Risky business: health and safety in the sex industry over a 9 year period

East London Project: a participatory mixed-method evaluation on how removing enforcement could affect sex workers' safety, health and access to services in East London

Background

Sex workers' risk of violence and ill-health is shaped by their work environments, community and structural factors, including criminalisation.

Aim

We evaluated the impact of removing police enforcement on sex workers' safety, health and access to services.

Design

Mixed-methods participatory study comprising qualitative research, a prospective cohort study, mathematical modelling and routine data collation.

Setting

Three boroughs in London, UK.

Participants

People aged ≥ 18 years, who provided in-person sexual services.

Interventions

Simulated removal of police enforcement.

Outcomes

Primary - recent or past experience of sexual, physical or emotional violence. Secondary - depression/anxiety symptoms, physical health, chlamydia/gonorrhoea, and service access.

Results

A combination of enforcement by police, local authorities and immigration, being denied justice when reporting violence, and linked cuts to specialist health and support services created harmful conditions for sex workers. This disproportionately affected cisgender and transgender women who work on the streets, use drugs, are migrants and/or women of colour. Among women (n = 197), street-based sex workers experienced higher levels than indoor sex workers of recent violence from clients (73% vs. 36%), police (42% vs. 7%) and others (67% vs. 17%); homelessness (65% vs. 7%); anxiety and depression (71% vs 35%); physical ill-health (57% vs 31%); and recent law enforcement (87% vs. 9%). For street-based sex workers, recent arrest was associated with violence from others (adjusted odds ratio (AOR)) 2.77, 95% confidence interval (CI) 1.11 to 6.94). Displacement by police was associated with client violence (AOR 4.35; 95% CI 1.36 to 13.90) as were financial difficulties (AOR 4.66; CI 1.64 to 13.24). Among indoor sex workers, unstable residency (AOR 3.19; 95% CI 1.36 to 7.49) and financial difficulties (AOR 3.66; 95% CI 1.64 to 8.18) contributed to risk of client violence. Among all genders (n = 288), ethnically and racially minoritised sex workers (26.4%) reported more police encounters than white sex workers, partly linked to increased representation in street settings (51.4% vs. 30.7%; p = 0.002) but associations remained after adjusting for work setting. Simulated removal of police displacement and homelessness was associated with a 71% reduction in violence (95% credible interval 55% to 83%). Participants called for a redirection of funds from enforcement towards respectful, peer-led services.

Limitations

Restriction to one urban locality prevents generalisability of findings. More interviews with under-represented participants (e.g. trans/non-binary sex workers) may have yielded further insights into inequities. Correlation between different risk factors restricted outcomes of interest for the modelling analyses, which were largely limited to experience of violence.

Conclusion

Our research adds to international evidence on the harms of criminalisation and enforcement, particularly for women who work on street and/or are racially or ethnically minoritised. Findings add weight to calls to decriminalise sex work, tackle institutionally racist, misogynist and otherwise discriminatory practices against sex workers in police and other agencies, and to (re)commission experience-based, peer-led services by and for sex workers particularly benefiting the most marginalised communities.

Future work

Realist informed trials, co-produced with sex workers, would provide rigorous evidence on effective approaches to protect sex workers' health, safety and rights.

Funding

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number 15/55/58.

Correlates of Client-Perpetrated Violence Against Female Sex Workers in Bogotá

This paper aims to estimate the prevalence of client-perpetrated violence against female sex workers (FSWs) in Bogotá and to understand what structural and environmental factors are associated with such victimization. The project used secondary data from interviews with 2,684 FSWs. Multivariable binary logistic regression was used to test for associations with client-perpetrated violence. Findings reveal that factors such as experiencing police harassment and social stigma were positively associated with client-perpetrated violence. Situational factors such as providing services in motels, hotels, on the street, and in cars were also associated with increased odds of becoming a victim of violence.

SARS-CoV-2 antibody prevalence among homeless people and shelter workers in Denmark: a nationwide cross-sectional study

BACKGROUND

People experiencing homelessness (PEH) and associated shelter workers may be at higher risk of infection with "Severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2). The aim of this study was to determine the prevalence of SARS-CoV-2 among PEH and shelter workers in Denmark.

DESIGN AND METHODS

In November 2020, we conducted a nationwide cross-sectional seroprevalence study among PEH and shelter workers at 21 recruitment sites in Denmark. The assessment included a point-of-care test for antibodies against SARS-CoV-2, followed by a questionnaire. The seroprevalence was compared to that of geographically matched blood donors considered as a proxy for the background population, tested using a total Ig ELISA assay.

RESULTS

We included 827 participants in the study, of whom 819 provided their SARS-CoV-2 antibody results. Of those, 628 were PEH (median age 50.8 (IQR 40.9-59.1) years, 35.5% female) and 191 were shelter workers (median age 46.6 (IQR 36.1-55.0) years and 74.5% female). The overall seroprevalence was 6.7% and was similar among PEH and shelter workers (6.8% vs 6.3%, p = 0.87); and 12.2% among all participants who engaged in sex work. The overall participant seroprevalence was significantly higher than that of the background population (2.9%, p < 0.001). When combining all participants who reported sex work or were recruited at designated safe havens, we found a significantly increased risk of seropositivity compared to other participants (OR 2.23, 95%CI 1.06-4.43, p = 0.02). Seropositive and seronegative participants reported a similar presence of at least one SARS-CoV-2 associated symptom (49% and 54%, respectively).

INTERPRETATIONS

The prevalence of SARS-CoV-2 antibodies was more than twice as high among PEH and associated shelter workers, compared to the background population. These results could be taken into consideration when deciding in which phase PEH are eligible for a vaccine, as part of the Danish national SARS-CoV-2 vaccination program rollout.

FUNDING

TrygFonden and HelseFonden.

