Termination of pregnancy TOP was illegal and therefore not officially offered.
The use of SRH services and commodities by FSWs was overall insufficient and the coverage of the peer outreach limited The intervention package that was developed intended to address, where possible, the gaps detected and is described in detail elsewhere In brief, the targeted component comprised the strengthening and expansion of the peer outreach activities, the provision of additional services at the Night Clinic, and clinical outreach. The number of peer educators PEs , comprising both Mozambican and foreign FSWs, was increased, a micro-planning approach was adopted based on the Avahan model 26 , the geographical range and scope of services was expanded, and additional training conducted.
At the Night Clinic, lubricants, female condoms, contraceptive implants, emergency contraception and referral for cervical cancer screening were added to the scope of services. Clinical outreach services, offering HIV testing and condoms, were conducted during 5 months by one NGO, and the same services, plus STI screening and contraception, were offered throughout the intervention period by another NGO.
To improve access to public services, a focal point for FSWs was appointed at four of the eight public health centers, who served as the contact person for FSW-related issues and regularly met with FSW representatives. Linkages were strengthened by establishing referral systems between the Night Clinic, outreach services and the public health services, and having regular joint meetings.
The intervention was gradually implemented from mid onward and evaluated during the first months of The evaluation assessed whether the intervention was feasible; acceptable to policy makers, health managers and providers; reasonable in cost and sustainable; effective in increasing uptake of services and acceptable to FSWs; and equitable. It applied a convergent parallel mixed-methods design 27 , The results of the other evaluation components feasibility, acceptability, and sustainability are available online Quantitative indicators of service uptake were measured at baseline and end-line through face-to-face interviews of a representative sample of FSWs recruited by respondent-driven sampling 30 , Both surveys were independent from each other and did not necessarily include the same FSWs.
Procedures at baseline have been detailed elsewhere 18 , 21 , 29 and were identically repeated in the second survey. Some of the recruitment chains died rapidly and an additional five seeds were therefore recruited. The questionnaire assessed if the FSW had a need for different SRH commodities and services condoms, contraception, STI care, HIV testing, HIV care, cervical cancer screening and sexual violence services , if the FSW had used the service, where the services had been obtained, satisfaction with the availability of services, and exposure to peer outreach.
Prevalence estimates and confidence intervals were calculated, adjusted for the unequal probability of inclusion due to varying social network sizes and the similarities in characteristics of persons within social networks using the Stata Version Nationality and city of residence were included in all models. For those who had sought care, we calculated prevalence estimates of where FSWs had most recently sought care and assessed for statistically significant changes, adjusting for nationality, city of residence and time residing in the area. Participants were recruited by the PEs and were at least 18 years old.
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The number of participants per FGD ranged from five to nine. Using a semi-structured guide in English or Portuguese, a moderator explored where FSWs sought SRH services and why, perspectives toward the availability of SRH services, changes over the past 2 years, and persisting barriers to care.
The topics discussed with the FSW PEs included their appreciation of the feasibility, adequacy, effectiveness, and sustainability of the peer outreach activities. The discussions were audio-recorded, transcribed, and analyzed using NVivo 11 QSR International independently by two researchers. The FSW transcripts were deductively and selectively coded 32 , applying an axial matrix with in the Y -axis the themes choice of place where SRH care sought, availability and quality of services, and barriers to access and in the X -axis if the appreciation was positive or negative, and changes over the past 2 years.
All study participants gave written informed consent; confidentiality was safeguarded through the use of non-identifying survey codes and storing information in password-protected computers. Table 1 presents the characteristics of the participants of the two surveys. In the second survey, there were relatively more FSWs who resided in Tete City, had Mozambican nationality, were single, resided in the area for more than 3 years, and had a large number of clients.
There were also differences in number of non-commercial partners fewer in the second survey , proportion reporting HIV-positive status lower , and proportion reporting to have been forced to have sex higher. Table 1. Characteristics of study participants in the pre- and post-intervention surveys. Most participants were residing in Moatize, the median age was 26 years, the median number of years doing sex work in the Tete-Moatize area was three, and the median number of clients in the past week five.
