The sexual health of male sex workers in England: analysis of cross-sectional data from genitourinary medicine clinics

Differences in STI/HIV Burden and Sexual Health Care-Seeking Behavior Among First- and Second-Generation Migrant and Western-Born Male Sex Workers Who Have Sex With Men in the Netherlands: A Retrospective Cohort Study

BACKGROUND

Globally, migrant sex workers have a higher burden of sexually transmitted infections (STI)/human immunodeficiency virus (HIV). This large study aimed to assess demographics, STI/HIV burden, and sexual health care-seeking behavior of first-generation migrant and second-generation migrant male sex workers who have sex with men (MSW-MSM) versus Western-born MSW-MSM.

METHODS

Coded STI clinic consultations (n = 6970) from 3116 individual MSW-MSM attending any Dutch STI clinic between 2016 and 2021 were included. First-generation migrant: born outside of northern/central/southern/western Europe/North America/Oceania. Second-generation migrant: ≥1parent born outside of northern/central/southern/western Europe/North America/Oceania. Multivariable logistic regression analysis assessed associations between MSW-MSM groups and STI in first consultation in the data. A Cox proportional hazard regression compared the incidence of a first repeat consultation between migration groups, stratified by STI in first consultation. All analyses were adjusted for age and urbanity of STI clinic region.

RESULTS

First-generation migrant MSW-MSM (n = 1085) were mostly born in Latin America (50%), whereas second-generation migrant MSW-MSM (n = 368) mostly originated from North Africa (30.4%). The proportion of STI diagnoses differed (33.2%, 29.3%, 23.3%; P < 0.001) between the first-generation migrant, second-generation migrant, and Western-born MSW-MSM. First-generation migrant MSW-MSM versus Western-born had an adjusted odds ratio of 1.6 (95% confidence interval, 1.3-1.9) of STI diagnosis in the first consultation. First-generation migrant MSW-MSM versus Western-born had an adjusted hazard ratio of 1.5 (95% confidence interval, 1.3-1.8) of having a first repeat consultation at any time, when stratified for no STI in the first consultation.

CONCLUSIONS

The STI/HIV burden is high among all 3 MSW-MSM groups. First-generation migrants have higher odds of STI, but retention in care seems similar. Results highlight the importance of low-threshold STI testing and care for (migrant) MSW-MSM.

Perceived risk and condomless sex practice with commercial and non-commercial sexual partners of male migrant sex workers in London, UK

Background: Since the emergence of HIV and the AIDS pandemic, the majority of risk-reduction interventions have been centred on the use of condoms in sex workers.   Methods: This qualitative study recruited 25 male migrant sex workers in London to understand their risk perception and condomless sex experiences within the context of sex work and private life. The data was collected using face-to-face interviews, analysed using thematic analysis, and the findings interpreted through the theory of planned behaviour.   Results: The themes explain that condomless sex with clients occurred when participants consciously accepted to perform this service deploying a risk assessment of clients, faulty strategies, and sexual practices to reduce their risk; or when they lost control because of recreational drugs, feeling attraction to clients, were in precarious circumstances, or were victims of violence. Conversely, condomless sex with non-commercial partners occurred according to the type of relationship, with formal partners it was rationalised through emotional aspects attached to this kind of relationship, while with casual partners it was connected to sexual arousal and the use of alcohol and drugs.  Conclusions: Reinforce educational interventions to deliver STI-HIV information, enhance the use of condoms, and to address specific contextual factors that facilitate condomless practice with commercial and non-commercial sexual partners.

High HIV/STI prevalence among cisgender men and transgender women sex workers attending community-based centres in Barcelona, Spain: The Sweetie Project

Background

The aim of this study was to describe the socio-demographics, and the sexual and health-seeking behaviours of cisgender men and transgender women sex workers (M & TWSW) attending community-based organisations (CBOs) in Barcelona, Spain, as well as to estimate the prevalence of HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), Chlamydia Trachomatis (CT) and Neisseria gonorrhoeae (NG) among them at different anatomical sites.

Methods

The Sweetie Project was a community-based cross-sectional study of 147 M & TWSW recruited in two CBOs in Barcelona between 2017 and 2018. A nurse collected biological samples from rectum, pharynx and urethra from the subjects at each CBO and the participants self-completed an epidemiological questionnaire.