Violent and Nonviolent Crimes Against Sex Workers: The Influence of the Sex Market on Reporting Practices in the United Kingdom

Previous research has shown that sex workers experience extremely high rates of victimization but are often reluctant to report their experiences to the police. This article explores how the markets in which sex workers operate in the United Kingdom impact upon the violent and nonviolent crimes they report to a national support organization and their willingness to report victimization to the police. We use a secondary quantitative data analysis of 2,056 crime reports submitted to the U.K. National Ugly Mugs (NUM) scheme between 2012 and 2016. The findings indicate that although violence is the most common crime type reported to NUM, sex workers operating in different markets report varying relative proportions of different types of victimization. We also argue that there is some variation in the level of willingness to share reports with the police across the different sex markets, even when the types of crime, presence of violence, and other variables are taken into account. Our finding that street sex workers are most likely to report victimization directly to the police challenges previously held assumptions that criminalization is the key factor preventing sex workers from engaging with the police.

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.

2017 European guideline for the screening, prevention and initial management of hepatitis B and C infections in sexual health settings

This guideline updates the 2010 European guideline for the management of hepatitis B and C virus infections. It is primarily intended to provide advice on testing, prevention and initial management of viral hepatitis B and C for clinicians working in sexual health clinical settings in European countries. The guideline is in a new question and answer format based on clinical situations, from which population/intervention/comparison/outcome questions were formulated. Updates cover areas such as epidemiology, point-of-care tests for hepatitis B, hepatitis C risk and 'chemsex', and HIV pre-exposure prophylaxis and hepatitis B. We have also included a short paragraph on hepatitis E noting there is no evidence for sexual transmission. The guideline has been prepared in accordance with the Europe protocol for production available at http://www.iusti.org/regions/europe/pdf/2017/ProtocolForProduction2017.pdf.

Prevalence of Sexually Transmitted Infections and Their Risk Factors among Female Sex Workers in Isfahan, Iran: A Cross-Sectional Study

OBJECTIVES

Female sex workers (FSWs) are at high risk of sexually transmitted infections (STIs) and form a core group to facilitate STI spreading. We aimed to estimate the prevalence of STIs among FSWs who attended Female Harm Reduction Center of Isfahan, Iran, and to determine the association between risky behaviors and STIs.

STUDY DESIGN

In a cross-sectional study, 99 FSWs were recruited and interviewed about demographic characteristics and risky behaviors. A trained midwife examined FSWs for genital ulcer, abnormal vaginal discharge, and cervicitis. Urine and genital specimens were collected and real-time polymerase chain reaction was performed to diagnose Neisseria gonorrhoeae, human papilloma virus (HPV), and Trichomonas Vaginalis. Data were analyzed via χ² test and logistic regression in StataCorp software (version 11) with 95% confidence interval.

RESULTS

Totally, 84.9% of FSWs reported STI symptoms, while 12.1% of them were infected with N gonorrhoeae, HPV, or T vaginalis. Human papilloma virus and gonorrhea prevalence rates were 5.7% and 8% in FSWs with STI-associated symptoms. Sexually transmitted infections showed significant association with duration of prostitution (odds ratio [OR]_HPV = 1.009 [95% confidence interval [95% CI: 1.004-1.01]; OR_gonorrhea = 1.01 [95% CI: 1.00-1.01]) and condom usage (OR_HPV = 0.11 [95% CI: 0.012-0.98]; OR_gonorrhea = 0.04 [95% CI: 0.005-0.33]).

CONCLUSION

Due to the literature gap on the Iranian FSWs' sexual health and the intense stigma around this subject, in Iran, our results would be useful for developing an efficient intervention program. The prevalence of STIs in Isfahan FSWs can be controlled with programs such as consistent condom use and STI treatment. In addition, as just one-tenth of FSWs with an STI symptom were positive for an STI, symptomatic diagnosis of STIs might be insufficient.

The Unanticipated Benefits of Behavioral Assessments and Interviews on Anxiety, Self-Esteem and Depression Among Women Engaging in Transactional Sex

Women engaging in transactional sex have disproportional mental health co-morbidity and face substantial barriers to accessing social services. We hypothesized that participation in a longitudinal research study, with no overt intervention, would lead to short-term mental health improvements. For 4-weeks, 24 women disclosed information about their lives via twice daily cell-phone diaries and weekly interviews. We used t tests to compare self-esteem, anxiety, and depression at baseline and exit. Tests were repeated for hypothesized effect modifiers (e.g., substance abuse severity; age of sex work debut). For particularly vulnerable women (e.g., less educated, histories of abuse, younger initiation of sex work) participation in research conferred unanticipated mental health benefits. Positive interactions with researchers, as well as discussing lived experiences, may explain these effects. Additional studies are needed to confirm findings and identify mechanisms of change. This work contributes to the growing body of literature documenting that study participation improves mental health.

Victimization and HIV Risks Among Croatian Female Sex Workers: Exploring the Mediation Role of Depressiveness and the Moderation Role of Social Support

To assess the association between victimization and HIV vulnerability among Croatian female sex workers (FSWs), a survey involving 157 FSWs recruited from Croatia's two largest urban areas was conducted in 2014. A majority of participants reported direct and indirect victimization, which was found to be significantly associated with condom use at most recent noncommercial sexual intercourse and sexually transmitted infection (STI) diagnosis in the past 12 months. The association between victimization and STI diagnosis was partially mediated by depressiveness and moderated by social support. The buffering role of social support points to the importance of including counseling services in HIV prevention programs in Croatia.

Maids, Migrants and Occupational Health in the London Sex Industry

It has been argued that norms of occupational health have weakened with diversification in the sex industry. We explore this issue in walk-in flats in London, focusing on relationships between managers (maids) and sex workers. Today, most maids are local and most sex workers are 'migrants'. We collected data on 117 maids and sex workers, and carried out intensive fieldwork with seven maids and 17 sex workers. Managers take prime responsibility for educating and inducting new workers. Authoritarian management has been considered bad for health both in these walk-in flats and in the '100 per cent condom use programme' criticized by sex workers' projects. Yet, we found that maids acted as friends and managers, which helped settle new sex workers. Over time, however, migrants were more affected by issues of isolation and exploitation than local workers. Alternative models of health promotion such as peer education must be seen in a wider legal context where the lack of rights makes it difficult to appeal against exploitation, or to become mobile.