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The sociodemographic characteristics of the FGD participants by type of participant are summarized in Table 2. Eleven were operating in the city of Tete and five in the city of Moatize. Table 3 compares uptake of SRH commodities and services over time. Substantial and—after adjusting for relevant confounders—significant increases were observed in consistent condom use with all partners We did not observe an increase in condom use at last sex with a client or care seeking for SGBV.
Table 3. Use of sexual and reproductive health commodities and services by female sex workers. Those who had a contact received condoms more often The increase in uptake of services, as measured by the composite index, differed between sub-populations Table 4. Table 4. Changes in the proportion accessing all sexual and reproductive health services, by characteristics of female sex workers.
Mozambican full-time FSWs stated that in particular the availability of male condoms and peer outreach improved, while Mozambican occasional FSWs remarked on the rise in availability of condoms and lubricants, but even more so for HIV testing and cervical cancer screening. There are changes, because with the help of the peer educators, advice as well, from the community-advisors, there is a lot of change. Mozambican full-time FSW. Looking back, it improved in fact, when you go there they receive you with urgency. Occasional Mozambican FSW. Zimbabwean FSWs held different views.
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Some felt that the availability had improved, but others not. We observed that, over the study, condoms were significantly more often obtained from PEs and organizations and less from the market or stalls, shops or supermarkets, public health facilities, and the Night Clinic. Compared to baseline, contraception, STI care, and HIV testing services were relatively less often procured at public health facilities post-intervention. Nevertheless, despite these declines, public facilities continued to be the most common source of SRH services.
Also, over the course of the study, the percent using services at the Night Clinic was lower than at baseline, although that these decreases were not statistically significant. Table 5.
Procuring services outside the Tete-Moatize area, mostly in the area where the FSWs were from, continued to be important, particularly for cervical cancer screening Focus group discussion participants mentioned the same sources for SRH commodities and care reported by the cross-sectional survey participants: mostly public health facilities, the Night Clinic and outreach services, and sometimes pharmacies or the market.
Mozambican occasional FSWs attributed the improved availability of HIV testing, condoms, and lubricants to the outreach. In relation to the past.
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Only these days we always see them and they come with all you need and they give it to you. The Mozambican FGD participants mentioned cost as the most important reason for choosing the Night Clinic or public facilities, because the services are free, while one has to pay at pharmacies, the market or traditional healers. The second most important motivation for a particular service provider was proximity. Zimbabwean FSWs also mentioned cost and proximity, but for these women, being treated with respect and feeling secure were stronger influences on their choice of provider.
These were given as a reason for procuring services in Zimbabwe, where they are less stigmatized. Zimbabwean FSW. Some of the Zimbabwean FSWs mentioned that levels of health worker abuse had reduced since the FSW focal points were introduced at public health facilities. It depends where you go. When you go where there is someone who represents the sex workers, they receive you well and you even do not have to stand in line. You arrive and they help you. The PEs also noted that the appointment of focal points at selected health facilities was a very useful approach and said to have had a positive effect on accessing the services.
Nevertheless, the fact that not all providers had been trained in FSW-friendly services still hampered access, in the event that the focal point was not present. This appeared to be facility-specific, with some facilities not having this problem, and, concurring with what the FSWs said, non-Mozambican FSWs still appeared to suffer more from discrimination by some providers than Mozambicans. She took the register and started to laugh. Table 6 shows the results on the responses given when women were asked, post-intervention, if they were satisfied with the availability of different SRH commodities and services.
Table 6. Satisfaction with the availability of sexual and reproductive health SRH services. In particular the availability of male condoms was said to be very good. Barriers to access were explored in the FGDs. The most common barrier to access public health facilities or the Night Clinic mentioned was the frequent stock-outs of certain family planning methods and STI drugs, in which event they were bought at pharmacies or the market. For example, some days ago I was bad with discharge.
