Sexual behavior, serological profile and use of psychoactive substances among sex workersABSTRACT
Objective: To analyze the prevalence of sexually transmitted infections (STIs) and the use of psychoactive substances among sex workers and their relationship with sexual behavior.
Method: Cross-sectional study conducted in the interior of the state of Goiás, Brazil, with sex workers. Sexual behaviors were assessed and information on substance use was obtained through the Alcohol, Smoking and Substance Involvement Screening. Laboratory tests detected human immunodeficiency virus (HIV), syphilis, hepatitis B, and hepatitis C. Descriptive analyses, chi-square, and logistic regression were performed.
Results: A total of 104 sex workers (88.4% women) participated in the study. The prevalence of STIs was HIV (1.9%), syphilis (14.4%), hepatitis B serological scar (3.8%), and hepatitis C (1.9%). Inconsistent condom use was reported by 64.4% of sex workers. The most prevalent patterns of substance abuse/dependence were tobacco (53.8%), alcohol (43.3%), cannabis (29.8%) and cocaine (26.9%). No significant associations were identified between condom use and substance use.
Conclusion: A high prevalence of syphilis, inconsistent condom use, and patterns of substance abuse/dependence were observed among sex workers. The findings reinforce the need for effective combined STI prevention strategies, harm reduction actions, and specific care interventions for this vulnerable population.
Descriptors:
Sexual behavior; Serology; Sexually transmitted infections; Drugs; Sex workers
RESUMO
Objetivo: Analisar a prevalência de infecções sexualmente transmissíveis (IST) e uso de substâncias psicoativas entre profissionais do sexo e sua relação com o comportamento sexual.
Método: Estudo transversal, realizado no interior do estado de Goiás, Brasil, com profissionais do sexo. Comportamentos sexuais foram avaliados e informações sobre o uso de substâncias foram obtidas pelo The Alcohol, Smoking and Substance Involvement Screening. Exames laboratoriais detectaram o vírus da imunodeficiência humana (HIV), sífilis, hepatite B e hepatite C. Foram realizadas análises descritivas, qui-quadrado e regressão logística.
Resultados: Participaram 104 profissionais do sexo (88,4% mulheres). As prevalências de IST foram: HIV (1,9%), sífilis (14,4%), cicatriz sorológica de hepatite B (3,8%) e hepatite C (1,9%). O uso inconsistente de preservativo foi relatado por 64,4% dos profissionais do sexo. Com maior padrão de uso abusivo/dependência verificou-se o tabaco (53,8%), álcool (43,3%), maconha (29,8%) e cocaína (26,9%). Não foram identificadas associações significativas entre o uso de preservativo e o uso de substâncias.
Conclusão: Evidenciou-se elevada prevalência de sífilis, o uso inconsistente de preservativo e o padrão de uso abusivo/dependência de substâncias entre profissionais do sexo. Os achados reforçam a necessidade de estratégias efetivas de prevenção combinada de IST, ações de redução de danos e intervenções assistenciais específicas para essa população vulnerável.
Descritores:
Comportamento sexual; Sorologia; Infecções sexualmente transmissíveis; Drogas; Profissionais do sexo
RESUMEN
Objetivo: Analizar la prevalencia de infecciones de transmisión sexual (ITS) y consumo de sustancias psicoactivas entre trabajadoras sexuales y su relación con el comportamiento sexual.
Método: Estudio transversal realizado en el interior del estado de Goiás, Brasil, con trabajadoras sexuales. Se evaluaron las conductas sexuales y se obtuvo información sobre el consumo de sustancias mediante la Prueba de Detección de Alcohol, Tabaquismo y Consumo de Sustancias. Las pruebas de laboratorio detectaron el virus de la inmunodeficiencia humana (VIH), sífilis, hepatitis B y hepatitis C. Se realizaron análisis descriptivos, chi-cuadrado y regresión logística.
Resultados: Participaron en el estudio 104 trabajadoras sexuales (88,4 % mujeres). La prevalencia de ITS fue: VIH (1,9 %), sífilis (14,4 %), cicatriz serológica de hepatitis B (3,8 %) y hepatitis C (1,9 %). El 64,4 % de las trabajadoras sexuales reportó uso inconsistente del preservativo. Se observaron mayores patrones de uso abusivo/dependencia de tabaco (53,8%), alcohol (43,3%), cannabis (29,8%) y cocaína (26,9%). No se identificaron asociaciones significativas entre el uso del preservativo y el consumo de sustancias.