Access to healthcare for long-term conditions in women involved in street-based prostitution: a qualitative study

BACKGROUND

Women involved in street-based prostitution (SBP) have well-documented health problems specific to their occupation, but access to care for other chronic health problems has not been explored. Primary care is seen as the optimal context to deliver care for people with long-term conditions because it is accessible, efficient, and can tackle inequalities related to socioeconomic deprivation. We aimed to explore the perspectives of women involved in SBP about access to health care for their long-term conditions.

METHODS

This was a qualitative study with women accessing a third sector organization in North West England. Semi-structured interviews were conducted with sixteen women involved in SBP and accessing support. Data were analysed using the principles of constant comparison and a framework approach.

RESULTS

Women described how they were living with ill health, which they found difficult to manage, and often impacted on their work. Women reported poor access to care and viewed any ensuing consultations in primary care as unsatisfactory.

CONCLUSION

This study highlights the unmet health needs of women who work in SBP, not just related to their occupation, but due to their co-morbid long-term conditions. Access to primary care was reported to be problematic and interactions with general practitioners not fulfilling their expectations, which impacted on future consultation behaviour. Understanding the health-seeking behaviours and self-management strategies of women involved in SBP with chronic health problems is essential in the design and commissioning of services and may reduce unscheduled care in this under-served group.

Non-paying partnerships and its association with HIV risk behavior, program exposure and service utilization among female sex workers in India

Background

In India, HIV prevention programs have focused on female sex workers’ (FSWs’) sexual practices vis-à-vis commercial partners leading to important gains in HIV prevention. However, it has become apparent that further progress is contingent on a better understanding of FSWs’ sexual risks in the context of their relationships with non-paying partners. In this paper, we explored the association between FSWs’ non-paying partner status, including cohabitation and HIV risk behaviors, program exposure and utilization of program services.

Methods

We used data from the cross-sectional Integrated Behavioral and Biological Assessment (IBBA) survey (2009–2010) conducted among 8,107 FSWs in three high priority states of India- Maharashtra, Andhra Pradesh and Tamil Nadu. Multiple logistic regression was used to examine the association between non-paying partner and cohabitation status of FSWs with HIV risk behaviors, program exposure and utilization of program services.

Results

FSWs reporting a non-paying partner were more likely to be exposed to and utilize HIV prevention resources than those who did not have a non-paying partner. Analyses revealed that FSWs reporting a non-cohabiting non-paying partner were more likely to be exposed to HIV prevention programs (adjusted OR: 1.7, 95% CI: 1.3 – 2.1), attend meetings (adjusted OR: 1.5, 95% CI: 1.2 – 1.8), and visit a sexually transmitted infections clinic at least twice in the last six months (adjusted OR: 1.6, 95% CI: 1.3 – 1.9) as compared to those reporting no non-paying partner. That said, FSWs with a non-paying partner rarely used condoms consistently and were more vulnerable to HIV infection because of being street-based (p < 0.001) and in debt (p < 0.001).

Conclusion

FSWs with cohabiting partners were more likely to be exposed to HIV prevention program and utilize services, suggesting that this program was successful in reaching vulnerable groups. However, this subgroup was unlikely to use condoms consistently with their non-paying partners and was more vulnerable, being street based and in debt. The next generation of HIV prevention interventions in India should focus on addressing relationship factors like risk communication and condom negotiation, including specific vulnerabilities like indebtedness and street based solicitation among women in sex work.

The sexual health of female sex workers compared with other women in England: analysis of cross-sectional data from genitourinary medicine clinics

Background

While female sex workers (FSWs) are assumed to be at increased risk of sexually transmitted infections (STIs), there are limited comparative data with other population groups available. Using routine STI surveillance data, we investigated differences in sexual health between FSWs and other female attendees at genitourinary medicine (GUM) clinics in England.

Methods

Demographic characteristics, STI prevalence and service usage among FSWs and other attendees in 2011 were compared using logistic regression.

Results

In 2011, 2704 FSWs made 8411 recorded visits to 131/208 GUM clinics, (primarily large, FSW-specialist centres in London). FSWs used a variety of services, however, 10% did not have an STI/HIV test at presentation. By comparison with other female attendees, FSWs travelled further for their care and had increased risk of certain STIs (eg, gonorrhoea OR_adj: 2.76, 95% CI 2.16 to 3.54, p<0.001). Migrant FSWs had better sexual health outcomes than UK-born FSWs (eg, period prevalence of chlamydia among those tested: 8.5% vs 13.5%, p<0.001) but were more likely to experience non-STI outcomes (eg, pelvic inflammatory disease OR_adj: 2.92, 95% CI 1.57 to 5.41, p<0.001).

Conclusions

FSWs in England have access to high-quality care through the GUM clinic network, but there is evidence of geographical inequality in access to these services. A minority do not appear to access STI/HIV testing through clinics, and some STIs are more prevalent among FSWs than other female attendees. Targeted interventions aimed at improving uptake of testing in FSWs should be developed, and need to be culturally sensitive to the needs of this predominantly migrant population.

The contribution of emotional partners to sexual risk taking and violence among female sex workers in Mombasa, Kenya: a cohort study

Objectives

To assess sexual risk-taking of female sex workers (FSWs) with emotional partners (boyfriends and husbands), compared to regular and casual clients. Experiences of violence and the degree of relationship control that FSWs have with emotional partners are also described.

Design

Cohort study with quarterly follow-up visit over 12-months.

Methods

Four hundred HIV-uninfected FSWs older than 16 years were recruited from their homes and guesthouses in Mombasa, Kenya. A structured questionnaire assessed participant characteristics and study outcomes at each visit, and women received risk-reduction counselling, male and female condoms, and HIV testing.