I went to the hospital, made an appointment, they said I needed Kanamycin and pills, those that you insert in the vagina. The practice of public health providers asking for bribes persisted. This was in particular the case for obtaining TOP or post-abortion care. A common practice in TOP appeared to be to first seek medicines from traditional healers or at the market and then go to a health facility for post-abortion care vacuum aspiration.
However, high prices were often asked, also at the public health facilities. It is available, yes. But when you go there after an abortion, to have a washing, you have to give money, at least a little bit, to be attended. Mozambican occasional FSW. Participants agreed that disrespectful treatment by public health providers had diminished, but still persisted, at least by some providers. It was only insults, contempt and they only insulted you, insulted you.
But now, it is better. They do with more fear. I was sick, uh, instead of giving me advice, she only made it worse with insults. Zimbabwean FSWs complained more strongly about persisting ill treatment and said that often Mozambicans do receive treatment, but Zimbabwean FSWs do not. They recommended that these services should be offered at the Night Clinic. This is visible in MaRo's own discussion of this situation, where he describes the iteration between these two cards as "contradictory" given the magic rules framework, and his ruling was based on a personal philosophy rather than any logic of the rules.
Even in MaRo's original ruling, he claimed that the interaction could go either way. In this case as highlighted by MaRo's later ruling , a player can still conceded the game at any time. This makes it a 2-card 0-mana win combo, which is the simplest first turn win combo in all of magic.
The downside? Sign up to join this community. The best answers are voted up and rise to the top. Home Questions Tags Users Unanswered. Asked 6 months ago. Active 5 months ago. Viewed times. Errata: You pay any costs for the drink. Ignore all errata. Zags Zags The first linked article, authored by Mark Rosewater and published on the Wizards of the Coast official website contains the following statements: I wear many hats at Wizards of the Coast, one of which is that of silver-bordered rules manager.
If you have a question I didn't address, you can write to me at my blog for an answer. You actually found an official reference to the blog. Good job. I do not agree at all that this gives the rulings the "same force of authority", but it does mean that they can be considered "rulings" rather than "opinions". If I ask Magic rules manager Eli Shiffrin a question on social media, the answer is treated as a final and binding ruling on the issue, because he is the highest authority on the Magic rules, and the medium he uses to convey information doesn't change that.
I see no compelling reason not to treat silver-bordered rules manager Mark Rosewater's answers about silver-bordered cards the same way. Malco's answer highlights the danger of using things like social media as a source of authority for things like this. Social media is very poorly suited as a medium for conveying information that should be presented in a living document like card rulings. In typical silver-border fashion, things have gotten a bit contradictory March 10, So who pays?
Malco Malco 6, 20 20 silver badges 56 56 bronze badges. We explored these possibilities. We assumed that infection among workers at refusing venues was similar to prevalence at participating venues, but if not, PLACE could overestimate prevalence. Obtaining a sufficient size sample is generally not a problem for venue-based sex worker surveys because protocols typically identify replacement venues to ensure targets are met. We did not anticipate that 19 of 64 venues would refuse participation or close prior to Spring Festival. Recruiting from additional venues during Spring Festival was not feasible.
Because we interviewed and tested female workers at PLACE venues regardless of whether they reported sex work or not, we can estimate the percentage with a positive test among subgroups of workers most likely to include women actually engaged in sex work who deny it. The percentage of all female workers with a positive test including women who reported one or no sexual partners in the past year was 6. Several scenarios could result in the RDS estimate being too low. Underestimates could arise if: 1 infected subgroups were not linked through the peer network; 2 if the interview location was less accessible to those infected; 3 if participants who refused testing were more likely to be infected than those who agreed to testing; or 4 if a large number of respondents did not meet the eligibility criteria eg, because somehow screening methods were not effective or definitions were not clear, or the incentives attracted people who were not eligible.
We explored these possibilities in a limited way. RDS recruited few sex workers from Liuzhou counties. The finding that RDS missed geographic pockets of sex workers has been previously reported, 24 and in hindsight, establishing RDS offices in the counties may have increased participation from the counties, albeit at the risk of significantly increasing costs and introducing the complication that different recruitment sites may not recruit from the same network.