Results

The highest prevalence observed was for HIV infection (25.3%) followed by bacterial STIs (NG 19.2% and CT 10.3%). The most prevalent anatomical site was pharyngeal (17.7%) followed by rectal (13.8%). More than half of participants who had a pharyngeal infection presented an isolated pharyngeal infection (57.7%) and half of those who had a rectal or urethral infection presented an isolated infection respectively. The seroprevalence of HCV and HBV was 2.4% and 34.2% respectively. There was a poor but statistically significant correlation between HIV and rectal CT infection ( r = 0.31), previous exposure to HCV ( r = 0.27) or self-reported STI ( r = 0.23), as well as between previous exposure to HCV and rectal CT ( r = 0.21) or self-reported STI ( r = 0.20).

Discussion

The Sweetie Project confirms the high burden of HIV and bacterial STIs among a sample of M&TWSW recruited in CBOs and reinforces the need to routinely screen them at all exposed anatomical sites.

Longitudinal uptake of the human papillomavirus vaccine among gay, bisexual and other men who have sex with men in British Columbia, Canada 2012-2019

OBJECTIVES

In 2015, a publicly funded human papillomavirus (HPV) vaccination programme was implemented for gay, bisexual and other men who have sex with men (gbMSM) up to age 26 years in British Columbia, Canada. We assessed trends and correlates of HPV vaccine uptake from 2012 to 2019 in a cohort of gbMSM in Vancouver.

METHODS

We recruited sexually active gbMSM aged ≥16 years using respondent-driven sampling from February 2012 to February 2015 and followed them until July 2019. We evaluated self-reported HPV vaccine trends using mixed-effects logistic regression and identified factors associated with uptake using multivariable mixed-effects Poisson regression.

RESULTS

A total of 719 participants were recruited and completed the baseline visit, of whom 549 were unvaccinated with at least one follow-up visit. The median age was 33 years and 23% were living with HIV. HPV vaccination increased from 4% in 2012 to 28% in 2019 (p<0.001) among gbMSM >26 years, and from 9% in 2012 to 20% in 2017 (p<0.001) among gbMSM ≤26 years. Vaccination uptake increased after September 2015, following vaccination policy expansion (adjusted rate ratio (aRR)=1.82, 95% CI 1.06 to 3.12). In multivariable models, increased vaccination was associated with age ≤26 years vs ≥45 years (aRR=3.90; 95% CI 1.75 to 8.70), age 27-44 vs ≥45 years (aRR=2.86; 95% CI 1.46 to 5.62), involvement in gay community sports teams (aRR=2.31; 95% CI 1.15 to 4.64) and other groups (aRR=1.71; 95% CI 1.04 to 2.79), awareness of HIV-postexposure prophylaxis (aRR=5.50; 95% CI 1.31 to 23.09), recent sexually transmitted infection testing (aRR=2.72; 95% CI 1.60 to 4.60) and recent sex-work (aRR=2.59; 95% CI 1.08 to 6.19).

CONCLUSIONS

Although we observed increases in HPV vaccination uptake from 2012, by 2019 HPV vaccination still remained below 30% among gbMSM in Vancouver, BC. Additional interventions are needed to increase vaccine uptake.

Lack of full citizenship rights linked to heightened client condom refusal among im/migrant sex workers in Metro Vancouver (2010-2018)

In Canada, im/migrant sex workers face stigma, health access barriers, and overlapping marginalisation, with end-demand law reforms in 2014 postulated to exacerbate these inequities. Yet, little quantitative evidence on how immigration status shapes HIV/STI risk exists. Drawing on community-based longitudinal cohort data (AESHA, 2010-2018), we used multivariable confounder models with logistic regression to model (1) the independent effect of precarious immigration status (any status revocable under criminal charges: permanent residency/temporary residency/undocumented) on client condom refusal, and (2) the moderating effect of precarious status on the relationship between condom refusal and exposure to end-demand law reform (2015-2018). Over this 8-year study involving 758 sex workers in Metro Vancouver, 16.0% were im/migrants, of whom 57% had precarious immigration status at baseline. 16.5% of participants experienced client condom refusal. Precarious immigration was associated with increased odds of facing condom refusal (adjusted odds ratio [AOR] 2.53, 95% confidence interval [CI] 1.37-4.68), and these odds were heightened post-end-demand law reforms (AOR 4.35, 95%CI 1.21-15.66). Our findings suggest that lack of citizenship rights may enhance barriers to safer sex negotiation and increase HIV/STI risk among sex workers, highlighting the need for sex work and immigration policy reforms.