Results

Four or more unprotected sex acts in the past week were reported by 21.3% of women during sex with emotional partners, compared to 5.8% with regular and 4.8% with casual clients (P<0.001). Total number of unprotected sex acts per week was 5–6-fold higher with emotional partners (603 acts with 259 partners) than with regular or casual clients (125 acts with 456, and 98 acts with 632 clients, respectively; P<0.001). Mostly, perceptions of “trust” underscored unprotected sex with emotional partners. Low control over these relationships, common to many women (36.9%), was linked with higher partner numbers, inconsistent condom use, and being physically forced to have sex by their emotional partners. Half experienced sexual or physical violence in the past year, similarly associated with partner numbers and inconsistent condom use.

Conclusions

High-risk sexual behaviour, low control and frequent violence in relationships with emotional partners heighten FSWs' vulnerability and high HIV risk, requiring targeted interventions that also encompass emotional partners.

"This is our sanctuary": perceptions of safety among exotic dancers in Baltimore, Maryland

Occupational safety researchers have increasingly recognized the important influence of social and structural factors on safety perception and behaviors in occupational settings. This qualitative study was conducted to explore the nature of the safety climate of exotic dance clubs in Baltimore, Maryland and the mechanisms through which this sexual geography informs dancers' perceptions of safety and experience of sex work. Structured observations and semi-structured qualitative interviews (N=40) were conducted with club dancers, doormen, managers, and bartenders from May through August, 2009. Data were analyzed using an inductive approach whereby themes emerged from the data itself. Atlas-ti was used for data analysis. Perceptions of safety within exotic dance clubs were born from an interplay between the physical, social, and symbolic environments. These perceptions were closely tied to dancers' construction of sex work inside versus outside the club. Understanding the contextual factors, which influence how dancers understand and prioritize risk in their work settings, is crucial for creating policies and programs, which effectively reduce risk in this environment.

Human trafficking and health: a conceptual model to inform policy, intervention and research

Human trafficking is an international crime renowned for extreme forms of violence against women, men and children. Although trafficking-related violence has been well-documented, the health of trafficked persons has been a largely neglected topic. For people who are trafficked, health risks and consequences may begin before they are recruited into the trafficking process, continue throughout the period of exploitation and persist even after individuals are released. Policy-making, service provision and research often focus narrowly on criminal violations that occur during the period of exploitation, regularly overlooking the health implications of trafficking. Similarly, the public health sector has not yet incorporated human trafficking as a health concern. We present a conceptual model that highlights the migratory and exploitative nature of a multi-staged trafficking process, which includes: 'recruitment', travel-transit', 'exploitation' and 'integration' or 'reintegration', and for some trafficked persons, 'detention' and 're-trafficking' stages. Trafficked persons may suffer from physical, sexual and psychological harm, occupational hazards, legal restrictions and difficulties associated with being marginalised or stigmatised. Researchers and decision-makers will benefit from a theoretical approach that conceptualizes trafficking and health as a multi-staged process of cumulative harm. To address a health risk such as trafficking, which spans geographical boundaries and involves multiple sectors, including immigration and law enforcement, labour, social and health services, interventions must be coordinated between nations and across sectors to promote the protection and recovery of people who are trafficked.

Correlates of current transactional sex among a sample of female exotic dancers in Baltimore, MD

Transactional sex work, broadly defined as the exchange of money, drugs, or goods for sexual services, occurs in a wide range of environments. There is a large body of research characterizing the risks and harms associated with street- and venue-based sex work, but there is a dearth of research characterizing the risk associated with the environment of exotic dance clubs. The current study aimed to: (1) characterize the nature of female exotic dancers' sex- and drug-related risk behaviors, (2) to examine the role of the club environment in these behaviors, and (3) to examine correlates of currently exchanging sex. From June 2008 to February 2009, we conducted a cross-sectional study among women who were aged 18 years or older and reported exotic dancing within the past 3 months (n = 98). The survey ascertained socio-demographic characteristics, personal health, medical history, sexual practices, drug use, and employment at clubs on the block. Bivariate and multivariate Poisson regression with robust variance was used to identify correlates of current sex exchange. Participants were a median of 24 years old, and were 58% white; 43% had not completed high school. Seventy-four percent reported ever having been arrested. Twenty-six percent reported having injected heroin and 29% reported having smoked crack in the past 3 months. Fifty-seven percent reported using drugs in the club in the past 3 months. Sixty-one percent had ever engaged in transactional sex, and 67% of those did so for the first time after beginning to dance. Forty-three percent reported selling any sex in the club in the past 3 months. In multiple Poisson regression, factors associated with current sex exchange included: race, ever having been arrested, and using drugs in the club. High levels of both drug use and transactional sex among this sample of exotic dancers were reported. These findings indicate that there are a number of drug- and sex-related harms faced by exotic dancers in strip clubs, implicating the environment in the promotion of HIV/STI risk-taking behaviors. Prevention and intervention programs targeting this population are needed to reduce the harms faced by exotic dancers in this environment.

Stigma and sex work from the perspective of female sex workers in Hong Kong

While the stigma surrounding sex work is both well documented and easily recognised, few studies examine stigma in this context from the perspective of the sex workers themselves. In this article we report on a study using a modified grounded theory approach to analyse a series of semi-structured interviews with 49 female sex workers in Hong Kong, in order to examine the ways in which this group experiences and negotiates the stigma which arises from their employment in the sex industry. Sex workers in Hong Kong were subject to various stigmatising forces in their daily lives in their interactions with the public, the police and their families. These processes could have a negative impact on the sex workers' health, both through obvious manifestations such as physical or verbal abuse and through more subtle processes such as those which generated or perpetuated vulnerability and those which compelled the sex workers to conceal their identities and withdraw themselves from social networks. These findings are situated in the context of broader research surrounding sex work, drawing attention to the consequences of stigma on health and their interaction with health-service providers, before briefly discussing possible means of overcoming stigma-related barriers to providing adequate healthcare for this marginalised group.

