Oral presentation at the 8th annual Canadian Conference on HIV/AIDS Research, in May 1999, in Victoria, BC.

Comparison of HIV Incidence and Risk Behaviours between Male Sex Trade Workers and Other Young MSM in an Ongoing Prospective Study

Mary Lou Miller, Amy E. Weber, Steve Martindale, Keith Chan, James W. Tigchelaar, Martin T. Schechter, and Robert S. Hogg, for the Vanguard Project; UBC and the BC Centre for Excellence in HIV/AIDS.

Objective: To compare HIV incidence, demographic characteristics, substance use and sexual behaviours among male sex trade workers relative to other young gay and bisexual men.

Methods: Incidence of HIV infection, sexual behaviours and substance use were determined for participants completing baseline questionnaires and HIV tests as of 01/99. Contingency table analysis was used to compare characteristics of those who had been paid for sex in the previous year vs. those who hadn't.

Results: Relative to the remainder of the cohort (n=621), men who had been paid for sex in the previous year (n=110) were significantly younger, less educated, reported lower incomes and were more likely to be non-white (43% vs. 26%; unless otherwise indicated, all p<0.001). Sex trade workers (STW) were also significantly more likely to have unstable housing, to have ever been institutionalised, to be depressed and to use both injection and non-injection drugs. They reported consensual sex with both men and women at a younger age, and were significantly more likely to have ever experienced non-consensual sex (50% vs. 32%). They were also more likely to have had unprotected insertive (p<0.001) and receptive (p<0.05) anal sex with a casual partner in the previous year. In comparing STW with stable vs. unstable housing, those with unstable housing were significantly less educated, more likely to have ever been incarcerated, report bisexual activity, use crack and inject drugs. HIV incidence was much higher among STW relative to the remainder of the cohort (5% vs. 0.9%; p<0.001), and was also much higher for STW with unstable housing relative to those with stable housing (8.96% vs. 3.48%; p=0.016).

Conclusions: Male sex trade workers are vulnerable to HIV infection due to unfavourable living conditions, substance use and sexual risk behaviour. Unstable housing appears to place STW at particular risk for HIV infection.

Acknowledgements:

I would like to take this opportunity to acknowledge the Principal Investigator of this study, Dr.Robert Hogg; the Co-Investigators as listed on the slide; and the National Health Research Development Program of Health Canada for project funding.

I would also like to acknowledge the work of several individuals, including: volunteer recruiter Garry Johnson; participating doctors and nurses, particularly James Tigchelaar of the Street Nurse Program, members of the Community Advisory Committee and the participants themselves.

Primary Objective:

The Vanguard Project was launched in May, 1995, as an expansion of the Vancouver Lymphadenopathy-AIDS Study (VLAS) which has been running since 1982. The primary objective of the Vanguard Project is to monitor HIV incidence rates and associated risk factors among young men having sex with men (MSM).

Eligibility Criteria:

• 18 to 30 years old at baseline
• Living in Greater Vancouver area
• Gay, bisexual, and/or MSM
• No previous HIV-positive test result

Eligible participants are males between the ages of 18 and 30, living in the Greater Vancouver area, who have not previously tested HIV-positive.

The study is open to all men who have sex with men, regardless of whether they self-identify as gay, bisexual or straight.

Eligible subjects who agree to participate are asked to complete an annual self-administered questionnaire and submit a blood sample for HIV antibody testing, for which they provide informed consent. The questionnaire includes demographics, sexual behaviour with regular and casual partners, sex-trade involvement, recreational drug use and psycho-social issues.

Study design:

• Open cohort
• Annual HIV antibody test
• Self-administered questionnaire

The study is designed as an open cohort, where individuals can enroll at any time. Subjects have been recruited through a variety of mechanisms, the most successful of which have been through street clinics and through direct outreach at community events and bars. At enrollment and throughout follow-up, participants are also provided with referrals to physicians, counselors, medical clinics, community agencies and support services.

Objectives:

• To compare HIV incidence, prevalence, demographic characteristiics, substance use and sexual behaviours among male sex trade workers realitive to other young gay and bisexual men.
• To compare HIV incidence, prevalence, demographic characteristiics, substance use and sexual behaviours among male sex trade workers with unstable versus stable housing.

