facilitate recall. These results contribute to the growing body of literature advocating the importance of addressing environmental conditions that increase HIV risks, as a means to stemming the epidemic.