Sex Worker Health Outcomes in High-Income Countries of Varied Regulatory Environments: A Systematic Review

There is significant debate regarding the regulation of the sex industry, with a complex range of cultural, political and social factors influencing regulatory models which vary considerably between and within countries. This systematic review examined the available evidence on the relationship between different approaches to sex industry regulation in high-income countries, and associated effects on sex worker health status. Objectives included identification of sex worker health outcomes, including sexual health, substance use and experience of stigma and violence. A search was performed electronically in eight scholarly databases which yielded 95 articles which met the criteria for inclusion. Findings suggested that sex workers in legalised and decriminalized countries demonstrated greater health outcomes, including awareness of health conditions and risk factors.

Implications of Migration Patterns and Sex Work on Access to Health Services and Key Health Outcomes: A Qualitative Study on Male Migrant Sex Workers in London

Objectives

This paper describes migration toward the UK, sex work involvement, use of health services, and health issues.

Methods

This qualitative study interviewed twenty-five men. The data were analyzed using thematic analysis.

Results

Five main themes emerged: emigration, migration routes, sex work entrance, use of health services, and main health outcomes.

Conclusions

Discrimination and social exclusion were identified before and during migration. Participants had used the NHS system and told positive experiences. They reported STI-HIV, recreational drugs and mental health issues. Findings suggest the influence of migration and sex work on their vulnerabilities and health outcomes.

Epidemiology of gonorrhoea: a global perspective

Although understanding the local epidemiology of gonorrhoea is critical for local efforts, understanding the multinational epidemiology may support development of national and international prevention and control policies and strategies. In this paper, current epidemiology of gonorrhoea is reviewed through an international lens and with a focus on selected populations. The World Health Organization (WHO) estimates that ~87 million new gonococcal infections occurred among people aged 15-49 years in 2016. Gonorrhoea rates are rising in many countries. Gay, bisexual and other men who have sex with men, racial or ethnic minorities, Indigenous populations and sex workers appear to bear disproportionate burdens of gonorrhoea. International travel can facilitate spread of gonorrhoea, including resistant strains, across international borders. Critical gaps in epidemiological knowledge are highlighted, including data on gonorrhoea among transgender persons and the burden of extragenital gonorrhoea. Even as further data are gathered, action - informed by currently available data - is needed now to confront this growing international threat.

Preventing sexually transmitted and blood borne infections (STBBIs) among sex workers: a critical review of the evidence on determinants and interventions in high-income countries

Background

Across diverse regions globally, sex workers continue to face a disproportionate burden of HIV and other sexually transmitted and blood borne infections (STBBIs). Evidence suggests that behavioural and biomedical interventions are only moderately successful in reducing STBBIs at the population level, leading to calls for increased structural and community-led interventions. Given that structural approaches to mitigating STBBI risk beyond HIV among sex workers in high-income settings remain poorly understood, this critical review aimed to provide a comprehensive synthesis of the global research and literature on determinants of HIV and other STBBIs and promising intervention practices for sex workers of all genders in high-income countries.

Methods

We searched for publications over the last decade (January 2005–March 2016) among sex workers (cis women, cis men, and trans individuals). Data obtained from quantitative peer-reviewed studies were triangulated with publicly available reports and qualitative/ethnographic research where quantitative evidence was limited.

Results

Research demonstrates consistent evidence of the direct and indirect impacts of structural factors (e.g., violence, stigma, criminalization, poor working conditions) on increasing risk for STBBIs among sex workers, further compounded by individual and interpersonal factors (e.g., mental health, substance use, unprotected sex). Sub-optimal access to health and STBBI prevention services remains concerning. Full decriminalization of sex work has been shown to have the largest potential to avert new infections in sex work, through reducing workplace violence and increasing access to safer workspaces. Promising practices and strategies that should be scaled-up and evaluated to prevent STBBIs are highlighted.

