to address the perceived public health threat from the human immunodeficiency virus ( hiv ) epidemic in peru , studies were conducted in the 1990s to characterize the sexual practices and prevalence of genital tract infections ( gtis  sexually transmitted infections and bacterial vaginosis ) and hiv among female sex workers ( fsws ) and their clients . results suggested that the relatively high percentage of men ( 4459% ) interacting with fsws could serve as a bridge in the transmission of sexually transmitted infections ( stis ) to the general public [ 13 ] . these findings also concluded , however , that while the hiv prevalence among fsws in peru was higher than that of the general population , the estimates for this at - risk population were relatively low for a concentrated epidemic setting and the rate of ongoing transmission was considered slow [ 2 , 4 ] . the validity of periodic sti / hiv surveillance surveys that continue to report hiv prevalence among fsws has been a lingering question . it has been the norm to rely on a convenience sample of women who attend free government sti clinics although it is known that a segment of the fsw population does not access or underutilizes these services [ 5 , 6 ] . concern regarding a sudden and hidden spread of hiv and stis among fsws is periodically raised due to on - going bridge potential from the sexual networks of bisexual men [ 79 ] . moreover , as poor healthcare - seeking behavior can prolong the infectious period for curable stis , transmission patterns may change quickly among fsws who have unprotected sex , are new to this occupation , and/or are less accustomed to seeking and receiving medical services for stis [ 10 , 11 ] . in collaboration with the general directorate of epidemiology at the ministry of health ( moh ) of peru , the asociacin civil impacta salud y educacin ( hereafter referred to as impacta ) , a local nongovernmental organization , conducted a cross - sectional study on clandestine fsws to serve as a followup to a comparable study of this vulnerable fsw subpopulation . for over 100 years female sex work in peru was tolerated and controlled with required worker registration , mandatory periodic clinical exams of fsws to maintain a valid health license , and an informal recognition of sex work venues . in 1993 fsws were no longer required to register , and in 1997 periodic exams became voluntary . the term clandestine originally referred to women who did not register , but currently refers to women who never or seldom use free public health sti services for recommended , periodic health checks and who frequent commercial sex venues that are not recognized and not commonly accessed by government sti prevention outreach programs . the purpose of this study was to provide a profile of gti prevalence , sexual health status , and health - seeking behaviors amongst clandestine fsws in peru . for this descriptive , cross - sectional study a convenience sample of clandestine fsws based in lima , peru was recruited in 2002 and 2003 . participants self - identified as fsw and were initially approached at their clandestine sex workplaces by peer educators who served as study recruiters . behavioral surveys and a clinical examination including gti testing were conducted at an impacta clinic in a discreet and accessible location . to optimize inclusion we used two primary recruitment strategies . first , over a nine - month period , weekly open - house sessions were hosted at the clinic site for members of the clandestine sex work community . four trained peer educators made several weekly visits to network with sex workers and venue gatekeepers . this resulted in the identification of 75 clandestine sex work venues , including streets or parks and other commercial sex venues not formally recognized by the peruvian government . secondly , women who attended open houses were briefed on the study , encouraged to participate and asked to refer their colleagues who might be eligible for the study . this strategy , considered a form of snowball sampling , is frequently used to recruit members of hard - to - reach populations [ 12 , 13 ] . sample selection criteria were tailored to be consistent with the national definition of a sex worker and intentionally sought to include a high - risk subpopulation of fsw . women were eligible if they were 1859 years of age , had not participated in the government 's hiv sentinel surveillance survey during the past year , had pursued periodic medical attention for gtis fewer than twice during the past four months , had at least nine clients during the last work week , and reported problems with condom use at any time during the last six months ( problems