Mapping HIV/STI behavioural surveillance in Europe

BACKGROUND

Used in conjunction with biological surveillance, behavioural surveillance provides data allowing for a more precise definition of HIV/STI prevention strategies. In 2008, mapping of behavioural surveillance in EU/EFTA countries was performed on behalf of the European Centre for Disease prevention and Control.

METHOD

Nine questionnaires were sent to all 31 member States and EEE/EFTA countries requesting data on the overall behavioural and second generation surveillance system and on surveillance in the general population, youth, men having sex with men (MSM), injecting drug users (IDU), sex workers (SW), migrants, people living with HIV/AIDS (PLWHA), and sexually transmitted infection (STI) clinics patients. Requested data included information on system organisation (e.g. sustainability, funding, institutionalisation), topics covered in surveys and main indicators.

RESULTS

Twenty-eight of the 31 countries contacted supplied data. Sixteen countries reported an established behavioural surveillance system, and 13 a second generation surveillance system (combination of biological surveillance of HIV/AIDS and STI with behavioural surveillance). There were wide differences as regards the year of survey initiation, number of populations surveyed, data collection methods used, organisation of surveillance and coordination with biological surveillance. The populations most regularly surveyed are the general population, youth, MSM and IDU. SW, patients of STI clinics and PLWHA are surveyed less regularly and in only a small number of countries, and few countries have undertaken behavioural surveys among migrant or ethnic minorities populations. In many cases, the identification of populations with risk behaviour and the selection of populations to be included in a BS system have not been formally conducted, or are incomplete. Topics most frequently covered are similar across countries, although many different indicators are used. In most countries, sustainability of surveillance systems is not assured.

CONCLUSION

Although many European countries have established behavioural surveillance systems, there is little harmonisation as regards the methods and indicators adopted. The main challenge now faced is to build and maintain organised and functional behavioural and second generation surveillance systems across Europe, to increase collaboration, to promote robust, sustainable and cost-effective data collection methods, and to harmonise indicators.

European guideline for the management of hepatitis B and C virus infections, 2010

These are the guidelines on hepatitis B and C management for IUSTI/WHO in Europe, 2010. They describe the epidemiology, diagnosis, clinical features, treatment and prevention of hepatitis B and C with particular reference to sexual health clinical practice.

Commercial sexual practices before and after legalization in Australia

The nature of sex work changes over time for many reasons. In recent decades around the world, there has been movement toward legalization and control of sex economies. Studies of the possible impact of legalization mainly have focused on sexually transmitted infections and violence, with little attention to change in the diversity of sexual services provided. This study examined the practices of sex workers before and after legalization of prostitution. Cross-sectional surveys of comparable samples of female sex workers were conducted in 1991 (N = 200, aged 16-46 years) and 2003 (N = 247, aged 18-57 years) in Queensland, Australia, spanning a period of major change in regulation of the local industry. In 2003, male clients at brothels and private sole operators (N = 161; aged 19-72 years) were also interviewed. Over time, there was a clear increase in the provision of "exotic" sexual services, including bondage and discipline, submission, fantasy, use of sex toys, golden showers, fisting, and lesbian double acts, while "traditional" services mostly remained at similar levels (with substantial decrease in oral sex without a condom). Based on comparisons of self-reports of clients and workers, the demand for anal intercourse, anal play, and urination during sex apparently exceeded supply, especially in licensed brothels. Within this population, legalization of sex work coincided with a substantial increase in diversity of services, but it appears that in the regulated working environments, clients who prefer high risk practices might not dictate what is available to them.

HIV and sexual risk behavior among commercial sex workers in the Netherlands

In 2002-2005, a cross-sectional study to assess the potential for HIV transmission was carried out among 557 female and male-to-female transgender commercial sex workers (CSW) in three cities in the Netherlands. Female CSW (F-CSW), drug-using female CSW (DU), and transgender sex workers were recruited in street-based and establishment-based sites. An anonymous questionnaire was administrated by interviewers and a saliva sample was collected for HIV antibody testing. The overall HIV prevalence was 5.7% (31/547; 10 samples were excluded because of "intermediate" test results). HIV was more prevalent among transgender (18.8%, 13/69) and DU (13.6%, 12/88) sex workers than among F-CSW (1.5%, 6/390). Of the HIV positive CSW, 74% were unaware of their infection. Consistent condom use with clients was 81%. Regular condom failure with clients was reported by 39%. In multivariate analyses, transgender sex workers (OR = 22.9), drug-using CSW who ever injected drugs (OR = 31.1), African (OR = 19.0), and South European ethnicity (OR = 7.2) were independently associated with HIV. Condom failure (PRR = 2.0), anal sex (PRR = 2.1), and drug use (PRR = 3.8) were associated with inconsistent condom use with clients. There is a potential risk for further spread of HIV, through clients and (private) partners of sex workers, to the general population. Targeted health promotion activities are indicated for transgender sex workers and drug-using female CSW; active HIV testing must be continued.

A descriptive profile of abused female sex workers in India

This descriptive study presents the profiles of abused female sex workers (FSWs) in Chennai, India. Of 100 abused FSWs surveyed using a structured questionnaire, severe forms of violence by intimate partners were reported by most (98%) respondents. Of the total sample, 76% experienced violence by clients. Sexual coercion experiences of the FSWs included verbal threats (77%) and physical force (87%) by intimate partners and forced unwanted sexual acts (73%) by clients. While 39% of the women consumed alcohol before meeting a client, 26% reported that their drunkenness was a trigger for violence by clients. The findings suggest that there is an urgent need to integrate services, along with public-health interventions among FSWs to protect them from violence. Recognition of multiple identities of women in the contexts of intimate relationships versus sex work is vital in helping women to stay safe from adverse effects on health.

A pooled analysis of the effect of condoms in preventing HSV-2 acquisition

BACKGROUND

The degree of effectiveness of condom use in preventing the transmission of herpes simplex virus 2 (HSV-2) is uncertain. To address this issue, we performed a large pooled analysis.