As Research Nurse for the Vanguard Project and a former street nurse in Vancouver, I've had much experience working with gay/bisexual men and street-involved populations. Very little information is available on male sex-trade workers, who are assumed to be at even higher risk of HIV infection than gay and bisexual men in general.

The objective of the present analysis is to compare HIV incidence and prevalence demographics, sexual behaviours and drug use among male sex-trade workers relative to other gay and bisexual men in our prospective cohort study. In addition we aimed to compare the previously mentioned characteristics between male sex trade workers with unstable versus stable housing.

Definition:

For the purposes of this study, we defined "paid sex" in the questionnaire as: "Sex exchanged for money, drugs, goods, clothing, shelter or protection."

This may be a broader definition than what is commonly understood as prostitution. A number or participants in this cohort do not fit the stereotype of street hustlers. For instance, some of the respondents are also post-secondary students.

We also differentiated between "being paid for sex" according to this definition, and "paying someone else for sex." Respondents were asked whether they had ever engaged in these activities, and if they had done so in the year prior to their baseline questionnaire.

Recruitment Strategies:

Many street-involved sex-trade workers identify as heterosexual (or straight) and don't want their peers to know they have sex with other men. This acts as a barrier to participation in a cohort such as ours. We therefore recognized that special efforts were needed made to include street youth and sex-trade workers in the study.

Publicity:

Recruitment of the street-involved sex-trade workers occurred primarily at the outreach clinic specializing in street youth. For example, pizza parties were held to attract street youth and food vouchers were offered on completion of the questionnaire and the HIV antibody test.

The majority of sex trade workers heard about the study either through the street youth clinic or from their friends and/or other participants. Word of mouth was nearly twice as effective for the sex trade workers than for the rest of the cohort, while printed materials were only half as effective in recruiting sex trade workers as for the rest of the cohort.

While general outreach efforts into the gay community were very effective in recruiting participants for the study, only 10% of sex trade workers in the study were reached in this way, compared to 43% of the rest of the cohort.

Results:

As of January 1999, completed questionnaires and HIV test results were available for 720 men at baseline.

Of these, 188 participants (or 26% of the total) reported selling sex to another male at some point in their lives, 15% in the previous year.

11% report buying sex from another male at some point in their lives, 4% have done so in the previous year.

Demographics of MSM who have been paid for sex:

The remainder of results are restricted to the 110 men who reported having been paid for sex in the previous year. Relative to the remainder of the cohort (n=621), men who were paid for sex in the previous year were significantly more likely to be younger and non-white. Of the 110 men, 29% were Aboriginal, 5% Asian, and 4% Black.

A number of factors suggest that men being paid for sex in our cohort are more likely to be of lower socio-economic status, as indicated by lower education and income and living in unstable housing (defined as living primarily in a hotel or transition house, on the street or in jail).

These men were also more likely to have been institutionalized in a psychiatric ward, to be depressed, and to have been in jail.

Sexual experiences:

The following slide compares sexual experiences among the 110 men who reported having been paid for sex in the previous years to the remainder of the cohort.

As seen here, these men were significantly more likely to engage in consensual sex with males and females at younger ages, and were more likely to report having sex with both men and women. These men were much more likely to report having sex outside (for example: in parks), which is consistent with their unstable housing.

They were also more likely to have bought sex from someone else, relative to the rest of the cohort, although my experience suggests that those buying sex are generally older than the age range of this cohort.

Finally, these men were much more likely to report a history of sexual abuse, usually as a child.

Drug Use:

This slide describes recreational drug use for the 110 men who reported having been paid for sex in the previous year compared to the rest of the cohort.

As seen here, these men were significantly more likely to have reported use of most recreational drugs. The majority also reported using these drugs more than once a week. It is important to note that these men were significantly more likely to also inject drugs. These findings also indicate a high prevalence of the use of crack, which is generally uncommon in Vancouver.

Unprotected sex: REGULAR partners

The following depicts unprotected sex among men being paid for sex compared to the rest of the cohort, for men with regular male sex partners. Regular partners are defined as someone respondents have sex with at least once a month.

Due to the wording of the questionnaire, we aren't able to differentiate between clients and non-clients. It should not be assumed that regular partners exclude clients, since many sex workers have "regular" clients or "sugar daddies" - often married men - who may in fact be their primary male partner.

As seen here, men being paid for sex were actually more likely to use condoms for oral sex with regular partners compared to the remainder of the cohort, but rates of unprotected anal sex were similar.