were defined as a condom breaking , falling off , or not being used ) . written informed consent was obtained from all participants after the study was explained , and eligibility was confirmed based on study inclusion and exclusion criteria . a trained female counselor administered the behavioral health questionnaire to participants prior to the medical exam . the behavioral survey was developed based on questionnaires previously used in international , regional , and local studies . vaginal fluid from the upper lateral wall of the vagina was collected with a cotton swab and prepared for wet mount and gram stain evaluation . gram stain was used to diagnose bacterial vaginosis ( bv ) on basis of the nugent score criteria . trichomonas vaginalis was detected using the wet mount examination and the in - pouch tv culture system ( biomed ) . candidiasis was evaluated based on the wet mount examination looking for pseudohyphae and/or blastoconidia blastospores . finally , a 10 cc venous blood sample was collected to conduct serological tests for treponema pallidum ( syphilis ) using rapid plasma reagin ( rpr  nosticon ii kit ; biomerieux ) and t. pallidum microhemagglutination assays ( mha - tp ) confirmatory tests ( biomerieux ) . to detect hiv antibodies the enzyme - linked immunosorbent assay ( elisa ) was used ( vironostika hiv uni - form ag / ab kit ; biomerieux ) together with western blot assay to confirm positive results ( genetic system hiv-1 western blot kit ; biorad ) . elisa was also used to diagnose herpes simplex virus type 2 ( hsv-2 genital herpes ; herpes select 2 elisa igg ; focus diagnostic ) . all microscopy was performed at the screening site and all other testing was done at the impacta central laboratory . a follow - up visit was scheduled after two weeks to provide the results of laboratory tests , as well as hiv and sti post - test counseling . impacta community advisory board provided input and recommendations for educational materials and study design and implementation . the study protocol was reviewed and approved by the general epidemiology program of the moh of peru . the impacta bioethics institutional committee reviewed and approved all ethical aspects of protocol , study informed consent , outreach strategies , and educational materials . in addition , the university of washington irb reviewed and approved the data analysis proposal . we used descriptive statistics to assess the range , mean , and standard deviation of sociodemographic , behavioral , and clinical exam variables . the open - ended question regarding location of work yielded qualitative responses ; these were subsequently categorized as street / park , house of appointments , brothel , and other . descriptive statistical methods were used to explore candidate risk factors for bv , t.  pallidum , and hsv-2 genital herpes . candidate risk factors and potential confounders were assessed individually in relationship to all gti outcomes with a sample size of 20 or more . in general covariates included age , level of education , marital status , number of dependents , estimated income from sex work , years as sex worker , work venue , number of clients in the past week , condom use and problems with condom use with 3 most recent sex partners , use of hormonal contraceptives , use of lubricants , anal sex , and months since last clinic visit . factors associated with a gti outcome with p  0.1 using bivariate poisson and logistic regression were considered for multivariate regression modeling . confounders were included in these models when they changed the magnitude of association of primary interest by at least 10% . multivariate modeling was carried out using either logistic regression to estimate odds ratios ( ors ) or poisson regression to estimate prevalence rate ratios ( prrs ) . poisson regression with robust variance estimation was used for outcomes with an overall prevalence greater than 10% which was the case for bv and for hsv-2 seropositivity [ 16 , 17 ] . overall 212 of 226 female study participants recruited from 75 work locations met all inclusion criteria and were willing to be tested for all gtis . over half of the recruited women came from the two neighboring city districts of la victoria ( 38% ) and lima cercado ( downtown lima ; 28% ) . the age of recruited women ranged from 18 to 53 years ; the mean age was 28 ( sd = 7.0 ) ( table 1 ) . participants attained a mean of nine years of education ( sd = 3.1 ) ; 41% of the women had completed at least a secondary - level education , that is , eleven or more years of education . only 31% lived with a husband or male partner , while over 90% reported being responsible for dependents . the age for