Are sex workers at risk for HIV?
It depends on who they are and how they work. The people who are most vulnerable to HIV infection are street workers, most of whom are poor or homeless, and many of whom are young, have a history of childhood abuse and are likely to be drug or alcohol dependent. Street prostitutes are extremely vulnerable to violence from clients, police, and sometimes their lovers. Male and female sex workers who work off the street (in brothels, massage parlors, their own apartments, or escort services) are much less likely to become infected, largely because they are less likely to depend on drugs or alcohol and more likely to be able to control the sexual transaction and insist on condoms. (1)
A study of 1,396 female sex workers in six US cities found an HIV seroprevalence of 12%, ranging from 0-47.5% depending on the city and the level of injecting drug use. (2) A study of 235 male street sex workers in Atlanta, GA, found 29.4% seroprevalence, with highest rates among those who had receptive anal sex with nonpaying partners. (3)
What puts sex workers at risk?
Injection drug use was the main risk factor for HIV infection for female prostitutes in six US cities. (2) Female injection drug users who trade sex for money or drugs are more likely to share needles than female injectors who do not engage in sex trading, and are less likely to use new needles or to clean old ones. (4)
Drug use can increase both the likelihood of sex work and unsafe sex. A study of crack cocaine users recruited from the streets in three urban neighborhoods found that 68% of women who were regular crack smokers had exchanged sex for drugs or money. Of those, 30% had not used a condom in the past 30 days. (5)
Recently, observers have found an association between HIV infection and heavy crack use and unprotected fellatio. This may be due to poor oral hygiene and damage to the mouth from crack pipes, high frequency of fellatio, and inconsistent condom use. (6)
Sex workers may agree to unprotected sex if a client offers substantially more money, if they are desperate for money to buy drugs, or if business has been slow. In some cases, clients may use violence to enforce unsafe sex. Police in many cities routinely confiscate condoms when they arrest or stop prostitutes, and prostitutes may not be able to obtain more condoms immediately. Thus, in some situations, sex workers are powerless to insist on condoms for safer sex.
Like many people in committed relationships, sex workers may find it difficult to discuss condoms or safer sex practices with their partner at home. In one study, although 94% of sex workers used condoms at some point with their clients, only 25% had used condoms with their partners at home. (7)
What are barriers to prevention?
The illegality of prostitution in the US drives the industry underground and engenders a strong distrust of both police and public health authorities among sex workers. This makes effective HIV prevention outreach difficult. Also, in many areas, possession of condoms is used as evidence of prostitution and therefore can be grounds for arrest for street-based and off-street sex workers. (8)
Desperation and lack of resources can override prevention concerns. Drug-addicted people may turn to prostitution to earn money to pay for the high cost of illegal drugs. Many homeless youth have no training or means of support, and rely on prostitution for survival. Attention to the more immediate concerns of food, housing and addiction often takes priority over future concerns of HIV infection.
What's being done?
Some rural counties in Nevada have legal prostitution governed by the state Board of Health. The Board requires that condoms be used for all acts of sex and that sex workers must be licensed and undergo weekly STD tests and monthly HIV tests, at their own expense. (9) As of 1993, no women tested positive out of a total of 20,000 HIV tests of sex workers. (10) Licensed prostitutes receive no sick leave or health insurance, and if they tested HIV-positive would be terminated without counseling or assistance. (9)
The California Prostitutes' Education Project (CAL-PEP) provides condoms, STD/HIV testing, AIDS education and drug treatment referral through regular and repeated street outreach . Outreach workers are former prostitutes who are trained in AIDS prevention. The project successfully encouraged prostitutes to use condoms regularly on the job, but found it difficult to influence condom use in private relationships. (7)
On the Streets Mobile Unit-Options in New York City, NY, runs vans that bring over 4,000 street prostitutes friendship, food, clothes, condoms, HIV/STD testing and counseling and needle exchange. They also help prostitutes get public assistance and/or drug treatment. Rates of HIV infection among clients have declined since 1989. (11)
The Threshold Project in Seattle, WA, helps homeless youth acquire the skills necessary to live independently without sex work. Most of the clients in this program had been emotionally, physically, or sexually abused. The two-year program offered a series of progressively more independent living experiences, and in follow-up, 42% of participants remained in stable living situations without sex work. (12)
When free methadone maintenance was offered to heroin-addicted street prostitutes in southern California, most enrolled. After one year, personal income from prostitution and other crime was reduced 58% and income from legal sources increased 86%. (13)
Internationally, many HIV prevention efforts aimed at sex workers have addressed structural and policy considerations. In Thailand, the Ministry of Public Health began a 100% condom-use program in all sex establishments in several provinces. After the intervention in Samut Sakhon province, the number of condoms used increased from 15,000 to 50,000 a month, and STD incidence decreased from 13% to 0.3-0.5%. (14)
In Bulawayo, Zimbabwe, a multiplicity of approaches reached sex workers and clients. AIDS training targeted nurses and health care professionals, as well as non-conventional audiences such as hotel and bar workers and taxi drivers. Community outreach relied on sex worker and client peer educators and provided widespread condom distribution. STD services in the city were also strengthened. (15)
What still needs to be done?
