A smartly dressed couple check into a four-star city hotel armed with a bottle of champagne and condoms. In a building across the street, a couple who has just met is putting on a condom. In a parking lot of the local high school, in the backseat of a car, two young people, high on dope, are removing one after finishing sex. Out in the suburbs, a man puts one on before he has sex with his regular partner at his home. In a bathroom of a public transportation system, another man is performing oral sex on his male partner.
No, these are not couples engaged in affairs. They are not people who have just met at a bar, nor teenagers after the school dance. They are certainly not long-time lovers. They are all people who are part of the sex industry -- sex workers and their clients.
Are Sex Workers Spreading HIV?
Historically, sex workers have been blamed for transmitting sexually transmitted diseases, including HIV. But in many parts of the world the reality may be quite different. It is difficult to determine precisely the incidence of HIV infection among sex workers, or the prevalence of safer sex practices during commercial sex transactions. Like other marginalized populations, sex workers often receive scant attention from both public health officials and researchers. The stigma attached to sex work, and the criminal sanctions it can entail, make reliable data hard to come by. There is almost no information about male sex workers. Nevertheless, some limited studies have been done around the world in the more than two decades of the pandemic, and the results do not seem to bear out the premise that sex work by itself contributes disproportionately to the spread of the virus.
Outside of Africa, the incidence of HIV among sex workers is generally about the same as in the population as a whole. This is true even in developing countries, although the incidence does vary geographically.
In Europe, HIV incidence is low, including among sex workers As with other populations, however, the incidence rises dramatically among those who use intravenous drugs. In Vienna, where sex workers are registered and regularly screened for various STDs, the few found to be HIV positive reported that they were IV drug users or had sexual partners who were. In Seville, Spain, sex workers who used intravenous drugs were eight times as likely to be HIV positive as were those who used non-intravenous drugs. In the Netherlands, where sex work is legal and regulated and where drug use is largely approached from a public health rather than a criminal point of view, both non-IV-drug-using female sex workers and their male clients were found to have an extremely low incidence of HIV, and that was concentrated among sex workers who had recently come from AIDS-endemic countries.
In a similar study to that mentioned above, non-IV-drug-using female sex workers in Amsterdam reported not only no HIV infection but consistent condom use. Conversely, a small group of transgender Dutch sex workers among whom there was a fairly high incidence of HIV reported not using condoms during receptive anal sex. In Glasgow, where HIV rates are low even among IV drug users and where almost 75% of female sex workers also inject drugs, all of the HIV-positive sex workers studied have been found to be IV drug users.
The story in Asia is complicated, and data are spotty. The only large-scale study of HIV among sex workers in Asia was done in the Philippines, evaluating 25,392 sex workers in 64 cities between 1987-89, before the pandemic had become widespread in the region. This study showed that the prevalence of HIV was 0.08%; however a study a year later showed 0.23%, suggesting an increase. In China, most women arrested for prostitution have been found to have active STDs, primarily gonorrhea, but no correlation has been found between HIV and sex work. Interestingly, the Chinese government has suggested a link between HIV and sex work as part of its campaign to eliminate the sex trade, even as it denies that HIV is a public health problem within its borders. Thailand, on the other hand, has often been cited as a model for government regulation of sex work. Although prostitution is officially illegal, in the early '90s the Thai government began working with brothel owners to enforce 100% condom use. Free condoms were given to brothels, and sex workers were told to insist on condoms. Establishments that allowed unprotected sex were shut down. As a result, condom use increased from 14% in 1989 to over 90% by 1994. Over the same period, the number of new STI cases among men treated at government clinics plummeted by over 90%. HIV infection rates among military recruits fell from 4% in 1993 to below 1.5% in 1997.
In other geographical areas or populations where HIV has not been studied specifically, researchers often use other STDS with which the virus has been associated as surrogates to help them gauge the incidence of infection. In Tokyo, sex workers have been found to have high rates of hepatitis C and Treponema pallidum. At the very least, the data from Japan and China should serve as a reminder that there are other things besides HIV to which sex workers and their customers may be vulnerable. This might indicate that concerns should not be focused on stigmatizing HIV with sex workers, but on implementing public health programs that will provide education and access to care and treatment for HIV and STDs for everyone who might be engaging in high-risk behaviors. We all know that high incidence rates of STDs are often linked to high HIV incidence rates.
There is limited information on HIV among sex workers in North and South America. The only large-scale study -- of over 960 female Peruvian prostitutes over a three-year period -- was conducted in the early 1990s and showed some HIV infection (0.3%) and a much larger incidence of HTLV-1, hepatitis B and C. 17.6% had HTLV-1 antibody, 59.8% had hepatitis B antibody, and 0.7% had antibody to hepatitis C. There are virtually no data on sex workers in the United States, possibly because of government refusal and private reluctance to recognize this population. One study of HIV-positive tuberculosis patients in Los Angeles found that nearly all had risk factors that included prostitute contact, multiple sex partners, and histories of STDs, leading public health officials there to recommend screening all TB patients for HIV.