the first sex work transaction ranged from 12 to 48 ; the mean age was 23.5 ( sd = 6.1 ) . the mean duration acknowledged sex work was 4.5 years ( sd = 4.6 ) ; 29% self - identified as a sex worker for less than a year . consistent with this skewed distribution , the median number of partners in the past week was 24 ( iqr = 15 , 40 ) , while the mean was 31 ( sd = 25.5 ) . fsws reported the street or park as the most common work venue ( 51% ) . sex venues traditionally sanctioned by the peruvian government , such as house of appointments and brothels , were less common among this population . a smaller percentage of fsws identified massage parlors as their work venue and a few reported establishing contacts with clients by telephone and internet . ninety - three women reported not using a contraceptive method ; among these , 5 women reported not using contraception because they did not menstruate or have a uterus . among 207 women , 37% reported relying on oral contraceptives , while only 10% identified using condoms as a contraceptive method . the average number of pregnancies was 2.5 ( sd = 1.3 ) . among 202 women who had been pregnant , 68% reported clinical and laboratory examination results indicated an hiv seroprevalence of 2.4% in this population ( table 2 ) . forty - five percent were diagnosed with bv defined as a nugent score between 7 and 10 . four of the 5 hiv - positive cases were also bv positive compared to 44% of the hiv - negative fsws . overall , 88% were diagnosed with at least one gti , primarily due to high hsv-2 levels ; 36.7% were coinfected with two different gti and another 11.5% were infected with three or more . the majority of women ( 69% ) reported knowing of an hiv testing site , and 153 ( 73% ) had ever tested for hiv in the past ( table 3 ) . one hundred thirty - three of those who tested did so voluntarily ( 87% ) ; among these women 116 reported knowing their hiv test results which represent 55% of all study participants . study participants were asked to describe symptoms or signs they recognized as a gti among women and men . the majority mentioned vaginal discharge ( 69% ) and 24% recognized genital ulcers as signs of a female gti ( table 3 ) . urethral secretions ( 62% ) and genital ulcers ( 45% ) were the two most common signs mentioned for a male gti .   to probe healthcare - seeking behaviors , fsws were first asked whether they had experienced two gti symptoms in the previous 12 months ; overall , 76% reported vaginal discharge , and 12% reported a genital ulcer ( table 3 ) ; 23 of the women who reported a genital ulcer also reported vaginal discharge . a total of 162 ( 76% ) women who reported either vaginal discharge or a genital ulcer were then asked questions regarding healthcare - seeking and sexual behaviors in response to these conditions . roughly 20% of the women provided qualitative responses describing other first recourse behaviors including doing nothing , consulting with friends , and following their standard intravaginal regimen of washing or using herbs . thirty - eight percent of the 162 fsws with vaginal symptoms reported never having visited an sti clinic or no visits in the past year ; furthermore 41% indicated they had informed their sexual partner and 56% reporting abstaining from sex . seventy - three percent of women reported using a condom consistently during the last sex acts with each of their 3 most recent sex partners ; another 26% indicated using a condom with one or two of their recent partners , while 3 women never used a condom . we aggregated the data to identify differences in condom use by type of sexual partner . of the of 635 sex partners described by study participants 64% were casual clients , 27% were regular clients ( caseritos ) , 5% were husbands or stable partners , and 4% were significant friends . fsws reported using condoms during nearly all sex acts ( 98.3% ) with a recent casual and regular ( caserito ) client ( 99% and 97% , resp . ) . in contrast , condoms were used in just 12% of sex acts with significant friends and 3% of sex acts with husbands or stable partners . among women who reported using condoms with the past 3 sex partners , table 4 presents unadjusted and adjusted prr for risk factors associated with bv . in an unadjusted model , bv was positively associated with working in a street or park - based venue ( prr = 1.47 ) and with condom use problems ( prr = 1.61 ) while negatively associated with more years of education ( prr = 0.95 ) , more consistent condom use ( prr = 0.59 ) , and lubricant use ( prr = 0.69 ) . in multivariate analysis , however , only consistent condom use was statistically significant ( prr = 0.64 , 95% ci , 0.420.98 ) .  
