Background
Female sex workers (FSWs) and injection drug users (IDUs) are often categorized as two of the four populations "most at risk" for becoming infected with HIV due to behaviours that heighten their vulnerability to the virus. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), the term, "most-at-risk populations" (MARP), refers to men who have sex with men, injection drug users, sex workers and their clients.
These risk behaviours are believed to drive the HIV epidemics in western countries, former Soviet republics and Asia, where HIV is concentrated in specific populations [
1].
Interventions for MARP tend to focus on the needs of adults, with the objective of reducing their risk for HIV through prevention, behaviour-change education and risk-reduction strategies. But, to date, little attention has been paid in the published literature to the vulnerabilities faced by their children or to interventions focused on keeping these potentially vulnerable families together, improving the wellbeing of both parents and children, and reducing the risk of both generations for becoming infected with or transmitting HIV.
This review aims to synthesize evidence from disparate sources (including research, advocacy and programmatic information) describing the vulnerabilities and sources of resilience of the children of female sex workers and drug users, and to document the two selected models of care in low-and middle-income countries that have been put in place to assist these groups. In the following sections, we analyze peer-reviewed and grey literature to begin to answer four research questions:
1.
What are the vulnerabilities faced by the children of drug users and FSWs?
2.
What are their sources of resilience?
3.
Are there interventions that have focused on mitigating the vulnerability of children and addressing the needs of these families?
4.
What do we know about the effectiveness or impact of these interventions?
While our original objective for this literature review was to focus specifically on the children of female sex workers and injection drug users in low- and middle-income countries, we found very little information specific to the children of IDUs. However, we did find a great deal of published work more broadly focused on drug and alcohol addiction in general. Likewise, we found that the most relevant literature on the children of drug users is from developed countries, and the United States in particular. As a result, we broadened our original scope in order to draw inferences from the global literature about the children of drug users of any type in low- and middle-income countries. By contrast, the literature on children of sex workers globally is limited, but the majority of the information we did find is focused on lower resource countries.
Synthesizing what is known about the types of vulnerability and resilience experienced by children of these groups, the types of assistance families need to minimize children's vulnerability, and the effectiveness of the interventions that exist is useful for several reasons. First, attention needs to be drawn to the reality that sex workers and drug users are often parents whose children potentially face vulnerabilities unique to their family situation. Second, understanding the needs of these children is necessary for creating relevant, evidence-based interventions focused on supporting their families. Finally, documenting the types of care that do exist and assessing their effectiveness is critical for scaling up and adapting successful interventions to new contexts.
Literature review methodology
This literature review utilized both electronic and manual search methods to locate relevant peer-reviewed articles and grey literature from all low- and middle-income countries. We expanded our inclusion criteria to all countries regardless of income level only after our search for sources from lower resource contexts turned up little useful information. The following online databases and search engines were searched to identify relevant studies:Ovid/Medline, PubMed, Child Development and Adolescent Studies, PsychInfo, Published International Literature on Traumatic Stress, Sociological Abstracts, Social Services Abstracts, Web of Science, Google Scholar, Popline/One Source, the New York Academy of Medicine Grey Literature Report, and Public Affairs Information Service Archive. Organizational websites and references of all relevant sources were searched manually.
Our search paired the terms "parent", "child", "youth", and "orphan" with the following, using various combinations: "most-at-risk populations", "risk factors", "vulnerability", "resilience", "HIV/AIDS", "commercial sex worker", "female sex worker", "prostitution", "drug user", "drug use", "substance abuse", "substance abusing parents", "addiction", "intervention", "child care", "education", "prevention", "child victims", "injection drug use", "child welfare", "parent-child", and "child of impaired parents".
We also contacted staff from relevant programmes to ask about interventions being implemented for children of sex workers and drug users. Correspondence and phone interviews with these key informants provided the most relevant information on interventions in low- and middle-income countries.
Terminology and definitions
This review faced a number of semantic challenges. First, the definition of "sex work" is profoundly unclear and runs a wide gamut of very different types of transactional sex, including but not limited to: brothel-based prostitutes; waitresses or bar girls who sell sexual favours within the establishments where they are employed; street walkers; dancing girls; caste-based devadasis in India; kanjar families in Pakistan; and courtesans or in taiwaifs South Asia who entertain men they call "husbands" and receive cash and other material gifts.