Conclusión: Se evidenció una alta prevalencia de sífilis, un uso inconsistente del preservativo y un patrón de abuso/dependencia de sustancias entre las trabajadoras sexuales. Los hallazgos refuerzan la necesidad de estrategias eficaces combinadas de prevención de ITS, acciones de reducción de daños e intervenciones de atención específicas para esta población vulnerable.
Descriptores:
Comportamiento sexual; Serología; Infecciones de transmisión sexual; Drogas; Trabajadoras sexuales
INTRODUCTION
Sex workers, defined as individuals who receive money in exchange for consensual sexual services or erotic performances, are among the populations most vulnerable to sexually transmitted infections (STIs), facing structural challenges that hinder the adoption of effective preventive practices1. Exposure to multiple partnerships, negotiation of condom use, and the use of psychoactive substances are contributing factors to the increased prevalence of STIs2.
The high burden of STIs among sex workers has been evidenced in different contexts. A study conducted in 12 Brazilian cities, found that the HIV rate among these workers was estimated at 5.3%.3. The global prevalence of HIV among sex workers, reported by 85 countries, is 2.5%, ranging from 0% to 62.3%4. In addition to HIV, other STIs, such as syphilis and viral hepatitis, also have a high incidence in this group, representing a significant public health problem due to high reporting rates and their implications for morbidity and mortality5,6. The high STI rates among sex workers are directly associated with multiple vulnerability factors, including limited access to healthcare services, difficulties in consistently adopting preventive measures, and engagement in risky sexual behaviors.
Risky sexual behavior refers to practices that increase the likelihood of STI transmission and is associated to multiple individual and contextual factors. Inconsistent condom use and multiple sexual partners are examples of risky sexual behaviors, which pose significant challenges to reducing STIs among sex workers7. Previous evidence indicates that between 25.6% and 32.1% of sex workers reported inconsistent condom use8,9, and this practice was associated with an increased risk of STI diagnosis in this population10.
It is important to highlight that inconsistent condom use, both with clients and steady partners, constitutes a significant risky sexual behavior among sex workers. Studies point out that this practice represents one of the main challenges for preventive interventions in this population, being associated with structural factors, occupational stigmas, sexual negotiation dynamics, and use of psychoactive substances8,9,10. The World Health Organization defines psychoactive substances as those which, when ingested or administered, act on the central nervous system, altering its function and potentially causing changes in mood, perception, behavior, and states of consciousness11.
Abuse of psychoactive substance can impair judgment, reduce the ability to negotiate condom use, and increase vulnerability to STIs9. A systematic review and meta-analysis estimated the prevalence of problematic alcohol use among female sex workers at 41%12, while another study identified prevalences of 21.5% for amphetamines and 16.9% for cannabis13. Given the high prevalence of psychoactive substance use in this population group, it is essential to understand the relationship between use of substance and sexual behavior in order to generate evidence that supports more effective prevention and harm reduction strategies.
Scientific literature shows that alcohol and other drug use is associated with greater involvement in unprotected sexual practices12,14. A study conducted in Brazil with female sex workers found that abusive alcohol use was associated with a higher likelihood of inconsistent condom use15. Similarly, another study conducted in Kenya showed that problematic use of illicit substances, such as cannabis and amphetamines, was significantly associated with a higher risk of inconsistent condom use among female sex workers13.
Despite the relevance of this topic, there are gaps in the literature, especially regarding the relationship between substance use and risky sexual behavior among sex workers, with an emphasis on the Brazilian context. It is important to note that existing studies often focus on samples composed exclusively of female sex workers6,9,12,13,15 which limits understanding of the diversity of experiences within this population group. Furthermore, there is a lack of studies using validated instruments to assess the patterns of consumption of different classes of substances12,16. The present study aims to overcome this limitation by including a more diverse sample and using a validated instrument to assess the patterns of consumption of different classes of substances. Therefore, it is necessary to investigate this relationship, considering that substance use may contribute to the adoption of risky sexual behaviors, particularly inconsistent condom use, consequently increasing vulnerability to STIs.
