Conceptualizing the impact of indirect violence on HIV risk among women involved in street-level prostitution

Drawing on a review of the existing literature and on the knowledge derived from many years of direct work with sex workers in the inner city, we conceptualize the mutually reinforcing relation that exists among violence, drug use, and risk for HIV/AIDS among women involved in street-level prostitution. While recognizing the centrality of violence victimization, we call attention to the need to examine exposure to indirect (or witnessed) violence (when the person is the witness rather than the direct victim of violence) as a factor that increases drug- and sex-related HIV risk in this population. Specifically, we hypothesize that the emotional sequela that results from continued exposure to indirect violence has a direct effect on patterns of drug use (including drug use initiation, relapses, and changes in quantity, frequency, and mode of ingestion), and increases women's vulnerability to sexual transmission of HIV by making them more vulnerable to sexual attacks, and less able to demand use of condoms. The impact of indirect violence is especially detrimental when the woman witnesses serious violent acts against other sex workers.