An initial gap in service access, HIV prevention and harm reduction for survival sex workers was identified as a key issue through informal conversations between health providers, staff, and sex workers at an inner city drop-in centre. In operation since 1987, Women's Information Safe Haven (WISH) Drop-In Centre Society connects with an estimated 200 women engaged in survival sex work per night. While the mandate is not exclusive to Aboriginal women, over half of the women that come through its doors are of First Nations, Metis and Inuit ancestry. The project works closely with WISH's well-established Aboriginal Health and Safety Project for Women in the Sex Trade (AHIP), as well as other key Aboriginal and sex work collaborators.

In 2004, researchers were approached to collaborate on an initial needs assessment of women attending the drop-in. The results led to the conception and design of both a research and a service arm 29. The service arm focuses on peer outreach, resource development, and ongoing wellness nights at the drop-in that help to support the knowledge translation activities of the research arm. The CBR project partnership, initiated in late 2005, was developed and continues to be supported through active consultation and exchange of information between researchers and community. The community co-investigators represent sex work, Aboriginal, and youth service organizations. The research is guided by a sex-for-work perspective and adheres to participatory-action research methodologies 3233. In particular the project is guided by the OCAP principles of ownership, control, access and possession initially developed by the First Nations' Governance Committee and subsequently adopted by the Canadian Aboriginal AIDS Network (CAAN). Providence Health/UBC Ethics Review Board provided ethical approval for this study. In addition, PACE (Prostitution Alternatives, Counselling and Education (PACE) Society) Policy Group provided community ethics review from a sex work research and policy perspective and the project adheres to these best practices 34.

A key component of the project is capacity-building among a team of women in survival sex work, supported by an open Community Advisory Board (CAB), that inform all stages of the project. Initial CAB tasks were to identify the working role of the CAB and develop a hiring process for peer team of women. The hiring process aimed to ensure a transparent process, including extensive and flexible options for informing and inviting women to contact the project (outreach, community agency visits, open house for women) and the creation of a community-peer hiring panel (CAB members). Through this process, a team of women with a lived experience of survival sex work were hired, trained and support to play an active role in guiding, developing and conducting the research. These positions are low-threshold employment positions that work from a harm reduction perspective, similar to models of other sex work and drug-user groups. There is considerable focus on capacity building and training, as well as ongoing support and referral for addictions counselling, drug treatment, supportive housing, and child care. Extensive training modules were conducted in collaboration with local community agencies and sex work groups, including sex work specific training created and conducted by PACE Society on lateral oppression, vicarious trauma, debriefing and conflict resolution; participatory-action research principles, methodologies, ethics, and informed consent; and health, HIV/HCV prevention, and harm reduction conducted by community health providers, sex work groups, and Aboriginal agencies.

In keeping with community-based research principles, this project adopts multiple research methodologies, including ongoing qualitative focus group discussions, social mapping, and a prospective cohort (6 monthly interview questionnaires and HIV screening) over a three-year period. All focus group discussions are facilitated or co-facilitated by a member of the peer team and inform the 'lived experiences' of survival sex work and barriers to and facilitators for prevention and harm reduction efforts. Individual informed consent is obtained prior to the discussion group and verbal rather than written consent is provided at the time of the interview, due to participant concerns of confidentiality. Discussion groups last approximately two hours and all participants receive Can$25 compensation for their expertise and time.

A particularly novel component of the project is the social mapping, a participatory-action research tool that facilitates community access to hidden populations and highlights local expertise. Initial piloting of the maps with over 60 women facilitated by the Maka peer team has informed subsequent recruitment and outreach efforts for both research and service arms of this project. In particular, women are provided with a map of Vancouver's Downtown Eastside and surrounding communities and asked to mark 1) strolls where they work and live; 2) current working conditions (lighting, phones); 3) high and low risk areas for violence and bad dates; 4) working areas impacted by police presence and harassment; 5) areas of health and syringe availability and disposal.

Given the difficulty in accessing a representative sample of sex workers due to the illegal and clandestine nature of sex work and unknown boundaries of this population 35, mapping and time-space sampling strategies were used to enhance attempts to obtain a representative sample of survival sex workers, supported by standard outreach recruitment strategies used among street-involved populations. Time-space sampling strategy is a probability-based method used to enrol members of a hidden population at times and places where they congregate rather than live 3637, with physical spaces (such as bars, parks, or sex work strolls) rather than persons as the primary sampling unit. Although time-space sampling has been primarily used with MSM populations in gay venues 3637, the adaptation of this strategy to sex work research is promising. Based on sex work strolls identified through the ongoing mapping in 2006, the peer outreach team conducted systematic outreach during staggered working hours (late night, early morning and daytime) and locations (sex work strolls) to invite women to participate. A researcher or nurse accompanied the outreach team during the late night outreach hours to ensure safety through use of a vehicle and facilitate mobile outreach to more dispersed areas. Staggered days of the week as well as times of the month were used to ensure as representative a sample as possible. Following initial recruitment, the majority of women were invited to participate in the interviews the following day at the project office, an area close to several of the strolls. Based on youth consultations and identified barriers among younger women, specific community drop-in and commercial spaces (such as corner stores, coffee shops) were identified close to the strolls to conduct the interview questionnaires with youth. As well, if business was slow, women conducted the interviews during these late night hours and the worker, along with the Maka outreach team and nurse, would chose a safe and private location.