In the US, HIV research among prostitutes has focused largely on their role as vectors of infection for the general public. To prevent HIV infection among prostitutes, it is essential to address the context in which sex work is transacted, as well as the specific practices of the prostitutes. Placing the major burden for HIV prevention on prostitutes themselves may not be most effective tactic. Economic dependence and gender power imbalances can make it nearly impossible for prostitutes to demand safer sex. Laws and police attitudes towards carrying condoms must be eased to allow sex workers to protect themselves. Decriminalizing prostitution and regulating sex businesses would remove many obstacles to consistent condom use and safer sex. (16) Clients and brothel/ escort service owners also need to be more actively targeted in prevention programs.
Increased funding is needed for prevention programs that address the full range of problems sex workers face, both on and off the streets, especially programs staffed and managed by peers. Drug treatment, housing, child care and skills training for prostitutes are essential. Better health care services are needed for prostitutes, including diagnosis and treatment for STDs/HIV, care for injuries due to violence, and mental health care. A comprehensive HIV prevention strategy uses a variety of elements to protect as many people at risk as possible. Sex workers require a broad range of protective services, including HIV prevention.
References:
2. Centers for Disease Control and Prevention. Antibody to human immunodeficiency virus in female prostitutes. Morbidity and Mortality Weekly Report. 1987;36:157-161.
3. Elifson KW, Boles J, Sweat M. Risk factors associated with HIV infection among male prostitutes. American Journal of Public Health. 1993;83:79-83.
4. Kail BL, Watson DD, Ray S. Needle using practices within the sex industry. American Journal of Drug and Alcohol Abuse. 1995:21;241-255.
5. Edlin BR, Irwin KL, Faruque S, et al. Intersecting epidemics: crack cocaine use and HIV infection among inner-city young adults. New England Journal of Medicine. 1994; 331:1422-1427.
6. Wallace JI, Weiner A, Bloch D et al. Fellatio is a significant risk activity for acquiring AIDS in New York City street walking sex workers. Presented at the Eleventh International Conference on AIDS, Vancouver BC; 1996.
7. Dorfman LE, Derish PE, Cohen JB. Hey Girlfriend: an evaluation of AIDS prevention among women in the sex industry. Health Education Quarterly. 1992:19;25-40.
8. Cohen JB, Coyle SL. Interventions for female prostitutes. In HG Miller, CF Turner, LE Moses, eds. AIDS The Second Decade. Washington, DC: National Academy Press;1990.
9. Campbell CA. Prostitution, AIDS, and preventive health behavior. Social Science and Medicine. 1991;32:1367-1378.
10. Albert AE, Warner DL, Hatcher RA, et al. Condom use among female commercial sex workers in Nevada's legal brothels. American Journal of Public Health. 1995;85:1514-1520.
11. Whitmore R, Wallace JI, Weiner A, et al. HIV testing rates in New York City street walkers have declined. Presented at the Eleventh International Conference on AIDS, Vancouver, BC; 1996.
12. Schram DD, Giovengo MA. Evaluation of Threshold: an independent living program for homeless adolescents. Journal of Adolescent Health. 1991;12:567-572.
13. Bellis DJ. Reduction of AIDS risk among 41 heroin addicted female street prostitutes: effects of free methadone maintenance. Journal of Addictive Diseases. 1993;12:7-23.
14. World Health Organization, Global Programme on AIDS. Effective approaches to AIDS prevention. Report of a meeting, Geneva, Switzerland, May 1992.
15. Lamptey P. An overview of AIDS interventions in high risk groups: commercial sex workers and their clients. In LC Chen, et al, eds. AIDS and Women's Reproductive Health. New York: Plenum Press;1991.
16. Leonard Z, Thistlethwaite P. Prostitution and HIV infection. In C Chris, M Pearl, eds. Women, AIDS, and Activism. Boston, MA: South End Press;1990.
Prepared by Pamela Decarlo, Priscilla Alexander, Henry Hsu
Reproduction of this text is encouraged; however, copies may not be sold. The Center for AIDS
Prevention Studies at the University of California San Franciso is the source of this
information. For additional copies of this and other HIV Prevention Fact Sheets, please call the
National AIDS Clearinghouse at 800/458-5231. Comments and questions about this Fact Sheet may
be e-mailed to prevention_factsheets@quickmail.ucsf.edu. ©1996, University of California
1. Alexander P. Sex work, AIDS, and the law. Testimony before the National Commission on AIDS; 1992.
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