Africa, of course, is the global epicenter of the pandemic. Once again, epidemiological research is scarce, especially with regard to individuals engaged in sex work. Some limited studies done in the early 1990s found high and increasing incidences of seropositivity among female sex workers in Cameroon. Early speculation, based on very small studies, that HIV might be confined to discrete areas of the continent evaporated in the late 1980s when the infection rate among sex workers in Djibouti exploded. In 1987 in Djibouti, only 2% of sex workers were HIV positive, much lower than the incidence rate for that reported in any Eastern African country. However, in a later study in the early 1990s, HIV infection rates were found to be 36% for street sex workers and 15.3% in sex workers working as bar hostesses.
Is Prostitution a Risk Factor for HIV?
A 1994 study of HIV prevalence in female drug injectors in the U.S. found a 12.9% HIV prevalence among those involved in prostitution and 14.4% among those not involved. The women not involved in prostitution were less likely to be in contact with drug treatment or helping agencies and were less likely to have been tested for HIV than those engaged in sex work. Respondents in contact with treatment agencies and those involved in prostitution were more likely to be aware of their HIV status, with 72% of the HIV-positive nonprostitutes unaware of their status. While these results take sex work itself off the hook, drug use among sex workers appears to be high. Of 85 sex workers in a Glasgow study, 81% were IV drug users, their most commonly used drugs being heroin and temazepam. While 98% indicated that they always used condoms during vaginal intercourse, this only applied to commercial sex; only 17% always used condoms with their regular sexual partners, who were frequently drug users.
Clients of Sex Workers Increase Risk of Contracting HIV
While no clear behavioral pattern emerges for female sex workers, most are believed to have contracted HIV through heterosexual contact rather than through IV drug use. A study in Kingston, Jamaica, for example, tracing a sharp rise in seroprevalence, found that factors associated with infection in heterosexual men included history of other STDs, sex with prostitutes, and multiple sexual partners.
The story is complicated, however, by the presence of other risk behaviors among this population. In a London study, many HIV-positive men who used female sex workers also reported having sex with other men and using injected drugs; some also had had blood transfusions or gonorrhea, and a few said that they had also been paid for sex.
Past history of other STDs clearly correlates with HIV incidence. In a study of men who had other STDs and who used sex workers, every man who seroconverted had a genital ulcer of some kind related to the STD. The authors concluded that men with other STDs have a very high risk of acquiring HIV from prostitutes. Transmission of HIV from male to female in unprotected sex appears to be high. A study in Thailand found that almost all HIV-positive men who were unaware of their HIV status until they donated blood had had sex with prostitutes, and almost half of their wives or sex partners were also infected. Risk factors for transmission from male to female were genital herpes, gonorrhea, or chlamydia infection. By contrast, regular use of condoms decreased transmission to one-tenth that of the larger group.
Sex Workers as a Prevention Resource
Many who do HIV prevention work with sex workers find them to know a great deal about the human side of sex, including the behaviors and attitudes that go with it, making them an ideal source of knowledge about safer sex practices. Often, they have developed some expertise about the prevention of HIV and other STIs. Sex workers are aware of the implications of the spread of the disease, not only for their own lives and livelihoods, but also for their many sex partners, and in turn for the general population. As a result, many sex workers make it a practice to instruct their clients in safer sex practices before engaging in sexual contact with them.
There is now near-universal use of condoms by sex workers in industrialized countries. It is possible that this is having a far larger impact on the overall sexual culture than conversations that should be (but often aren't) happening in doctors' visits. It's difficult to prove, but probable, that sex workers have been more successful in safer sex education than all the television advertisements put together. After all, the best way for someone to learn something is to do it. Put in terms of positive reinforcement theories, the best way for a man to start to feel good about using condoms is to have someone put one on him and then proceed to give him a pleasurable experience. Yet sex workers are widely perceived to be a major reservoir of infection, the vectors for the transmission of HIV/AIDS into the general population. Some sex workers, of course, do have unsafe sex. Sometimes they are coerced into it by a threatening client, or they may simply be offered more money to dispense with the condom. Sometimes the workers themselves are affected by alcohol or drugs.
But often, even under these circumstances, many sex workers don't do anything unsafe. Why not? Because they have learned to take care of themselves; because they have self-esteem, because it has become a habit to carry condoms and use safer sex practices. Sometimes it's just that they want to keep on living so that they can continue using drugs. The key to stopping sexually transmitted diseases is control. The more control sex workers have over their lives, the more likely they are to develop self-esteem and the responsibility that comes with it. If they do not, they are more likely to be careless and risk being infected or infecting their partners with HIV. This doesn't mean that sex workers are not exposing themselves to HIV, but we need to stay aware that the issue is the risk behavior, whether through unprotected sex or IV drug use. Therefore it is important to provide public health policies that will allow sex workers to have just access to health care and prevention services.