 table 5 represents unadjusted prr and or of risk factors associated with hsv-2 and syphilis , respectively . women with hsv-2 out of 20 women found to be seropositive for syphilis , none had evidence of a recent infection ( vdrl titre  1  :  16 ) . as indicated in table 5 bivariate analysis revealed that syphilis - seropositive women tended to work in a street or park setting as compared to all other workplaces ( or = 4.49 ) , have fewer years of education ( or = 0.87 ) , be older , and have a greater number of years of experience in sex work ( or = 1.14 and or = 1.13 for each additional year , resp . ) . only age and workplace persisted in their independent association with syphilis seropositivity by multivariate analysis ( age : or = 1.12 , 95% ci , 1.051.19 ; street or park versus other workplace : or = 4.12 , 95% ci , 1.4513.15 ) . moderate - to - high levels of collinearity between several of the correlates seen in bivariate analyses , for example , age and numbers of years in sex work , likely precluded our ability to assess the independent effects of these factors in our modest sized sample . we did not detect an association between syphilis seropositivity and any of the measures of condom use captured under this study . this may be because none of the 20 seropositive women had serological evidence consistent with a recent infection . this study adds evidence of considerable burden of infection with some but not all gtis and hiv among a subpopulation of peruvian fsws . there are several limitations to our study ; principally that interpretation is based on cross - sectional data which precludes evaluation of the temporal relationship between risk factors and gtis . the statistical power to understand relationships with some correlates , particularly for hsv-2 , was limited as the sample size was small . participants were asked sensitive questions regarding their behaviors and thus their responses may have been affected by recall and social desirability biases . because we followed international standards for framing these questions and used rigorously trained interviewers , we believe these effects were minimized . the generalizability of study results to other clandestine fsws is likely limited due to the snowball sampling methods and recruitment efforts which favored the adjacent neighborhoods of lima cercado ( downtown lima ) and la victoria . participation bias may also have occurred if recruitment efforts predominantly captured women with existing conditions or pressing health concerns . our data revealed that the hiv seroprevalence of 2.4% in this study was lower than two historical estimates : one study reported a 9.6% seroprevalence among 146 clandestine fsws , compared to an estimate of 0.3% among 5,827 registered fsws ; in a second unpublished study researchers found a 5% seroprevalence of 311 clandestine sex workers in lima , peru . our data highlight effective efforts by the peruvian public health community to stave off widespread hiv transmission in this vulnerable population . nonetheless , despite nearly universal condom use with clients , fsws had an elevated risk of hiv infection in comparison to the general population of women who reported hiv seroprevalence consistently well below 1% for the same time period . participants had an hsv-2 seroprevalence rate of 80% which is similar to an estimate from a 1992 peruvian study of registered and unregistered fsws , but much higher compared to a 2002 estimate of 20% among women in the general population reported in a study of three peruvian coastal cities . no association with condom use was detected , consistent with the assessment that condom use is less effective against hsv-2 acquisition compared to other stis . evidently previous public health interventions were unsuccessful at preventing the steady accumulation of hsv-2 infections among fsws . over the past 10 years furthermore , the bv prevalence of 44.8% identified here is the highest estimate reported to date in peru and considerably higher than a comparable estimate of 20% among fsws , yet similar to the range of estimates reported for central american fsws . in our study women with bv were more likely to be diagnosed with another gti , and bv diagnosis was independently associated with lack of condom use , associations which are consistent with other studies [ 2529 ] . our estimate of 9% syphilis seroprevalence is comparable with an 11% estimate from the mid-1990s , but higher than the 3.3% reported earlier that decade   and 4.1% identified among primarily registered sex workers . our study reports no evidence of recent syphilis , consistent with an interpretation of low frequency of transmission . the prevalence rate of 2% for t. vaginalis was lower than 4.1% among 916 fws reported previously . our results suggest areas where efforts to build knowledge and awareness and to elicit sustained behavior change could further benefit sexual and reproductive health in this marginalized population . the high percentage of women who reported experiencing vaginal discharge or a genital ulcer in the past year likely does not capture the full range of gti - related morbidity in this population as familiarity with the range of associated symptoms was low . a minority of fsws recognized genital ulcers and malodorous vaginal discharge ( table 3 ) as gti symptoms despite high prevalences of hsv-2 and bv . moreover , nearly three - quarters of the women did not seek medical care as their first response to vaginal symptoms whereas pharmacies were the preferred source for medical attention suggesting that self - medication and alternatives to specialized gti services appear to be the preferred recourse . an underutilization of appropriate clinical services and an overreliance on informal sources of health care were further evidenced by findings indicating that 38% of participants with a history of vaginal symptoms