Considering these gaps, this study aims to provide evidence on the relationship between sexual behaviors and substance use, contributing to the development of more effective prevention strategies. Given this scenario, the present study seeks to answer the following questions: What is the prevalence of STIs among sex workers? Is there an association between the use of psychoactive substance and risky sexual behavior in this population? The objective of the study was to analyze the prevalence of STIs and use of psychoactive substance among sex workers and their relationship with sexual behavior.
METHOD
This is a cross-sectional, analytical study complied with the recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).
The research was conducted in Rio Verde, a municipality in the interior of the state of Goiás, Brazil, with an estimated population of 247,259. Data were collected through interviews using a standardized instrument covering sociodemographic variables, sexual behavior, and alcohol and drug use, as well as laboratory tests for HIV, syphilis, and hepatitis B and C.
The target population for this study consisted of sex workers aged 18 or older who reported having had at least one sexual intercourse in exchange for money in the last 30 days. Individuals with cognitive impairments, especially those related to psychoactive substance use, which could compromise their understanding of the data collection instrument, were excluded. The convenience sample consisted of 104 sex workers invited between February and May 2023.
Participant recruitment and data collection took place in locations previously mapped by the researchers, including workplaces and boarding houses where sex workers lived. This dynamic was determined by the researchers to ensure greater accessibility and adherence to the study. Initial contact was made in together with teams from the municipal healthcare network, who already had experience with this population. At the interview sites, sex workers were informed about the study objectives and invited to voluntarily participate in the study. Data collection was conducted in areas within the interview site that guaranteed privacy and confidentiality, ensuring a private space for the interview. Regardless of participation in the study, all sex workers approached had access to laboratory testing for STIs. Interviews were conducted by trained researchers and lasted an average of 25 minutes.
The sociodemographic variables assessed were: sex (male and female); age in complete years, calculated using the date of birth and presenting the average age; self-reported skin color (black and non-black); marital status (with and without a partner); children (none, one, two or more); housing (with family or friends and alone); years of schooling (from 4 to 7 years, from 8 to 11 years and 12 years or more); monthly income in minimum wages (up to 1; from 2 to 4 and 5 or more).
Participants’ sexual behavior was assessed using a questionnaire from the Information Counseling and Testing Centers Information System (Sistema de Informação dos Centros de Testagem e Aconselhamento - SI-CTA)17 which included the following questions: length of time working as a sex worker (up to 24 months; more than 24 months), types of sexual relations (with women, men, or both), number of clients per day (up to 3; 4 or more) and per month (up to 20; 21 to 40; 41 or more), and whether they had oral or anal sex in the past month (yes or no).
Condom use in the last month, both with steady partners and with clients, was considered the dependent variable. For its definition, participants answered the questions: “How often did you use a condom when having sexual intercourse with clients in the last month?” and “How often did you use a condom when having sexual intercourse with your steady partner in the last month?” Response options included: “Never”, “Rarely”, “Frequently”, and “Always”. For analysis purposes, any response other than “Always” was classified as inconsistent condom use.
After the interviews, blood samples were collected by venipuncture in a private space within the interview and screening locations, ensuring privacy and safety. The samples were packaged and transported to the Counseling and Testing Center (CTC) following biosafety protocols for serological testing for HIV, syphilis, and hepatitis B and C. Participants were instructed to return to the CTC within five business days to receive their results, along with post-test counseling. Those with positive results referred to follow-up and treatment at specialized public healthcare units.
The serological profile assessment, performed through laboratory analysis, followed the recommendations of the Department of STI/AIDS and Viral Hepatitis of the Brazilian Ministry of Health18. Laboratory analysis was essential for determining the prevalence of STIs in the study population, providing an accurate diagnosis and helping to identify the vulnerability of this population.
HIV screening was performed by immunochromatography. Reactive samples were subjected to a second test. If both tests were positive, a new sample was collected by fingerstick and submitted to the Abon test for confirmation. Subsequently, viral nucleic acid was quantified by PCR at the regional reference laboratory.
Laboratory diagnosis of syphilis was performed using treponemal and non-treponemal assays, using microparticle chemiluminescence and VDRL. In cases of discordant results, an immunochromatography test was used. Diagnosis of HBV infection was performed by chemiluminescence, using HBsAg and total anti-HBc assays, both using the Architect - Abbott system. The sample was considered reactive for HBV if both markers were positive. The anti-HBs marker was used to assess vaccine immunity (isolated anti-HBs) or previous infection (total anti-HBs and reactive anti-HBs), also by chemiluminescence.