Sex Work, Public Policy, and HIV
In 1986, the First International Conference on Health Promotion stated that for "all people to achieve their fullest health potential" they need "a secure foundation in a supportive environment, access to information, life skills and opportunities for making healthy choices." In order to achieve such potential, the people need to "take control of those things which determine their health."
In May 2003 however, Congress passed the United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act (Global AIDS Act), and in December 2003 it passed the Trafficking Victims Protection Reauthorization Act (TVPRA). The Global AIDS Act bars the use of federal funds to "promote, support, or advocate the legalization or practice of prostitution." This language has been used by the U.S. government to require that organizations receiving U.S. global HIV/AIDS funding must adopt specific positions opposing prostitution, making it virtually impossible to work with this population.
These restrictions were first applied to foreign nongovernmental organizations only, with the law specifically exempting the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Health Organization (WHO), the International AIDS Vaccine Initiative, and any "United Nations agency." In June 2005, however, the U.S. Agency for International Development issued a directive requiring that funding for AIDS programs be given only to those organizations -- both U.S. and foreign -- with policies explicitly opposing prostitution and sex trafficking. Such funding restrictions parallel other similar, and increasing, efforts to force public health organizations to comply with ideologies that often run counter to both public health practice and human rights standards. It appears that sex workers are not included among "all people."
Previously, funding had allowed the establishment of community drop-in centers, where sex workers gathered and received support from others and information relevant to their health. Condoms and other safe-sex accessories were also available. Outreach workers were able to share prevention messages and information not only about safer sex but about needle-exchange programs. The current low incidence of HIV/AIDS in the sex industry attests to the success of many of these programs. At some of these centers, medical clinics were set up to provide anonymous HIV testing for sex workers. Anyone who tested positive was followed up for care. At some clinics, sex workers participated in the interviewing process for hiring staff -- a striking example of patient empowerment.
Some in the HIV community are biased toward programs run solely by sex workers, but the participation of health professionals in health programs is important. Healthcare providers, clinical and nonclinical, need to have empathy and to appreciate that sex workers can be part of the solution, not part of the problem.
This is more difficult in countries where the economic or social situation of sex workers makes it difficult for them to use or to purchase condoms. Countries where AIDS has had significant impact on the sex industry are those in which there is little support for sex workers. In such countries, sex workers have had to organize and to educate themselves.
In Brazil, for example, the sex workers' organization in Rio de Janeiro is trying to teach its members about AIDS and safer sex. In Thailand the group Empower teaches sex workers to negotiate safer sex in English, the language most commonly used by tourists. In Nepal, a research project involving voluntary HIV testing of sex workers resulted in the promotion of condom use and its significant increase. Sex workers subsequently set up their own network of support and education groups -- the first organization of its kind in Nepal.
In Africa, sex workers use condoms less frequently than their counterparts elsewhere, and the incidence of AIDS among sex workers has increased dramatically. But education of both clients and workers can make a difference. One campaign in central Africa, which combined education with the distribution of condoms, reported that 75% of the sex workers involved began using them.
According to WHO, "In order to achieve ... risk-reducing practices, it is essential to avoid discrimination against people engaged in prostitution, and to ensure their active participation in prevention and care efforts." Most countries, however, deal with sex work by legislating against it. This forces sex workers to hide, which has the effect of cutting them off from society and keeping them from prevention and/or care services. There is little evidence that prohibitive legislation affects the amount of commercial sex available. But it does affect the health, welfare, and self-esteem of sex workers, which are in inverse proportion to the legal sanctions against them.
Prostitution law reform is good for health -- and its beneficial effects could be considerably accelerated by giving sex workers the information, the international connections, the support, and the resources they need. Perhaps one day the word "prostitute" can become synonymous with "safer-sex educator."
The results of international studies are fairly consistent and indicate that, outside of East Africa, the prevalence of HIV in sex workers is generally low, and not significantly different from the HIV incidence in the population as a whole. While prostitution per se is not a significant risk factor for acquiring HIV infection, IV drug use is, and a significant proportion of sex workers are also IV drug users. Men who use sex workers do have a higher risk of acquiring HIV, but only if they have other STDs or engage in other high-risk behaviors (e.g., anal sex without a condom).
The bottom line: if you use a condom correctly, your risk of contracting HIV from a sex worker is probably no greater than the risk from your girlfriend or boyfriend. But if you don't use a condom, your risk increases greatly, especially if you also have an STI. As with all risk behavior, it's what you do, not who you do it with, that matters.
Luis Scaccabarrozzi is Director of Treatment Education at ACRIA.