METHODS

We identified prospective studies with individual-level condom use data and laboratory-defined HSV-2 acquisition. Six studies were identified through a review of publications through 2007: 3 candidate HSV-2 vaccine studies, an HSV-2 drug study, an observational sexually transmitted infection (STI) incidence study, and a behavioral STI intervention study. Study investigators provided us individual-level data to perform a pooled analysis. Effect of condom use was modeled using a continuous percentage of sex acts during which a condom was used and, alternatively, using absolute numbers of unprotected sex acts.

RESULTS

A total of 5384 HSV-2-negative people at baseline contributed 2 040 894 follow-up days; 415 persons acquired laboratory-documented HSV-2 during follow-up. Consistent condom users (used 100% of the time) had a 30% lower risk of HSV-2 acquisition compared with those who never used condoms (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.40-0.94) (P = .01). Risk for HSV-2 acquisition increased steadily and significantly with each unprotected sex act (HR, 1.16; 95% CI, 1.08-1.25) (P < .001). Condom effectiveness did not vary by gender.

CONCLUSIONS

To our knowledge, this is the largest analysis using prospective data to assess the effect of condom use in preventing HSV-2 acquisition. Although the magnitude of protection was not as large as has been observed with other STIs, we found that condoms offer moderate protection against HSV-2 acquisition in men and women.

Transactional sex among men and women in the south at high risk for HIV and other STIs

Transactional sex refers to selling sex (exchanging sex for money, drugs, food, shelter, or other items) or purchasing sex (exchanging money, drugs, food, shelter, or other items for sex). These activities have been associated with a higher risk for HIV and other sexually transmitted infections in a variety of populations and settings. This paper examines correlates of purchasing and selling sex in a large sample of drug users, men who have sex with men, and sex partners of these groups. Using respondent-driven sampling, participants were recruited between 2005 and 2008 in two urban and two rural counties in North Carolina. We used multiple logistic regressions to examine separate models for selling and purchasing sex in men and women. In addition, we estimated direct and indirect associations among independent variables in the logistic regression models and transactional sex using structural equation models. The analysis shows that factors associated with women selling and buying sex include being homeless, use of stimulants, bisexual behavior, and neighborhood disorder. There was also a significant difference by race. For men, the factors associated with selling and buying sex include being homeless, bisexual behavior, and not being in a relationship. Although neighborhood violence and disorder show significance in bivariate associations with the outcome, these associations disappear in the structural equation models.

Sexually transmissible infections among sex workers and their clients: variation in prevalence between sectors of the industry

OBJECTIVES

The risk of sexually transmissible infection (STI) among sex workers and their clients may be higher than the general population. However, many studies have categorised workers or clients into homogenous groups for the purposes of analysis. The aim of the present study was to assess variations in self-reported STI rates among licenced brothel, private and illegal sex workers and their clients.

METHODS

In 2003, self-report data were collected from female sex workers and their male commercial clients residing in the state of Queensland, Australia. Overall, 247 sex workers (aged 19-57 years) and 185 of their respective clients (aged between 19 and 72 years) completed anonymous questionnaires.

RESULTS

There was little variation in self-reported lifetime STI prevalence of licenced brothel, private and illegal (predominantly street-based) sex workers, although licenced brothel workers were less likely to report ever being diagnosed with gonorrhoea or pubic lice in the past (P = 0.035 and 0.004 respectively). In contrast, clients accessing illegal services reported higher lifetime STI (36.0%, 95% confidence interval (CI) 20.2-55.6) than men recruited through private sex workers (20.0%, 95% CI 11.4-32.5) and clients from licenced brothels (7.6%, 95% CI 3.7-14.5).

CONCLUSIONS

This study found high self-reported lifetime prevalence of infection among sex workers and their clients. It is notable, however, that lower STI rates were reported by clients and sex workers from licenced brothels. This would suggest that risk of infection is not equivalent across industry sectors and highlights some of the inherent risks associated with generalisation across the sex industry.

Trapped in circle of threats: violence against sex workers in Thailand

Most researchers studying sex work have focused on the risks of sexually transmitted diseases, predominantly HIV, for sex workers, their clients, and subsequent partners. Violence against these women often goes undocumented and unnoticed. Consequently, few researchers have addressed violence against sex workers, and these few have generated limited evidence about the nature of violence from the sex-worker perspective--especially the street sex worker perspective. In this study, we used qualitative methods to explore characteristics of violence against street sex workers and how violence influences personal and societal health risks. The participants were 28 female street sex workers. The data were collected through in-depth interviews with 23 women, one focus group with 5 women, and observations of these women in their working and social environment. The results revealed that violence against sex workers can be clustered into three categories, threat to their life and health, threat to control of work and financial security, and finally, threat to humanity. Because they are disadvantaged, and engage in illegal employment, theses women were trapped in a circle of threats. To reduce violence, sex work should be decriminalized along with strategies to decrease poverty and social inequality. A special agency needs to be established to protect the rights and safety of sex workers.

Violence, dignity and HIV vulnerability: street sex work in Serbia

Sex work can be contextualized by violence, social and material inequality, and HIV vulnerability. We undertook a qualitative study to explore female and transvestite sex workers' accounts (n = 31) of HIV risk environment in Belgrade and Pancevo, Serbia. Violence emerged as a key theme. Accounts emphasise the ubiquity of multiple forms of everyday violence - physical, emotional, social - in street sex work scenes, linked to police as much as clients. We highlight the salience of emotions in sex work risk management, in which the preservation of dignity is of prime importance. Accounts draw upon narratives of hygiene and responsibility which, we argue, seek to resist portrayals, normative to this setting, of sex workers as contaminated and irresponsible. Findings highlight how the ubiquity of the risk of violence in street sex work scenes reflects institutionalised social inequalities and injustices. Sex workers are inevitably participant in the cycle of symbolic violence they seek to resist. The challenges for HIV prevention are therefore considerable, and require interventions which not only seek to foster safer micro-environments of sex work but structural changes in the welfare, criminal justice and other social institutions which reproduce the cycle of violence faced by sex workers day to day.

