Association of Violence Against Female Sex Workers Who Use Drugs With Nonfatal Drug Overdose in Kazakhstan

This cross-sectional study examines the association between intimate partner violence, nonpartner violence, and nonfatal drug overdose among female sex workers who use drugs in Kazakhstan. Question Is violence against female sex workers (FSWs) who use drugs associated with an increased risk of nonfatal overdose in Kazakhstan? Findings This cross-sectional study of 400 FSWs who use drugs found that intimate partner and nonpartner violence, especially severe physical violence, were significantly associated with experiencing nonfatal overdose. This study also found that a history of incarceration was associated with increased risk of overdose in this population. Meaning The findings of this study suggest that harm reduction programs must consider the unique needs of women, including services to address gender-based violence and the needs of women after incarceration, to more effectively engage women in overdose prevention efforts. Importance Female sex workers (FSWs) who use drugs face increased risk of intimate partner violence (IPV) and nonpartner violence (NPV). The association between violence and drug overdose is unknown. Objective To examine the association between IPV, NPV, and nonfatal drug overdose among FSWs who use drugs in Kazakhstan. Design, Setting, and Participants This cross-sectional study included 400 adult FSWs in Kazakhstan who reported illicit drug use in the past year, exchanged sex for money or drugs, and reported having unprotected sex in the past 90 days. Baseline data were collected from February 2015 to May 2017 from Project Nova, an HIV prevention study among FSWs who use drugs in Kazakhstan. Data analysis was conducted from April 2019 to March 2020. Exposures Lifetime and recent (past 90 day) experiences of physical, sexual, and psychological IPV and NPV using the Revised Conflict Tactics Scale. Subtypes of violence were identified using exploratory factor analysis. Main Outcomes and Measures Lifetime and recent incidence of nonfatal overdose; sociodemographic characteristics as well as lifetime and recent sex work and drug use behaviors were also collected. Results The 400 participants had a mean (SD) age of 34.1 (8.4) years. Most experienced food insecurity (358 [89.5%]) and homelessness (232 [58.0%]) in the past 90 days; one-third (130 [32.5%]) reported a history of incarceration. Most (359 [89.7%]) experienced some form of violence; 150 (37.5%) reported a lifetime nonfatal overdose, of whom 27 (18.0%) reported nonfatal overdose in the past 90 days. Lifetime severe physical violence (adjusted odds ratio [aOR], 1.27; 95% CI, 1.02-1.59; P = .03), engagement in sex work for more than 10 years (aOR, 2.54; 95% CI, 1.50-4.28; P < .001), and a history of incarceration (aOR, 4.34; 95% CI, 2.58-7.32; P < .001) were associated with greater odds of nonfatal overdose. Engaging in sex work for more than 10 years (aOR, 3.97; 95% CI, 1.36-11.61; P = .01) and a history of incarceration (aOR, 3.63; 95% CI, 1.39-9.48; P = .008) were associated with greater odds of recent nonfatal overdose. Conclusions and Relevance In this study, violence against FSWs who use drugs in Kazakhstan was associated with increased odds of nonfatal overdose. Harm reduction programs for women should consider including services to address gender-based violence and the needs of women after incarceration.