reported never having visited an sti clinic or no visits in the past year ; 27% had never tested for hiv and an additional 28% had not tested in the past year . stigma , driven by discriminatory treatment and concerns for confidentiality , is a major reason for reluctance to use free sti clinic services . some in the peruvian context have worked towards strengthening the capacity for pharmacies to provide information and medication based on syndromic sti case management approaches [ 32 , 33 ] ; however the effectiveness of these approaches for fsw populations has not been assessed . although clandestine fsw in this study reported nearly universal consistent condom use with either new or regular clients , much lower levels were reported for noncommercial sex partners such as a regular partner or similar condom use differentials have been reported elsewhere in the region [ 24 , 34 ] . yet , of the 162 women who reported vaginal symptoms in this study , a minority informed their sexual partner and only 56% avoided sex . these findings highlight the need to address both the potential sti transmission to and the burden of sti among stable partners of fsws , themselves a potential bridge population to lower risk segments of the general population . the reproductive health profile of participants revealed an average of 2.5 pregnancies ( sd = 1.3 ) . although reported condom use in the context of commercial sex was high , complementary use of contraceptive methods was lacking . patterns indicate that condoms are perceived principally as sti prevention rather than a family planning method . an integral part of the sti prevention message is the distribution of free condoms at sti clinics . thus survey response on condom use as a contraception method may reflect the lack of integration between sti prevention and family planning programs in peru with respect to these interrelated behavior change objectives . abortion in peru is illegal thus limiting our ability to understand the prevalence of unsafe abortions and their impact on maternal morbidity and mortality [ 3537 ] . previous studies estimated the peruvian abortion rate to be one of the highest in latin america [ 38 , 39 ] . the 68% of ever pregnant women reporting having had at least one abortion is higher than the 53% reported for 514 columbian fsws . given the self - medication behavior through pharmacies as reported in our study and the availability of medications including mifepristone and misoprostol ( ru486 ) , it is plausible that medical abortions are becoming more widely used by this population . this study supports the notion that fsws are not only a vulnerable population due to gti risk and their sequelae , but also because of an elevated risk of reproductive health problems . these risks likely arise from a constellation of disadvantages including limited access to reproductive health information , possible unmet demand for family planning methods and the cumulative effect of seeking to terminate unwanted pregnancies . ( public health polices related to fsws have not changed in the past 10 years , and family planning is currently not included in the protocol of sti clinical exams for fsws . requesting reproductive health information requires a separate appointment , often at a different clinic . ) . the nearly universal condom use with clients reported in our study of a subpopulation of fsw who were relatively new to commercial sex or did not attend public sti clinics suggests a noteworthy achievement of a proactive approach to sti and particularly hiv prevention in peru since the 1990s . nonetheless , the high burden of some stis , bv , and abortions in this population also indicates that a services - access gap likely persists . furthermore , infrequent condom use with stable partners and other noncommercial partners presents a challenge and appears to be particularly worrisome potential source of infection / reinfection with gti . these findings also justify renewed efforts to support outreach services to marginalized fsw populations with integrated behavior change messages that include building awareness of sti symptoms in men and women , promoting availability of free sti services and alternative hiv testing sites , and educating fsws to differentiate appropriate healthcare - seeking behavior from inadequate self - medication patterns . data reported here also highlight the urgent need both to integrate family planning and reproductive health services into existing client - friendly sti clinical services and to stay abreast of innovation in female - controlled methods that expand options to prevent pregnancy and sti , particularly during sex with those intimate or non - commercial partners who are unlikely to use condoms .
sociodemographic and behavioral characteristics of 212 peruvian female sex workers ( fsws ) were analyzed . 
 the association between genital tract infections ( gtis ) and risk factors by multivariate analysis was evaluated . 
 eighty - eight percent of fsws were diagnosed with at least one gti ( hsv-2 80.1% , bv 44.8% , candidiasis 9.9% , syphilis seropositivity 9.4% , trichomonas vaginalis 2.4% , hiv seropositivity 2.4% ) . reported condom use with clients was nearly universal ( 98.3% ) , but infrequent with husband / regular partners ( 7.3% ) . in multivariate analysis bv 
 was negatively associated with more consistent condom use ( prr = 0.63 , 95% ci , 0.420.96 ) . 
 many had not visited a sexually transmitted infection ( sti ) clinic or been tested for hiv in the past year ( 40.6% , 47.1% , resp . ) . 
 nonclient contraceptive use was low ( 57% ) and induced abortion was common ( 68% ) . high gti burden and abortions suggest that a services - access gap persists among marginalized fsws 
 . continued health outreach programs and integrating family planning and reproductive health services into existing sti clinic services are recommended .