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This poster was presented
as part of a poster discussion on internatinal sex trade issues
at the 4th AIDS Impact Conference in July, 1999, in Ottawa, Ontario. (Previous versions of this poster have been presented
at the 11th annual BC AIDS Conference in November, 1998, in Vancouver,
BC; and at the XII International Conference on AIDS in July, 1998,
in Geneva, Switzerland.)
Characteristics of Male Sex Trade Workers enrolled
in a Prospective Study of HIV Incidence
Garry Johnson;
Mary Lou Miller; Amy E. Weber; Keith Chan; Martin T. Schechter;
and Robert S. Hogg
for the Vanguard Project, the University of
British Columbia and the British Columbia Centre for Excellence
in HIV/AIDS.
ABSTRACT
OBJECTIVES:
To compare HIV incidence, demographic characteristics, substance
use and sexual behaviours among male sex trade workers relative
to other young gay and bisexual men in an ongoing prospective
cohort.
METHODS: Incidence
of HIV infection, sexual behaviours and substance use were determined
for participants who had completed 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. Sex trade workers (STW) were also significantly
more likely to have unstable housing, to have ever been institutionalized,
to be depressed and to use 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 and receptive 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).
APPLICATION OF RESULTS: 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.
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 in an ongoing prospective
cohort.
BACKGROUND
The Vanguard Project is a prospective study of HIV incidence
and risk behaviours which began in May, 1995. Eligible participants
are males between the ages of 18 and 30, living in the Greater
Vancouver area, who have not previously tested HIV-positive.
(NB: The age of eligibility has recently been reduced to
15, but at the time of this analysis all participants were >
18 years at baseline).
The study is open to all men who have sex with men, regardless
of whether they self-identify as gay, bisexual or straight.
Recruitment of subjects involved outreach at gay community
events, use of print materials (e.g. posters, brochures, condom
packages), and recruitment by health care professionals at HIV
testing clinics and local physicians' practices.
Recruitment of street-involved sex trade workers occurred primarily
at an outreach clinic specifically aimed at street youth.
METHODS
Study Design:
Eligible participants who provide informed consent complete
an annual self-administered questionnaire and submit a blood sample
for HIV antibody testing and storage.
The questionnaire includes information on demographics, sexual
behaviour with both men and women, and psychosocial scales (e.g.
7-item Centres for Epidemi-ologic Studies depression scale1
[CES-D]).
For the purposes of this study, we defined "paid sex"
in the questionnaire as: "Sex exchanged for money, drugs,
goods, clothing, shelter or protection."
The questionnaire also differentiated between "being paid
for sex," 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 baseline.
"Regular" partners were defined as men respondents
had sex with "at least once a month," whereas "casual"
partners were those they had sex with "less than once a month."
Statistical Analysis:
Prevalence of HIV infection and sexual and drug-using behaviours
were determined for men who had completed a baseline questionnaire
and HIV test as of May, 1999.
Contingency table analysis was used to compare characteristics
of men who reported being paid for sex in the previous year, versus
those who had not. All reported p-values are two-sided.
Among men who tested HIV-negative at baseline and returned
for follow-up, HIV incidence density and corresponding 95% confidence
intervals were calculated separately for men who had been paid
for sex in the previous year versus the remainder of the cohort.
And finally, a multivariate logistic regression analysis was
used to identify independent factors associated with involvement
in the sex trade.
RESULTS
Paid Sex:
As of May, 1999, baseline questionnaires and HIV test results
were available for 761 men.
Two hundred and five participants (27%) reported ever having
been paid for sex by another male, 16% in the previous year (Table 1).
Eighty five (12%) reported ever paying another male for sex,
4% in the previous year.
Socio-demographics:
Relative to the remainder of the cohort (n=636), men who were
paid for sex in the previous year (n=125) were significantly younger
and were more likely to be non-white (Table 2).
Men being paid for sex were also less educated, had lower incomes
and were significantly more likely to report unstable housing.
These men were also significantly more likely to have ever
been in a psychiatric ward, to have high depression scores, and
to have ever been incarcerated.
Housing Stability:
In comparing sex workers with stable housing to sex workers
with unstable housing, those with unstable housing were significantly
less educated, and were more likely to have ever been incarcerated
or institutionalized, to report bisexual activity, to use crack
and to inject drugs (table not shown).
Sexual Experiences:
Men who had been paid for sex had engaged in consensual sex
with males and females at younger ages, and were more likely to
report currently having sex with both men and women (Table 3).
Men who had been paid for sex were also significantly more
likely to report a history of sexual abuse.
Substance Use:
Men who had been paid for sex were significantly more likely
to drink heavily and to report use of most recreational drugs,
including injection drugs, in the previous year (Table 4).
Risk Behaviours:
As seen in Table
5, men being paid for sex were 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.
With casual male partners (Table
5), no difference was found in condom usage for oral sex,
but sex trade workers were significantly less likely to report
using condoms during anal sex (both insertive and receptive) relative
to the rest of the cohort.
HIV Prevalence and Incidence:
HIV prevalence and incidence were much higher among men who
had been paid for sex, relative to the remainder of the cohort
(Table
6). HIV prevalence was six and a half times higher among
sex workers, and HIV incidence was over five times higher.
Multivariate Analysis:
Table
7 shows the results of the logistic regression analysis
of independent factors associated with involvement in the sex
trade.
Living in unstable housing, having a high depression score,
having ever been in a psychiatric ward and drinking heavily were
found to be strongly associated with involvement in the sex trade.
LIMITATIONS
- Small sample size contributed to low statistical power.
- Definition of "sex trade" used was overly broad
and therefore results may not be generalizable.
- Limitations of the survey instrument did not allow for differentiation
between sex trade clients and regular/casual sex partners.
- Differential follow-up may have caused HIV incidence to be
underestimated.
CONCLUSIONS
Male sex trade workers (STWs) are at risk for HIV due to high
levels of unprotected anal sex and recreational drug use, particularly
injection drug use.
High rates of unstable housing, alcohol consumption, mental
illness and depression may increase their vulnerability to HIV
compared with other men who have sex with men.
The high rate of injection drug use (IDU) for STWs is of particular
concern due to the high HIV prevalence and incidence among IDUs
in Vancouver.2
Male sex trade workers may not be reached through conventional
prevention programs as many do not self-identify as gay men. For
these men, HIV/AIDS prevention must take into account their social,
cultural, economic and sexual realities.
ACKNOWLEDGEMENTS
The authors gratefully acknowledge the contributions of participating
doctors and nurses, particularly James Tigchelaar of the Street
Nurse Program; members of the Community Advisory Committee; Vanguard
Project staff; and the study participants themselves. Artwork
by John Ferrie. Poster designed by Steve Martindale.
REFERENCES
- Mirowsky J , Ross CE.
Age and Depression. J Health Soc Behav 1992, 33: 187-205.
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- Strathdee SA, Patrick
DM, Currie S, Cornelisse PGA, Rekart ML, Montaner JSG, Schechter
MT, O'Shaughnessy MV. Needle exchange is not enough: lessons
from the Vancouver Injection Drug Use Study. AIDS 1997,
8: F59-F65.
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