Through time-space sampling, a total of 205 women were initially invited and agreed to participate in a baseline visit over a six month period in 2006 (response rate of 93%), with ongoing 6 monthly follow-up visits scheduled to continue through 2008. Baseline and follow-up include detailed interview questionnaires administered by the peer interviewers and HIV screening by the project nurse, supported by extensive pre and post-test counselling. Women 14 years of age and older who have used illicit substances (not including marijuana) within the last month and are actively engaged in street-level sex work are eligible to participate. Semi-structured interview questionnaires elicit responses related to current and past experiences of sex work, violence and trauma, health and addition service access, working conditions, and sexual and drug-related harms. HIV screening is completed by the project nurse using the INSTI rapid HIV test (Biolytical, Vancouver), and new reactive tests are confirmed by western blot. A pre-test counseling questionnaire is completed by the project nurse on detailed questions relating to overall health, experiences with HIV and Hepatitic C testing, and current and past abuse experiences in order to facilitate counselling and referral to support services. Participants receive Can$25 compensation at baseline and each follow-up visit.

The concern of ensuring privacy and confidentiality of participants requires particular consideration in the sex work context, in addition to raising some key ethical issues related to HIV prevention research. Given the historically oppressive nature of research of sex work, significant concern from the onset by both the community partner and sex work activists was that the research did not further stigmatize a highly marginalized population of women, or falsely precipitate sex workers as "vectors of disease". A concern similarly voiced in other settings across the globe 3941. As such, the involvement of women in sex work and the community partner organization in all aspects of the research, from conception and design, to interpretation and dissemination of results, is a core aspect of ensuring accountability of the research.

Two key ethical issues emerged of important relevance in HIV related research with sex work populations. First, while HIV is a reportable illness using the standard ELISA test, the new rapid point of care test provides women with the opportunity to receive anonymous HIV screening. Women are advised during extensive pre-test counselling that the INSTI test is not a diagnostic test, and a reactive test needs to be confirmed by a western blot, as per standard of care. Women have the choice of being referred to a physician for follow-up testing, or completing the follow-up testing at the Maka Project office. Early findings suggest increased acceptability and utilization of point of care testing among a highly marginalised population of women, with 96% of women agreeing to HIV screening at first visit. Within this context, the role of HIV reportability and disclosure in survival sex work needs to be explored 34, particularly given growing reports of the criminalization of non-disclosure in the Canadian setting42.

Secondly, reporting of violence experienced by youth less than 18 years of age is a major limitation to research with legal minors 43, and has been previously described in this setting among at-risk, street youth 44. A large number of youth (under 18 years of age) are involved in survival sex work, with early research from this project identifying a median age of sex initiation of less than 18 years. Of particular concern, initiation of sex work during adolescents (less than 18 years) was independently associated with a two-fold increased odds of baseline HIV infection 45. It is therefore crucial that sex work research engages adolescent and young women in the research during these critical time periods and identifies HIV prevention strategies tailored to this population. However a requirement by law is that any disclosure of violence among those less than 18 years of age must be reported to health authorities, including exploitation of a minor, thus placing the duty to report on researchers. Given the difficulty in engaging this population and the high rates of violence known among women and youth in survival sex work, this represents a substantial limitation. Further exploration of youth reporting requirements from a policy perspective is warranted, particularly as it relates to sex work and exploitation of minors.

Consistent with recent literature on public health partnerships 46, the CBR research project was developed through a process of co-construction of knowledge in the negotiated space of sex workers, community and the academic partners. This negotiated space is a process inherent in participatory-action research and public health partnerships with marginalized populations as it seeks to confront and reduce power imbalances. Evidence suggests that this transdisciplinary dialogue can propose new ends to public health, rather than applying standardized solutions to health disparities by outside experts 46.

However, a particular challenge to the CBR process in this community has been the balancing of interests of academic and community partners, as well as survival sex workers themselves. Three sets of partners are represented in the research: a service agency for sex workers, survival sex workers, and the researchers. Emerging discussions in community-based HIV prevention research have focused on the challenges of defining a "community" in the CBR process 47. In health, community often refers to individuals who share cultural, social or economic ties and a physical space 48, while others suggest a broader definition of common culture, social structure and awareness of an identity as a group. A particular concern from the onset of this project was that those working in service organizations do not necessarily reflect the voice of women on the street. Sex workers working in service organizations may have different access to resources than those who struggle daily with poverty and addictions, and as such, may have different perspectives on prevention needs. In order to ensure equal representation, our CAB includes at least equal number of survival sex workers. In addition, similar to other peer-based organizations in this community, women were hired into low threshold employment allowing those with survival sex work experience, a voice seldom heard in sex work activism, to play an active role in guiding the research process.

In addition to the many strengths of ensuring active involvement of those currently involved in survival sex work for both sex workers and researchers 383949, there were several challenges that emerged in terms of sustainability of low threshold employment positions for women, and time-investment in the process. The inherent need for significant flexibility in structure of peer positions that support women living with addictions and poverty presented challenges in sustainability and resources focused on training and support. Ongoing challenges with women in and out of corrections, detoxification and drug treatment, as well as issues of housing, childcare and addictions play a constant role in carrying out the project. For many women, their dual roles as researchers and participants constitutes both a positive experience, as well as a challenge. In particular, the shift in their positions within the street-level sex work community presented unique considerations in terms of protection of confidentiality and privacy as professionals. As well, the potential for issues, such as violence, to trigger women during the research process was of ongoing consideration. Extensive training carried out by sex work agencies and health providers, weekly project staff meetings, including a check-in and out, as well as ongoing debriefing sessions help facilitate and ensure a positive experience for both sex workers and researchers. Further, consideration of increased allocation of research resources for capacity-building and peer support will help to sustain the effectiveness of CBR partnerships.