We looked at the children of sex workers who sometimes run the risk of entering the profession or being trafficked, but not at children who have been trafficked or who have entered prostitution through means other than "inheriting" it from their mothers. Nor did we examine the relationship between the children of FSWs and their fathers, who are often their mothers' clients (i.e., the fourth MARP category). For simplicity, we use the term, "female sex worker", to include all categories of women participating in transactional sex. We did not find information on the children of male sex workers.
As mentioned, the focus of this paper was shifted from the children of IDUs specifically to the children of drug users more generally to encompass the drug use or substance abuse literature, which includes research on the impact of all forms of parental drug use (including alcoholism) on children. While drug injection is specified in the literature on populations most at risk for HIV, we opted to include the more general drug use literature to inform our discussion of child vulnerability and resilience. But the intervention we describe later is specific to mothers who inject drugs.
Finally, we set out to look at the vulnerabilities and resilience of, and interventions for the children of drug users and sex workers, using search terms specific to each group. However, overlap between these two groups is common as drug use can create a gateway into sex work and vice versa [
2‐
4]. We present information that is either generalizable across the two groups or distinct to each; however, we were not able to find data assessing the impact of "co-morbidity" on children whose parents are both drug users and sex workers.
Estimating the number of drug users and female sex workers who are parents
Estimating the number of people within most-at-risk populations who are parents is extremely difficult. Drug users and sex workers are often parents, although this fact has generally been ignored in the MARP literature.
As noted by the UNAIDS Reference Group for Estimates, Modelling and Projections, "estimating the numbers and associated prevalence for high risk populations is a fundamentally difficult exercise" [
5], creating a gap that undermines the validity of national estimates of HIV prevalence in concentrated epidemics [
6]. For instance, while the United Nations Office on Drugs and Crime estimates 18-38 million "problem drug users" and 11-25 million injection drug users worldwide [
7], we could not find global estimates of the proportion of drug users who have children.
Some country-specific estimates of children living with drug users have been calculated based on national household data. For instance, almost half a million children in the United Kingdom live with parents who reported drug use and problem drinking in the past year [
8]. Not surprisingly, similar estimates of the number of children affected by parental drug use are not available for countries without similarly sophisticated, national healthcare tracking systems.
Overall global estimates of the number of female sex workers also could not be found. A global estimate of 40 million is sometimes cited by activists, but we were unable to find the source of that estimate. Vandepitte
et al provide prevalence estimates of sex workers in urban areas of sub-Saharan Africa (0.7%-4.3% of the population), Asia (0.2%-2.6%), former Soviet countries (0.1%-1.5%), eastern Europe(0.4%-1.4%), western Europe (0.1%-1.4%) and Latin America (0.2%-7.4%) [
9]. But they admit that their method of arriving at these estimates is precarious at best (and most likely conservative) due to inconsistent definitions of what sex work entails.
Likewise, global estimates of the number of sex workers who have children or of the number of children whose mothers are sex workers could not be found. Total fertility rates of sex workers globally have also not been documented in the searchable literature. While HIV and other sexually transmitted infections can reduce female fertility [
6], the increased frequency of coital acts among sex workers also increases their exposure to pregnancy, arguably rendering their fertility to be little different from that of the general population. A study from Kenya reported that the mean number of children per their 385 sex worker respondents was 3.4 (± 2), making them comparable to the national mean of 3.2 [
2].
Vietnam was the only country found to specify children of sex workers and drug users as vulnerable, along with children who have been trafficked, street children, and children who are themselves engaged in drug use and sex work. While the Ministry of Labour, Invalids and Social Affairs (MOLISA) is able to give estimates of the numbers of children who fall into the latter categories, it indicates that data is not available on children of sex workers or drug users [
10].
Sources of vulnerability and resilience for children of drug users and sex workers
The children of drug users and sex workers can face unique risks, stigma and discrimination as a result of their parents' addictions or profession. However, this potential vulnerability can be ameliorated by potential sources of resilience connected to support networks, parent health, parent-child bonding, education, economic situation and other environmental factors [
11]. Research on the children of drug users in general focuses on their vulnerability to numerous forms of deprivation and abuse. A review of key articles from the past two decades yields a relatively long list of possible negative outcomes for children, ranging from cognitive developmental delays to neglect and abuse as a result of prenatal and postnatal exposure to parental addiction. However, research findings on the determinants of these various risks tend to be inconclusive, with family and community support networks, parental physical and mental health, and other socio-economic and environmental factors mediating child development outcomes and resilience [
11‐
23].