Conclusions

The high burden of STBBIs among sex workers across high-income settings is of major concern. This review uniquely contributes to our understanding of multilevel factors that potentiate and mitigate STBBI risk for sex workers of all genders. Research suggests that multipronged structural and community-led approaches are paramount to addressing STBBI burden, and are necessary to realizing health and human rights for sex workers. Given the heterogeneity of sex worker populations, and distinct vulnerabilities faced by cis men and trans sex workers, further research utilizing mixed-methods should be implemented to delineate the intersections of risk and ameliorate critical health inequalities.

[Data on the sexual health of providers and clients of sexual services for men who have sex with men in Germany]

Little is known about the sexual health of male providers and clients of transactional sex. The data of participants of the European MSM Internet Survey (EMIS-DE; N = 50,086) who live in Germany were analysed. The outcomes were testing for and diagnoses of HIV and other sexually transmitted infections (STIs), partner numbers, illicit drug use, and sexual happiness in two populations: (1) men who offered and (2) men who paid for transactional sex in the past 12 months.In the age group of under 30 years (n = 19,138), providers of sexual services (escorts) were compared with non-providers; in the age group of 30 years and above (n = 30,948), we compared men who paid for sexual services with those who did not. We applied univariable and multinomial, multivariable logistic regression analyses in both age groups.Of those under the age of 30, 8% (n = 1529) had been paid for sex in the last 12 months, of which 49% were only paid once or twice. Escorts had lower educational achievements, lived more commonly in large cities, were more often born abroad, self-defined less frequently as gay, and were more frequently single. They reported higher numbers of sex partners, more drug use, and more sexual happiness. Escorts were more frequently tested for HIV and STIs, and among the tested, more diagnoses of HIV and STIs were reported, but those with HIV were less likely to be treated.Among those over 30 years, 11% (n = 3334) had paid for sex, the majority (58%) only once or twice. Payers were older, lived more commonly in large cities, and were more likely to be single, bisexual, or living with a woman. Clients used more illicit drugs, sexual enhancement drugs, and sedatives, but reported less sexual happiness. They were less likely to be tested for HIV and STIs.

Associations between sex work laws and sex workers' health: A systematic review and meta-analysis of quantitative and qualitative studies

BACKGROUND

Sex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur.

METHODS AND FINDINGS

We searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing.

CONCLUSIONS

Together, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.

HIV and other STIs in male sex workers: Findings from a sexual health promotion intervention in Vietnam

Male sex workers (MSWs) in Vietnam are at high risk for acquisition and transmission of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs), yet are extremely disengaged from the healthcare system. This contributes to large numbers of untreated or late-treated infections and increased secondary transmission. We enrolled 995 MSWs in Hanoi and Ho Chi Minh City (HCMC) in a Sexual Health Promotion intervention that included face-to-face delivery of seven content modules, a clinical examination and testing for HIV, syphilis, gonorrhea and Chlamydia. Onsite treatment was provided for STIs, and those who tested positive for HIV were referred to local treatment centers. While 64.6% of participants had never been to a health service and fewer than half (41.2%) had ever been tested for HIV, 67.1% returned for test results. This testing identified 109 (11.0%) participants who were HIV-positive and 312 (31.4%) who tested positive for at least one other STI. Substantive differences were seen in MSWs from different cities, with those from Hanoi more likely to have ever visited a health service (57.8% vs. 24.9%) and to have taken a prior HIV test (54.1% vs. 37.9%) than those in HCMC. Sexual health promotion is a promising approach to engaging MSWs in health services.