Unprotected sex: CASUAL partners:

The following shows unprotected sex for male sex-trade workers relative to the rest of the cohort, for those with casual male partners. Casual partners are defined as those the men have sex with less than once a month.

Similar rates of unprotected oral sex with casual partners were detected for sex trade workers and the rest of the cohort.

Relative to the rest of the cohort, they were less likely to report using condoms during anal insertive and receptive sex with casual partners.

Finally, it should be noted that 21% reported being paid more to have sex without condoms, which is a reminder that among male sex trade workers, economic need may sometimes compromise decisions surrounding safer sex.

Incidence and Prevalence:

The following describes HIV prevalence at baseline for the 110 men who reported being paid for sex in the last year, relative to the remainder of the cohort.

Of participants for whom HIV test results were available 1.1% tested HIV-positive at baseline. Yet if we separate from the remainder of the cohort the STWs for whom test results were available, 7.5% tested positive at baseline relative to 1.1% in the rest of the cohort.

Since one of the eligibility criteria for participation in the study is that participants may not have previously tested positive, the HIV prevalence estimates shown here no doubt under-estimate the true HIV prevalence in the wider community.

Estimates of HIV Incidence per 100 person years indicates that male sex trade workers have a significantly higher rate of HIV seroconversion compared with the remainder of the cohort.

H.I.V. INCIDENCE and PREVALENCE

	Sex Trade Workers (n=110)	Rest of Cohort (n=621)	p-value
HIV Prevalence:	7.48 (2.49-12.46)	1.13 (0.30-1.97)	0.004
Incidence:	5.01 (0.10-9.92)	0.93 (0.28-1.57)	< 0.001

Comparison of Male Sex Trade Workers with Unstable vs. Stable Housing:

The subanalysis of male sex trade workers with unstable vs. stable housing revealed that those with unstable housing were more likely to have less than a high school education and to have ever been in jail. As well, those STW with unstable housing were more likely to report bisexual activity, the use of crack and injection drugs.

Comparison of incidence and prevalence rates for male STW with unstable and stable housing revealed similar rates of HIV prevalence for the two groups. However, the HIV incidence among male sex trade workers with unstable housing was significantly higher than those with stable housing.

HIV Incidence & Prevalence for STW with Unstable vs. Stable Housing

	Unstable (n= 53)	Stable (n= 57)	p-value
HIV Prevalence:	7.48 (0.46-15.22)	7.14 (0.39-13.89)	0.143
Cumulative Incidence:	8.96 (0-21.37)	3.48 (0-8.30)	0.016

Limitations:

• small sample size
• self-reported behaviours
• low literacy levels (including ESL)
• definitions of sex-trade and partnerships

A number of limitations should be borne in mind when interpreting our findings. Firstly, although we have made efforts to include as many sex-trade workers as possible in our study, these numbers are relatively small, and this group has proven more difficult to follow-up.

In addition, limitations of our questionnaire do not allow us to distinguish between clients and partners, and completion of the questionnaire is sometimes hampered by low literacy levels and English as a second language, and also by the influence of drugs or alcohol.

Conclusions:

• Male sex-trade workers are at higher risk for HIV infection than other gay and bisexual men in Vanguard.
• Those sex-trade workers with unstable housing are at greater risk for HIV seroconversion compared with those with stable housing.

Male sex-trade workers are vulnerable to HIV infection due to unfavourable living conditions and high rates of recreational drug use. The high rates of injection drug use are of particular concern since there is an ongoing HIV outbreak among the IDU community in Vancouver. While male sex trade workers were more likely to use condoms during oral sex than other MSM, rates of unprotected anal sex were similar.

Implications of findings:

Prevention efforts must:

• Target male STWs (both gay and straight identified)
• Emphasise condom use during anal sex
• Take into account cultural, socio-economic and sexual realities of individuals at risk for HIV acquisition

Our findings suggest that male sex-trade workers may not be reached through conventional prevention programmes as many do not self-identify as gay. Special efforts should be made to address the social issues and barriers to safer sex.

The fact that these men were more likely to use condoms for oral sex relative to the rest of the cohort is encouraging, and suggests that behaviour change can be attained. However, since unprotected anal sex carries a higher risk of transmission, it is clear that education needs to be reinforced.

Finally, our analysis indicates that prevention among male sex-trade workers must take into account their social, cultural, economic and sexual realities.

Thank you.