To determine HCV infection, anti-HCV antibodies were tested by chemiluminescence and subsequently confirmed by PCR at the regional reference laboratory. The serological test results were categorized as: HIV, syphilis, and hepatitis C (reactive or non-reactive); hepatitis B (reactive, non-reactive, serological scar, or vaccine response).
The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), developed by the World Health Organization, identifies the risk associated with the use of nine substances (tobacco, alcohol, cannabis, cocaine, amphetamines, inhalants, hypnotics, hallucinogens, and opioids) in the last three months. The Brazilian version demonstrated satisfactory psychometric properties for use in primary and secondary healthcare services19.
The ASSIST assesses several domains through objective, multiple-choice questions for each substance used, related to duration of use, recent use, desire to use, health, social, and legal problems, difficulty in stopping use, among others. The tool is scored by adding the total values of the responses for each substance, ranging from 0 to 39. Higher scores indicate greater risk and allow participants to be classified into three groups: low risk; moderate risk; and high risk. The low-risk classification refers to occasional use, moderate risk is characterized by abuse, and high risk relates to probable dependence on the assessed substance. Due to the small number of participants categorized as high risk, two categories were adopted in this study. According to the ASSIST manual, scores equal to or below 3 (10 for alcohol) were considered occasional use, and scores equal to or above 4 (11 for alcohol) were categorized as abuse/dependence11.
Analyses were performed using the Statistical Package for the Social Sciences (SPSS) (version 24), with descriptive and bivariate statistics. Categorical variables were presented as absolute and relative frequencies, while numerical variables were described as means and standard deviations.
Bootstrapping procedures (1,000 resamplings; 95% BCa CI) were applied to increase the reliability of the results, correct for any deviations from normality, and provide confidence intervals for the relative frequencies, representing population parameters of sex workers. To assess the association between condom use and psychoactive substance consumption, bivariate logistic regression analyses were performed. The model estimated the odds ratio (OR) and the respective 95% confidence intervals (95% CI), with condom use as the dependent variable (consistent use vs. inconsistent use) and the different risk classifications of substance use, according to ASSIST, as independent variables Each substance was analyzed separately, and participants categorized as occasional users were considered the reference group. The statistical significance level adopted was p < 0.0520-22.
The research was approved by the Research Ethics Committee (REC) of the Universidade de Rio Verde - UniRV, under CAEE number 28421820,1,0000,5077, in compliance with the recommendations of Resolution 466/12 of the National Health Council (Conselho Nacional de Saúde - CNS). Before the start of the interview, all participants received detailed information about the study, including its objectives, procedures, and data confidentiality. After this information, those who agreed to participate signed the Informed Consent Form (ICF).
RESULTS
A total of 110 sex workers were approached during the data collection, and there were 6 (5.45%) refusals, resulting in a final sample of 104 participants. Regarding sociodemographic characteristics, the average age of the sex workers evaluated was 30.53 (±7.99) years, predominantly female, 93 (88.4%), and Black, 72 (69.2%). Regarding marital status, 99 (95.2%) sex workers lived without a partner, 67 (64.4%) had children, 76 (73.1%) lived with family or friends, 49 (47.1%) had between 8 and 11 years of schooling, and 67 (64.4%) had a monthly income between 2 and 4 minimum wages (Table 1).
Table 2 presents sexual behaviors and the results of serological tests for STIs. Most participants had been working as sex workers for more than 24 months (51%). Among women, 97.8% reported inconsistent use of female condoms. Sexual relations were mostly with men (77.2%), and the majority served, on average, 4 or more clients per day (64.4%) and 41 or more per month (67.3%).
In the last month, 64.4% of sex workers reported inconsistent use of male condom with steady partners or clients, 81.7% performed oral sex, and 36.5% performed anal sex. Serological tests revealed that 1.9% tested positive for HIV, 14.4% tested positive for syphilis, 3.8% had a hepatitis B serological scar, 31.7% had immunity due to a vaccine response (anti-HBs), and 1.9% tested positive for hepatitis C.