Male Sex Workers in Spain: What has Changed in the Last Lustrum? A Comparison of Sociodemographic Data and HIV Sexual Risk Behaviors (2010-2015)

The purpose of this study is to compare the evolution of risky factors related to HIV infection among Male Sex Workers (MSW) in Spain between 2010 and 2015. Participants were 180 MSW: 100 in 2010 and 80 in 2015. Socio-demographic characteristics, condom use with clients and personal partners, and other aspects about HIV infection were explored (serostatus, HIV information, perceived risk and fear, and drug use). The proportion of Spanish MSW (nonimmigrants) (5.5 vs. 62.5 %), educational level (19.8 vs. 40.5 % reported university degree), and the percentage of self-identified as bisexual (20.2 vs. 55.8 %) increased in 2015, whereas the percentage of MSW who self-identified as sex workers (62 vs. 25.8 %) decreased. The percentage of condom use has decreased during oral sex (76.8 vs. 35.5 %), vaginal sex (97.6 vs. 50.7 %) and insertive (99.6 vs. 92.2 %) and receptive (99.7 vs. 93 %) anal sex. The proportion of MSW living with HIV climbed from 1.1 to 13.6 %. The possible influence of economic crisis over MSW's profile changes in the 5-year period, and the necessity of more efficient health strategies based on culture and sexual orientation are discussed. The evolution observed indicates that this population is still at high risk for HIV and STI, therefore governmental resources have to be increased due the consequences among MSW and general society.

Young male sex workers are at high risk for sexually transmitted infections, a cross-sectional study from Dutch STI clinics, the Netherlands, 2006-2012

Background

Male sex workers (MSW) are particularly exposed to sexually transmitted infections (STI) including HIV. In the Netherlands, data about STI among MSW are scarce. We estimated chlamydia, gonorrhoea, syphilis and HIV diagnoses among MSW attending STI clinics and determined associated factors to guide prevention policies.

Methods

Using 2006–2012 cross-sectional national surveillance data from Dutch STI clinics, we calculated the proportion of consultations with a positive test for any of three bacterial STI or HIV among MSW. Associated factors were determined by using Poisson logistic regression with robust variance.

Results

We identified 3,053 consultations involving MSW, of which 18.1 % included at least one positive bacterial STI test and 2.5 % a positive HIV test. Factors associated with bacterial STI and/or HIV diagnoses were respectively age groups < 35 y.o. and self-reporting homo- or bisexual preferences (aRR = 1.6; 95 % CI: 1.3–2.1), and age group 25–34 y.o. (aRR = 2.7; 95 % CI: 1.2–6.5) and self-reporting homo- or bisexual preferences (aRR = 24.4; 95 % CI: 3.4–176.9). Newly diagnosed and pre-existing HIV infection were associated with an increased risk for bacterial STI (aRR = 2.7, 95 % CI: 1.7–2.6 and aRR = 2.1, 95 % CI: 2.2–3.4 respectively). MSW with no history of HIV screening were more likely to be tested positive for HIV compared to those with a previous HIV-negative test (aRR = 2.6, 95 % CI: 1.6–4.3).

Conclusion

Health promotion activities should target MSW who are young, homo- or bisexual, those who are HIV-infected or who have never been tested for HIV, to increase early diagnosis, prevention and treatment.

The epidemiology of sexually transmitted infections in the UK: impact of behavior, services and interventions

Sexually transmitted infections (STIs) are a major public health concern. The UK has some of the most advanced STI surveillance systems globally. This article uses national surveillance data to describe remarkable changes in STI epidemiology in the UK over the last century and explores the behavioral and demographic shifts that may explain these trends. The past 10 years have seen considerable improvements in STI service provision and the introduction of national public health interventions. However, sexual health inequalities persist and men who have sex with men, young adults and black ethnic minorities remain a priority for interventions. Technological advances in testing and a shift in sexual health service commissioning arrangements will present both opportunities and challenges in future.

High burden of STI and HIV in male sex workers working as internet escorts for men in an observational study: a hidden key population compared with female sex workers and other men who have sex with men

BACKGROUND

Male sex work in the western countries has changed, including now a subculture of male sex workers who have paid sex with men arranged for via the internet. The men involved in this subculture do not easily identify themselves as sex workers nor as homosexual, and are therefore missed by regular health care and public health interventions. These male sex workers may form a hidden key population for sexually transmitted infections (STIs) and HIV, bridging towards other persons outside this context.