If the comparison were limited to sex workers in urban districts, the prevalence ratio would drop from 3. Only two of six recruitment chains had more than two infections See figure 2. Three chains with two or fewer infections primarily recruited from karaoke bars or karaoke TV. Because the RDS assumption of non-preferential recruitment constrains study managers from guiding the referral process toward members of the population who are likely to be missed, it is possible for recruitment chains to become trapped in low or high prevalence networks.
There is also some indication that the RDS prevalence estimate would have been higher if all RDS recruits had agreed to be tested. RDS recruitment chains. Red indicates a positive rapid test. Blue indicates a negative rapid test. No color represents missing data. Triangles represent women working at karaoke venues. Another possible explanation for the difference is that the PLACE sample captured women who were more frequently engaged in sex work whereas the RDS sample recruited people who were at lower risk because they less frequently engaged in sex work. It is difficult to fully assess the risk profiles of each group without information on the level of infection among clients, but there was no difference in the number of partners reported by PLACE versus RDS participants.
This study illustrates the challenges of surveillance among hidden populations. Two different sampling methods resulted in significantly different characterisations of the same target population.
A comparison of respondent-driven and venue-based sampling of female sex workers in Liuzhou, China
We focused on syphilis, but the findings are relevant to other sexually transmitted infections and relevant sexual risk behaviours as well. Our study confirms that countries should exert caution in selecting or changing surveillance methods 2 and illustrates the shift in estimated prevalence that can arise with a change in sampling methods. Concurrent implementation afforded insights into each method. We recommend that surveillance activities routinely include investigation of bias.
For venue-based methods, the proportion of non-venue-based sex workers should be estimated. The characteristics of venues that refuse and substituted venues and reasons for refusal should be analysed to assess sample representativeness. Venue-based studies may also want to assess bias arising from denial of sex work, possibly through a longer survey or an indepth interview of a subset of workers who initially deny sex work. Although obtaining information on the female workers who were not sex workers allowed useful exploration of survey bias and important information on another group at risk of infection, the PLACE method was not as efficient in obtaining a large sample of sex workers as other venue-based methods that screen out non-sex workers from the survey.
RDS studies would also benefit from routine investigation of key assumptions. Insight on recruitment bias and its impact on the RDS estimates can be gained by obtaining information on the characteristics of people in a participant's network, including network alters who were not invited to participate. Concurrently implemented surveillance protocols using different sampling methods can obtain different estimates of prevalence and population characteristics.
We recommend that more research be conducted on measuring bias in bio-behavioural surveillance estimates. We thank JL for her excellent work as study coordinator, and the physicians and the outreach workers in the study area for their hard work. We acknowledge the contribution of Dr Myron Cohen. Contributors: SSW: Overall PI for the study, responsible for implementation of the venue-based arm, and primary writer of the manuscript.
X-SC: Co-PI responsible for oversight of syphilis testing, field work, and implementation, contributed to interpretation of results and analysis. JKE: Responsible for multivariable analysis and review of paper. CMS: Responsible for overall technical oversight of all statistical issues and review of paper. JL: Responsible for interviewer training, day to day coordination of field work, data quality, review of manuscript, resolving data issues and data entry. GEH: Responsible for identification of study location, facilitating collaboration with people in China and review of manuscript.
Competing interest: The authors have no conflict of interest to declare. The opinions expressed are those of the authors and do not necessarily reflect the views of any government. Provenance and peer review: Commissioned; externally peer reviewed. National Center for Biotechnology Information , U. Sexually Transmitted Infections. Sex Transm Infect. Author information Article notes Copyright and License information Disclaimer.
Accepted Aug This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. This article has been cited by other articles in PMC. Abstract Objectives To compare two methods for sampling female sex workers FSWs for bio-behavioural surveillance.
Methods For the PLACE protocol, all female workers at a stratified random sample of venues identified as places where people meet new sexual partners were interviewed and tested for syphilis.