Regarding the risk classification of use of the different classes of drugs evaluated, tobacco was the substance with the highest number of sex workers classified as abuse/dependence (53.8%), followed by alcohol (43.3%). Regarding illicit substances, cannabis had the highest prevalence of users with abuse/dependence (29.8%), followed closely by cocaine (26.9%). Abuse/dependence among sex workers was also identified for hallucinogens (5.8%), amphetamines (4.8%), inhalants (3.8%), hypnotics (3.8%), and opioids (1.9%) (Table 3).
The Table 4 presents the frequencies and association analyses between condom use with clients and the risk classifications for the use of different substances. Inconsistent condom use was most common among sex workers with abuse/dependence on cocaine (71.4%), followed by alcohol (68.9%) and tobacco (66.1%). However, bivariate logistic regression analyses showed no statistically significant associations between the use patterns of use of the different substance classes and condom use.
DISCUSSION
This study assessed sexual behaviors, STIs serological profiles, and patterns of substance use among sex workers. Regarding risky sexual behavior, 64.4% of participants reported inconsistent use of male condom. Laboratory tests indicated that syphilis was the most prevalent STI in the sample, with 14.4% testing positive. Regarding psychoactive substance use, tobacco (53.8%), alcohol (43.3%), and cannabis (29.8%) were the substances most frequently used in patterns of abuse or dependence. Despite the high prevalence of risky behaviors, such as inconsistent condom use and substance abuse, no statistically significant association was observed between these variables.
The results of this study showed a higher frequency of inconsistent condom use than observed in other studies. In the United States, the prevalence was 39.2% among sex workers20. In a sample of sex workers in the Netherlands, inconsistent use was reported by 35.7% of women and 29.6% of men21. In the Brazilian context, few studies address condom use among sex workers. In one of the few investigations conducted, inconsistent condom use was identified in 20% of female sex workers, a considerably lower frequency than that found in this study (64.4%)15. Indeed, this is one of the first investigations to assess condom use among sex workers in the Brazilian context. When comparing condom use in the general population of Brazil, inconsistent condom use in the past 12 months was reported by 88.2% of the population, highlighting the magnitude of the issue of this sexual behavior as an important risk factor for STIs22.
Our results indicated that syphilis was the most prevalent STI among sex workers, with 14.4% of participants testing positive through laboratory diagnosis (95% CI: 7.7-21.2). This percentage is similar to that reported in studies conducted in other regions of Brazil. A study conducted in cities in the Amazon region identified a prevalence of 14.1% (95% CI: 9.8-17.8) among sex workers6. However, in some locations, such as the state of Pará, even higher rates were recorded, reaching 36.94%23. These variations in syphilis prevalence between different regions may be related to disparities in access to STI prevention, diagnosis, and treatment services, especially in rural areas of the country, where healthcare coverage may be more limited24.
The prevalence of HIV identified in this study (1.9%) was lower than the estimated global average for sex workers, which is 2.5%4. A 2016 study conducted in Brazilian capitals revealed an HIV prevalence of 5.3% among sex workers3, a rate higher than that found in the present investigation. These discrepancies may be associated with contextual factors, such as differences in testing services, prevention strategies adopted, and access to public policies aimed at risk reduction in this population.
Additionally, the National Harm Reduction Policy, aimed at minimizing social and health harms related to the problematic use of psychoactive substances has demonstrated a positive impact on reducing STI transmission25. In addition, access to pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) for HIV has been expanded, with both provided free of charge by the Unified Health System (Sistema Único de Saúde - SUS) as part of prevention strategies26. A study conducted in Brazil found that the adoption of a PrEP distribution policy reduced the rate of new HIV cases in the country by 7.8%27. In this context, combination prevention, which integrates biomedical interventions (such as PrEP and PEP), behavioral interventions (such as promoting consistent condom use), and structural interventions (such as reducing stigma and discrimination), emerges as an essential approach for addressing the multiple vulnerabilities to which sex workers are exposed. It is recommended that future studies consider including variables that assess knowledge, access, and use of these combination prevention strategies.
Regarding substance use, tobacco showed the highest prevalence of abusive or dependent use in our results, followed by alcohol. These findings reinforce the role of psychoactive substances as risk factors in the sexual health of sex workers. A cohort study of sex workers identified problematic alcohol use as a predictor of risky sexual behaviors, suggesting that interventions aimed at reducing substance use may be crucial in preventing STIs in this population group13.
