HIV This Week

Shinde S, Setia MS, Row-Kavi A, Anand V, Jerajani H. Male sex workers: are we ignoring a risk group in Mumbai, India? Indian J Dermatol Venereol Leprol. 2009;75:41-6.

Male sex workers have recently been recognized as an important risk group for sexually transmitted infections including human immunodeficiency virus infection. Although there are global studies on male sex workers, few such studies describe the behavioural patterns and sexually transmitted infections among this population in India. Male sex workers were evaluated at the Humsafar trust, a community based organization situated in suburban Mumbai, India. Shinde and colleagues report on the demographics, sexual behaviours, and sexually transmitted infections including HIV of these sex workers. Of the 75 male sex workers, 24 were men and 51 were transgenders. The mean age of the group was 23.3 (+ 4.9) years. About 15% were married or lived with a permanent partner. Of these individuals, 85% reported sex work as a main source of income and 15% as an additional source. All the individuals reported anal sex (87% anal receptive sex and 13% anal insertive sex). About 13% of male sex workers had never used a condom. The HIV prevalence was 33% (17% in men vs 41% in transgenders, P = 0.04). The sexually transmitted infection prevalence was 60% (58% in men vs 61% in transgenders, P = 0.8). Syphilis was the most common sexually transmitted infection (28%) in these male sex workers. HIV was associated with being a transgender (41 vs 17%, P = 0.04), age > 26 years (57 vs 28%, P = 0.04), more than one year of sex work (38 vs 8%, P = 0.05), and income P = 0.02). These male sex workers have high-risk behaviours, low consistent condom use, and high prevalence of sexually transmitted infections and HIV infections. These groups should be the focus of intensive public health interventions aimed at reduction of risky sexual practices, and prevention and care for both HIV and sexually transmitted infections.

Editors’ note: This study did not recruit any male sex workers involved solely in the heterosexual sex trade possibly because such men are less likely to attend this clinic treating sexually transmitted infections (STI). Among the sex worker participants were kothis, effeminate men who have sex with men but may also have sex with women, and hijras, male-to-female transgendered people who are primarily the receptive partners because of their female gender identity. Overall, only one-third reported always using condoms, with the most common reasons for non-use being non-availability (43%) and refusal of condom use by the partner (20%). Social marginalization of sex workers in India, as elsewhere, hampers the development of effective programmes to help them avoid HIV infection and obtain treatment for STI and HIV. They appear to be considerably more at risk of acquiring HIV infection than do women who sell sexual services and are particularly likely to benefit from improved access to condoms and skills training to enhance condom negotiation.

Shannon K, Strathdee SA, Shoveller J, Rusch M, Kerr T, Tyndall MW. Structural and Environmental Barriers to Condom Use Negotiation With Clients Among Female Sex Workers: Implications for HIV-Prevention Strategies and Policy. Am J Public Health. 2009;99:659-665.

Shannon and colleagues investigated the relationship between environmental-structural factors and condom-use negotiation between female sex workers and clients. They used baseline data from a 2006 Vancouver, British Columbia, community-based cohort of female sex workers, to map the clustering of hot spots for being pressured into unprotected sexual intercourse by a client and assess sexual HIV. The authors then used multivariate logistic modelling to estimate the relationship between environmental-structural factors and being pressured by a client into unprotected intercourse. In multivariate analyses, being pressured to have unprotected sexual intercourse was independently associated with having an individual zoning restriction (odds ratio [OR]=3.39; 95% confidence interval [CI]=1.00, 9.36), working away from main streets because of policing (OR=3.01; 95% CI=1.39, 7.44), borrowing a used crack pipe (OR=2.51; 95% CI=1.06, 2.49), client-perpetrated violence (OR=2.08; 95% CI=1.06, 4.49), and servicing clients in cars or in public spaces (OR=2.00; 95% CI=1.65, 5.73). Given growing global concern surrounding the failings of prohibitive sex-work legislation on sex workers’ health, there is urgent need for environmental-structural HIV-prevention efforts that facilitate sex workers’ ability to negotiate condom use in safer sex-work environments and criminalize abuse by clients and third parties.

Editors’ note: The buying and selling of sexual services has never been illegal in Canada, however it is illegal to communicate in public spaces for the purposes of sexual transaction and the law prohibits ‘keeping or transporting a person to a common bawdy-house”, thus restricting legal indoor sex work. This study used the risk environment framework as its theoretical base, hypothesising that macro- and meso-level factors outside the individual affect negotiation of individual risk. Trained peer researchers, who were former or current sex workers, interviewed 205 sex workers participating in the Maka Project cohort. They were recruited at sex work strolls at staggered times and spaces along these strolls. The analysis of the effects of enforcement of Canada’s prohibitive sex-work policies reveals the need for legal and policy reforms to create safer work environments in which exploitation by clients and third parties is effectively criminalised and condom use is readily and consistently negotiated.