**6. Methods**

278 Immunodeficiency

hardest hit.

Although harm reduction is most commonly applied to reducing harms related to drug use (especially intravenous drug use), harm reduction principles are increasingly being applied to sex work. The harms associated with sex work include the vulnerabilities that may lead to sex work, the harms that are introduced by engaging in sex work such as stigma [13], criminalisation, and the mutually reinforcing harms such as problem drug use and in particular injecting drug use [14]. The nature and extent of harms associated with sex work varies with the type of sex market they work in e.g. brothels, massage parlours, escorts, street work, however, the harms are greatest in street-based sex markets [15] and where sex

There are a number of layers in the risk environment in Ireland. In terms of sex work, there is the legal environment which criminalizes sex workers if they work in brothels or if they solicit sex on the streets[17]. Due to policing, risks are increased because sex workers cannot take time to negotiate with clients and assess the safety aspect of the transaction. To decrease their visibility on the street, there is the added risk of sex workers working in badly lit and remote areas where they are more likely to be victims of violent clients. Due to the societal disapproval of sex work, there is the risk of stigma[13] or public disclosure. The use of crack cocaine has been shown to be associated with street sex working in Dublin [18].

In response to the heroin epidemic in the 1980s in Dublin drug treatment clinics and harm reduction services (methadone maintenance, needle exchange programs etc.) were established [19] within a risk environment where illicit drug use is criminalized[17]. Despite the criminality associated with drug use, reported levels of cocaine use in Ireland are above the European average [20] and Ireland also reports the highest estimate of opioid use in the European Union [20]. The Irish Health Service Executive [21] reports that there are 9,264 people in methadone maintenance treatment, whilst it is estimated that there are another 10,000 heroin users who are not in treatment [22]. In the past heroin use was concentrated in Dublin however now it is spreading all over Ireland. Disadvantaged communities are

A tragic consequence of illicit drug use is early death. In Ireland in 2009 (the latest figures available) there were 357 deaths due to illicit drug use. Cocaine was implicated in 52 of these, heroin was implicated in 108 and methadone in 66 [23]. Poly substance (heroin and methadone) use was implicated in 117 deaths. The majority of those who died were aged between 25 and 44 years; the median age was 38 years. Delays in service provision are clearly a factor: drug users seeking treatment have to wait an average of three to 18 months

Although there are adequate health services available for sex workers in Dublin, sex workers are stigmatized [13] on many levels (due to injecting drug use, HIV or HCV infections, and sex working) and may hide their work from health personnel. There is also a high incidence of HCV (70%) among injecting drug users in Ireland [13]. Whilst it is not possible to ascertain the prevalence of HIV among drug using sex workers in Ireland and it is certainly unjust to consider them as vectors of disease, one fifth of the sex workers in our

for opioid substitute treatment depending on the area of Ireland they live in [20].

study [13] self-reported as being HIV positive.

workers' pre-existing vulnerabilities can be exploited [16].

The focus of this research was to gain an understanding of drug-using sex workers' lived experience of risk, in order to understand how the local risk environment (i.e. the physical, social, economic and policy environment) produces risks in their daily life and work contexts, and how drug-using sex workers implement strategies to manage and reduce the risk of harm. A qualitative methodology was chosen as being the most appropriate to answer the research question. Ethical permission for the study was sought and granted from the Drug Treatment Centre Board in Dublin and also from the Prison services.