The results on illicit substance use among sex workers revealed a considerable prevalence, with cannabis being the most prevalent drug for abuse/dependence (29.8%; 95% CI: 21.2-38.5%), followed by cocaine (26.9%; 95% CI: 19.2-36.5). These data reinforce the vulnerability of this group regarding illicit drug use. A systematic review study identified a 35% overall lifetime prevalence of illicit drug use among sex workers28.. In a study conducted in Kenya, a significant prevalence of harmful substance use was observed among sex workers. Approximately 29.9% of participants reported alcohol abuse/dependence, 21.5% of participants reported amphetamine abuse/dependence and 16.9% reported cannabis abuse/dependence, demonstrating that this risk behavior is a global phenomenon13.
The findings of this study indicate high rates of inconsistent condom use among sex workers who presented patterns of substance abuse or dependence. However, no statistically significant associations were identified between these variables. These results diverge from previous studies conducted in Brazil, which indicated a significant relationship between excessive alcohol consumption and inconsistent condom use among sex workers (OR = 5.07; 95% CI: 1.87-13.74)15. A systematic review evaluating young populations also found a significant association between alcohol and other drug use and inconsistent condom use2.
The absence of a statistically significant association between substance abuse/dependence and inconsistent condom use among sex workers suggests that this relationship may be more complex than a direct effect of substance use patterns on sexual behavior. An important aspect to consider is that the effect of consumption can vary depending on the frequency, quantity, and type of substance used. Alcohol, for instance, can impair decision-making and reduce condom negotiation, while stimulants, such as cocaine and amphetamines, can intensify impulsive behaviors in different ways. Furthermore, the interval between consumption and sexual activity may be a determining factor, given that the effects of some substances are transient and may not influence all decisions related to condom use29,30.
Despite the relevance of the findings, some limitations should be considered. The sample size may have impacted on the statistical analyses, reducing the power to detect subtle associations between the variables investigated. Furthermore, other variables that could act as mediators or moderators of this relationship were not analyzed, such as social support, access to healthcare services, length of professional experience, and mental health aspects, including impulsivity and depressive symptoms. Another limitation worth noting is the absence of sociodemographic variables in the bivariate logistic regression models, which could provide a broader understanding of the factors associated with risky sexual behavior and use of psychoactive substances. Future studies should consider these variables for a more comprehensive assessment of the relationship between substance use and inconsistent condom use among sex workers. Information on gender identity and sexual orientation was also not collected, which limits the identification of disparities among more vulnerable subgroups, such as transgender people, gays, lesbians, bisexuals, and other non-heterosexual identities.
The results of this study have important practical implications for health, with the potential to guide interventions aimed at preventing and controlling diseases in vulnerable populations. Public health policies need to implement programs that expand access to regular STI testing among sex workers, ensuring that these services are provided in accessible and confidential places. Furthermore, it is essential to develop practical harm-reduction interventions focused on substance use, such as offering drug addiction treatment programs and distributing prevention materials such as condoms and sterile syringes. Healthcare professionals should be trained to work directly in the areas where sex workers act, conducting regular educational campaigns on the risks of unprotected sexual behavior and the dangers of substance abuse. These actions can include preventive consultations, awareness workshops, and counseling to reduce risk behaviors, as well as promoting early detection and treatment of STIs.
CONCLUSION
This study identified a considerable proportion of risky sexual behavior, primarily due to inconsistent condom use among sex workers. Regarding STIs, syphilis had the highest prevalence, as identified through the serological profile assessment of sex workers. Despite the high frequency of substance abuse/dependence patterns, no significant associations were found with inconsistent condom use among sex workers.
This study contributes to the understanding of the serological profile, sexual behavior, and substance use among sex workers. The findings highlight the importance of further research, especially studies that explore other potential variables capable of influencing both the serological profile and sexual risk behaviors in this population. Given these vulnerabilities, there is a need to adopt combined prevention strategies that contextually integrate different interventions. Furthermore, the data point out to the need for practical interventions that integrate teaching aimed at the training of future healthcare professionals, empowering them to provide qualified and targeted care for this population, as well as fostering the development of specialized healthcare actions aimed at the specific needs of sex workers.
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Access to the dataset is available upon request from the corresponding author.