Motivational influences on the safer sex behavior of agency-based male sex workers

Although indoor male sex workers (MSWs) have been found to engage in lower rates of HIV risk behavior with clients than street-based MSWs, few studies have examined the motivations behind such practices. We interviewed 30 MSWs working for the same escort agency regarding their safer sex practices with clients and their reasons for these. As in other research, MSWs reported little risk behavior with clients. Five motivational themes related to safer sex on the job emerged: health concerns, emotional intimacy, client attractiveness, relationships, and structural work factors. Results suggest that participants engaged in rational decision-making relative to sex with clients, facilitated by reduced economic incentive for riskier behavior and a supportive social context. MSWs desired a safe sexual work place, personal integrity, and minimal negative consequences to personal relationships. Collaborating with sex work employers to study their role in encouraging a safer workplace may be important to future research.

Child prostitution in Thailand

Child prostitution is an old, global and complex phenomenon, which deprives children of their childhood, human rights and dignity. Child prostitution can be seen as the commercial sexual exploitation of children involving an element of forced labour, and thus can be considered as a contemporary form of slavery. Globally, child prostitution is reported to be a common problem in Central and South America and Asia. Of all the south-east Asian nations, the problem is most prolific in Thailand. In Thailand, there appears to be a long history of child prostitution, and this article explores the factors that underpin the Thai child sex industry and the lessons and implications that can be drawn for health care and nursing around the world.

Prevalence of human immunodeficiency virus, Chlamydia trachomatis, and Neisseria gonorrhoeae and risk factors for sexually transmitted infections among immigrant female sex workers in Catalonia, Spain

OBJECTIVES

To determine the prevalence of human immunodeficiency virus (HIV), Chlamydia trachomatis (CT), and Neisseria gonorrhoeae (NG) among immigrant female sex workers (FSW) according to their geographic area of origin and identify possible risk factors independently associated with current infection with CT and/or NG.

STUDY DESIGN

Cross-sectional study of 357 FSW in Catalonia in 2005. Information on sociodemographic and sex work characteristics, use of alcohol and drugs, sexual practices, and the use of social and health care services was collected. Oral fluid and urine samples were collected to determine the prevalence of HIV and CT/NG, respectively. Factors independently associated with CT/NG were assessed using multivariate logistic regression models.

RESULTS

A total of 36.4% of women were from Eastern Europe, 34.5% from Latin America, and 29.1% from Africa. Overall CT and NG prevalence were 5.9% [95% confidence interval (CI): 3.7-8.9] and 0.6% (95% CI: 0.1-2.0), respectively. No differences were observed by geographic origin. Three African women were HIV positive (overall HIV prevalence was 0.8%, 95% CI: 0.2-2.4). In multivariate analysis, younger age and unprotected sex with clients were associated with the presence of CT/NG.

CONCLUSIONS

The prevalence of sexually transmitted infections among FSW in Catalonia was lower than in other European countries. Even though the prevalence of HIV was only 0.8%, it could increase in the future given the high vulnerability of these women and their wide geographic mobility. It is necessary to continue with the work carried out by nongovernmental organizations (harm reduction programs, outreach programs, and safe sex workshops) as well as to facilitate the access to health centers, especially for the youngest women.

Sexually transmissible infections among female sex workers: an international review with an emphasis on hard-to-access populations

Background: Women who work commercially in sex work (female sex workers [FSW]) are considered a high-risk group for sexually transmissible infections (STI), yet the level of reported pathogens varies in studies around the world. This study reviewed STI rates reported in 42 studies of FSW around the world published between 1995 and 2006 and analysed the trends and types of populations surveyed, emphasising difficult to access FSW populations. Methods:Studies were retrieved by PUBMED and other search engines and were included if two or more pathogens were studied and valid laboratory methods were reported. Results: The five most commonly assessed pathogens were Neisseria gonorrhea (prevalence 0.5–41.3), Chlamydia trachomatis (0.61–46.2), Treponema pallidum (syphilis; 1.5–60.5), HIV (0–76.6), and Trichomonas vaginalis (trichmoniasis; 0.11–51.0). Neisseria gonorrhea and C. trachomatis were the most commonly tested pathogens and high prevalence levels were found in diverse areas of the world. HIV was highly prevalent mostly in African countries. Although human papillomavirus infection was surveyed in few studies, prevalence rates were very high and its aetiological role in cervical cancer warrant its inclusion in future FSW monitoring. Hard-to-access FSW groups tended to have higher rates of STI. Conclusions: The five most commonly detected pathogens correspond to those that are highly prevalent in the general population, however there is an urgent need to develop rapid testing diagnostics for all five pathogens to increase prevention and treatment, especially in outreach programs to the most vulnerable groups among FSW.

Maintaining sexual health in commercial sex workers in Australia: condom effectiveness, screening, and management after acquiring sexually transmissible infections

OBJECTIVE

To provide practical advice to health care providers and public health practitioners regarding screening and management of sexually transmitted infections (STIs) in sex workers, and to examine the effectiveness of condoms in reducing transmission of STIs.

METHODS

Medline search using the key words sex workers, prostitutes, condoms and these terms in conjunction with pregnancy, sexually transmitted infections (including the names of individual STIs), infectivity, exclusion periods. Additional articles were identified from cited references. Articles were selected on the basis of information provided on efficacy of condoms in STI prevention, prevalence of STIs in sex workers and changes following condom promotion, and advice about management of STIs in infected workers.

RESULTS

Condoms offer some protection (30-90%) against STIs passed in semen, urethral, vaginal or cervical secretions (such as HIV, gonorrhoea, chlamydia). They give little to no protection (0-30%) against diseases due to skin-to-skin contact such as genital herpes and genital warts. Transmissibility of STIs varies according to the sex of the exposed person and the sexual practice. Condom effectiveness against STIs also varies with gender, and experience and consistency of condom use.