The primary limitation of these research findings on possible vulnerabilities faced by children of drug users is that they come almost solely from high-income countries. Arguably, the risks and sources of resilience faced by children of addicted parents are potentially similar in contexts where certain drugs are illegal, drug use is stigmatized, and rehabilitation and risk-reduction programmes are difficult to access, if available at all. Overall, though, the generalizability of the information to low- and middle-income countries is unknown. At best, these findings can be useful for establishing research questions to be answered in lower resource contexts.
The literature on the children of sex workers, by contrast, is very small and, with a few exceptions, largely qualitative and ethnographic. While some useful articles look at US-based sex worker populations, most of the relevant research focuses on south Asia and Kenya. Specific vulnerabilities documented as affecting children of sex workers include: separation from parents, sexual abuse, early sexual debut, introduction to sex work asadolescents, low school enrolment, psychosocial issues arising from witnessing their mothers' sexual interactions with clients, and social marginalization [
2,
3,
24‐
29]. The research on sex workers and their families tends to have a particular focus on girls and their potential for sexual abuse, early sexual debut, witnessing adult sexual activity, grooming to enter the trade, and trafficking. Sex work is often handed on from parent to child as the family trade in some cases, or out of a real or perceived lack of other options [
28,
30].
Sources of potential resilience for children of sex workers are also dependent on a complex combination of economic, environmental and social factors. Pardeshi and Bhattacharya found that
devadasis had strong family support in their native villages [
27]. While many of these women sent their children to their village homes to live with extended family, they remained connected with their children and visited at least once a year. Women who kept their children with them reported their income, peers, and brothels organized around native villages as sources of support. In Kenya, the more educated a sex worker was, the more likely she was to prioritize education for her children [
2].
Examples of family-centred interventions
Some interventions have been implemented in low- and middle-income countries to assist families of drug users and sex workers, but they tend to be small, piecemeal and struggling to meet demand. The few interventions directed at children of FSWs and drug users that we did find all started with a focus on adults, but expanded their services as parents sought care for their children. Family Health International, for instance, started providing health care to children of at-risk parents in Cote d'Ivoire as more parents started seeking care. Many of these parents had previously been unable to access support because their children do not fit the national definition of an orphan or vulnerable child.
MAMA+ for IDU
Most information about family-centred care models for children of drug users comes from developed countries [
12‐
14,
16,
31,
32]. As Zuckerman notes, an addicted mother's interest in her baby is often the "healthiest" part of her life. But this interest is a double-edged sword that can exacerbate feelings of failure as much as provide a positive impetus to begin methadone maintenance or enter a rehabilitation programme [
13,
33].
In the US, drug rehabilitation programmes traditionally focused on the needs of men and did not accommodate a mother's reluctance to leave her children in order to enter residential treatment programmes. This started to change in the United States in the 1990s with the development of outpatient, family-focused treatment integrating screening of mothers during pregnancy for addiction and drug rehabilitation counselling, with, for example, primary health care for mothers and their children, legal assistance, food assistance and housing [
13].
The MAMA+ for IDU project in Ukraine is the single programme outside of developed western countries for which we were able to find solid, if limited, information on provision of services to children or families of IDUs. As can be seen in Table
1, the integrated, family-centred, "one-stop shopping" model of care offered by MAMA+ is similar to that pioneered in the United States by Zuckerman and others during the 1990s [
13].