METHODS

This clinic-based observational study included consultations by male sex workers (n = 212), female sex workers (n = 801) and in men having sex with men who did not report being paid for sexual contacts (MSM, n = 2703) who received STI and HIV testing and counselling at our clinic during the study period. In this study we compare the consultations in male sex workers to those in in female sex workers and MSM. Demographic characteristics and sexual behaviour of the male sex workers, female sex workers and MSM were compared using chi-square tests and non-parametric tests. Using univariate and multivariate regression analyses, determinants for STI positivity in male sex workers were evaluated.

RESULTS

Male sex workers tested positive for STI (including HIV) in 40 % of the consultations; female sex workers and MSM respectively in 9 and 14 % of the consultations. A new HIV infection was found in 8 % of the consultations of male sex workers. Male sex workers were a young population of migrant sex workers from Eastern Europe. They reported more often to also have sex contacts with women and other sex workers. Male sex workers are at a higher risk for one or more new STI than female sex workers and other MSM, even after correction for age, ethnicity, known HIV positivity and behavioural variables.

CONCLUSIONS

Male sex workers form a hidden key population that impacts the transmission of STI and HIV within the MSM population and, possibly, to the heterosexual population. They require specific targeted interventions. Although targeting male sex workers is labour intensive it is feasible and important to reduce STI transmission.

A new public health context to understand male sex work

Background

Researching male sex work offers insight into the sexual lives of men and women while developing a more realistic appreciation for the changing issues associated with male sex work. This type of research is important because it not only reflects a growing and diversifying consumer demand for male sex work, but also because it enables the construction of knowledge that is up-to-date with changing ideas around sex and sexualities.

Discussion

This paper discusses a range of issues emerging in the male sex industry. Notably, globalisation and technology have contributed to the normalisation of male sex work and reshaped the landscape in which the male sex industry operates. As part of this discussion, we review STI and HIV rates among male sex workers at a global level, which are widely disparate and geographically contextual, with rates of HIV among male sex workers ranging from 0% in some areas to 50% in others. The Internet has reshaped the way that male sex workers and clients connect and has been identified as a useful space for safer sex messages and research that seeks out hidden or commonly excluded populations.

Future directions

We argue for a public health context that recognises the emerging and changing nature of male sex work, which means programs and policies that are appropriate for this population group. Online communities relating to male sex work are important avenues for safer sexual messages and unique opportunities to reach often excluded sub-populations of both clients and male sex workers. The changing structure and organisation of male sex work alongside rapidly changing cultural, academic and medical discourses provide new insight but also new challenges to how we conceive the sexualities of men and male sex workers. Public health initiatives must reflect upon and incorporate this knowledge.

Risk-taking behaviours and HIV infection among sex workers in Portugal: results from a cross-sectional survey

OBJECTIVES

Sex workers (SW) are key populations at an increased risk of HIV infection. This study aimed to characterise risk-taking behaviours and assess HIV prevalence among SW in Portugal.

METHODS

A cross-sectional survey was conducted with 1040 SW using a participatory research approach. SW were recruited in sex-work locations and community-based organisation offices. Data were collected through a questionnaire with trained interviewers. An HIV rapid test was performed in 213 respondents.

RESULTS

Reported HIV prevalence was 8%: 17.6% of man-to-woman transgenders, 7.4% of women and 5% of men. Of SW reportedly living with HIV, 52.2% reported ever injecting drug use. Inconsistent condom use with clients in the last month was higher among male SW (26.5%) and with non-paying partners in the last year was higher among women (71.3%). Among reported HIV-positive SW, the proportions of inconsistent condom use were high. In multivariate regression analysis, reported HIV infection remained significantly higher among transgenders (OR 6.4; 95% CI 1.7 to 24.3), those older (OR 5.1; 95% CI 1.3 to 21.1), working outdoors (OR 5.4; 95% CI 1.9 to 15.6), having ever used psychoactive substances (OR 4.1; 95% CI 2.2 to 7.7) and earning ≤€1000 per month (OR 2.6; 95% CI 1.2 to 5.9). Of those who had an HIV rapid test, 8.9% were reactive; 73.7% were unaware of their seropositivity.

CONCLUSIONS

The HIV infection burden in SW is high. Efforts to promote HIV testing must be sustained in order to reduce undiagnosed infection. The diverse risk profiles of SW must be addressed in targeted HIV interventions. Prevention interventions should be systematically implemented within most-at-risk subgroups of SW.