Table 1
MAMA+ for IDU, Ukraine
• Early identification of HIV+ pregnant women and mothers with young children | • Psychological consultations | • Drug and alcohol rehabilitation |
• Identification of pregnant women at risk of abandoning infants | • Peer network and peer support groups | • Substitution therapy |
• Comprehensive antenatal and post-delivery healthcare referrals | • Legal assistance | • Other (non-specified) |
• Referrals to harm-reduction services | • Material support | |
• Home visits | • Child development consultations | |
• IDU team comprised of team coordinator, social workers, medical professional, drug and alcohol abuse consultant, psychologist and lawyer | | |
MAMA+ for IDU was piloted by Health Right International in Ukraine with funding from the Open Society Institute as an extension of the
United States Agency for International Development (USAID)-funded Prevention of Abandonment of Children Born to HIV-Positive Mothers programme (called MAMA+) offered to HIV-positive, pregnant women in Russia and Ukraine [
34]. The original project set out to reduce the number of children abandoned by HIV-positive mothers through the establishment of networks of agencies and specialists to identify seropositive pregnant women and mothers. The programme identified the primary drivers of abandonment as lack of information on HIV/AIDS and prevention of vertical transmission; stigma and discrimination at medical and social institutions and by families; financial pressure and homelessness; unplanned pregnancy; and lack of social and peer support.
Thirty-five percent of MAMA+ clients were IDUs, but in the original incarnation of the intervention, their drug addiction was not taken into consideration as a risk factor requiring additional support. In order to adequately meet the needs of this substantial portion of their target group, MAMA+ conducted a six-month pilot intervention focused on providing drug-addicted women with drug and alcohol counselling, risk reduction, legal assistance and referrals [
34].
The referral network was adapted to include harm reduction, drug-substitution therapy, and rehabilitation programmes. A drug and alcohol addiction consultant was hired, and new peer support groups started, focusing on the challenges created by dependence on illegal drugs. The comprehensive approach combined early identification and enrolment with home visits, and provided material, psychological and legal support (Table
1). Within six months of launching the project, 25 HIV-positive IDU pregnant women and new mothers were benefiting from services, in addition to 27 children and 19 other family members.
TASINTA for children of sex workers
We found information on 18 organizations providing care for the children of sex workers in Bangladesh, Cote d'Ivoire, Kenya, India, Nepal, Vietnam and Zambia. The information available on the programmes was largely gleaned from Internet searching and correspondence and phone interviews with programme implementers. It is, therefore, limited in terms of programmatic detail, information about the population served, and effectiveness or long-term impact.
The interventions we found tend to provide multi-faceted assistance to mothers and children across several categories, providing children with educational opportunities and a safe place to play, study, or sleep when their mothers are working. Likewise, the same programmes provide vocational training and alternative income-generation opportunities to mothers who want to leave sex work or reduce the number of clients they need to entertain in order to provide for their families. Other types of assistance provided include peer support, nutrition, housing and healthcare.
TASINTA (We Have Changed), started in Zambia in the 1990s, is the programme for which we were able togather the most comprehensive information [personal communication, Nkandu Luo]. TASINTA started as a programme to help sex workers protect themselves from HIV, but input from the women themselves made it clear that a more broadly based, family-centred approach was necessary. A list of TASINTA's services to FSWs and their children is provided in Table
2.
Table 2
TASINTA (We Have Changed), Zambia
• After-school drop-in centre | • Partnership with two institutions (Kasisi Orphanage and Hope House) to provide residential care and schooling for orphans | • Drop-in centre where mothers can learn alternative skills | • Assistance with school Fees | • Help women rent homes |
| | • Grants for small business start up | • After-school drop-in centre | • Reunite women with children living with extended family |
| | • Sponsorship of higher education courses for women with secondary school education | • School-age orphans attend boarding school at Hope House | • Partner with police and government to reduce exploitation and recruit women into programme |
| | • Programme participants become trainers and employees | | |
TASINTA's partnership with residential care facilities to serve as a boarding school for children whose mothers have died may at first seem antithetical to the family-centred care model. However, it appears that TASINTA is redefining family beyond the bounds of biological relationships in the best interests of the child to include what Richter calls "long-term, mutually supportive relationships" [
35].
After experimenting with reuniting orphans with extended family, TASINTA found that it was no longer able to monitor the care and safety of children and faced a situation where family members were selling the children into prostitution. Programme managers and clients working for the organization found themselves, not infrequently, searching for children and rescuing them: hence, the decision to place them in a residential environment they knew to be safe and where the children can remain close to adults they know and trust.
Competing interests
The authors declare they have no competing interests.
Authors' contributions
The paper was written by JB, and GB designed the literature search protocol, carried out research, and drafted and revised the manuscript. JC and JLS participated in drafting and revising the manuscript. MIB, MO, MB and DF designed the literature search protocol, carried out research, and contributed to the written content. All authors read and approved the final manuscript.