CONCLUSIONS

Sex workers require regular screening for STIs as condom use is not fully protective. Management of sex workers identified with infection requires understanding of the issues faced by sex workers, biological characteristics of the infective organism, treatment efficacy, and test sensitivity and specificity. Advice on frequency of STI testing, supply of medical certificates, management of condom breakage, and management of infected sex workers is proposed.

Health needs and service use of parlour-based prostitutes compared with street-based prostitutes: a cross-sectional survey

OBJECTIVES

To compare the health needs of prostitutes (sex workers) working in massage parlours with that of those working on the streets.

DESIGN

Cross-sectional survey.

SETTING

Inner city, UK.

POPULATION

Women aged 16 years and older selling sex in massage parlours.

METHODS

Interviewer-administered questionnaires were undertaken with 71 parlour workers, and results were compared with our previous findings for street sex workers.

MAIN OUTCOME MEASURES

Self-reported experiences of health and service use.

RESULTS

In comparison with street sex workers, parlour sex workers were less likely to report chronic (43/71 versus 71/71; P < 0.001) and acute (10/71 versus 35/71; P < 0.001) illnesses but more likely to be registered with a GP (67/71 versus 59/71; P = 0.06). They were more likely than street sex workers to have been screened for sexually transmitted infections in the previous year (49/71 versus 33/71; P = 0.011) and more likely to use contraception in addition to condoms (34/71 versus 8/71; P < 0.001). They were less likely to be overdue for cervical screening (5/46 versus 19/48; P = 0.001), and more of those booked for antenatal care in the first trimester attended all follow-up appointments (28/37 versus 14/47; P < 0.001). Fewer parlour sex workers used heroin (4/71 versus 60/71; P < 0.001), crack cocaine (5/71 versus 62/71; P < 0.001) or injected drugs (2/71 versus 41/71 versus; P < 0.001) They reported fewer episodes of intercourse per week (mean 14 versus 22; P < 0.001) with fewer different men (mean 11 versus 19; P < 0.001), less of whom were new (mean 8 versus 13; P < 0.001).

CONCLUSIONS

The two groups had very different health experiences, risk-taking behaviour and use of services. To be effective in improving health, different types of service delivered in different settings for different groups are required.

Designing out vulnerability, building in respect: violence, safety and sex work policy

One recent finding about the prostitution market is the differences in the extent and nature of violence experienced between women who work on the street and those who work from indoor sex work venues. This paper brings together extensive qualitative fieldwork from two cities in the UK to unpack the intricacies in relation to violence and safety for indoor workers. Firstly, we document the types of violence women experience in indoor venues noting how the vulnerabilities surrounding work-based hazards are dependent on the environment in which sex is sold. Secondly, we highlight the protection strategies that indoor workers and management develop to maintain safety and order in the establishment. Thirdly, we use these empirical findings to suggest that violence should be a high priority on the policy agenda. Here we contend that the organizational and cultural conditions that seem to offer some protection from violence in indoor settings could be useful for informing the management of street sex work. Finally, drawing on the crime prevention literature, we argue that it is possible to go a considerable way to designing out vulnerability in sex work, but not only through physical and organizational change but building in respect for sex workers rights by developing policies that promote the employment/human rights and citizenship for sex workers. This argument is made in light of the Coordinated Prostitution Strategy.

Extent, Trends, and Perpetrators of Prostitution-Related Homicide in the United States

Prostitute women have the highest homicide victimization rate of any set of women ever studied. We analyzed nine diverse homicide data sets to examine the extent, trends, and perpetrators of prostitution-related homicide in the United States. Most data sources substantially under-ascertained prostitute homicides. As estimated from a conservative capture-recapture analysis, 2.7% of female homicide victims in the United States between 1982 and 2000 were prostitutes. Frequencies of recorded prostitute and client homicides increased substantially in the late 1980s and early 1990s; nearly all of the few observed pimp homicides occurred before the late 1980s. These trends may be linked to the rise of crack cocaine use. Prostitutes were killed primarily by clients, clients were killed mainly by prostitutes, and pimps were killed predominantly by pimps. Another conservative estimate suggests that serial killers accounted for 35% of prostitute homicides. Proactive surveillance of, and evidence collection from, clients and prostitutes might enhance the investigation of prostitution-related homicide.

Sex worker health: San Francisco style

OBJECTIVES

To describe the characteristics of sex workers accessing care at a peer based clinic in San Francisco and to evaluate predictors of sexually transmitted infections (STI).

METHODS

We conducted an observational study of sex workers at St James Infirmary. Individuals underwent an initial questionnaire, and we offered screening for STI at each clinic visit. We performed univariate, bivariate, and multivariable analyses to assess for predictors of STI in this population.

RESULTS

We saw 783 sex workers identifying as female (53.6%), male (23.9%), male to female transgender (16.1%), and other (6.5%). 70% had never disclosed their sex work to a medical provider. Participants represented a wide range of ethnicities, educational backgrounds, and types of sex work. The most common substance used was tobacco (45.8%). Nearly 40% reported current illicit drug use. Over half reported domestic violence, and 36.0% reported sex work related violence. Those screened had gonorrhoea (12.4%), chlamydia (6.8%), syphilis (1.8%), or herpes simplex virus 2 (34.3%). Predictors of STI included African-American race (odds ratio (OR) 3.3), male gender (OR 1.9), and sex work related violence (OR 1.9). In contrast, participants who had only ever engaged in collective sex work were less likely to have an STI (OR 0.4).

CONCLUSIONS

The majority of sex workers have never discussed their work with a medical provider. Domestic violence is extremely prevalent as is work related violence. Working with other sex workers appears to be protective of STIs. STI prevention interventions should target African-American and male sex workers. Addressing violence in the workplace and encouraging sex workers to work collectively may be effective prevention strategies.

Estimating adult HIV prevalence in the UK in 2003: the direct method of estimation

BACKGROUND

Estimates of the total number of prevalent HIV infections attributable to the major routes of infection make an important contribution to public health policy, as they are used for planning services.

METHODS

In the UK, estimates were derived through the "direct method" which estimated the total number of diagnosed and undiagnosed HIV infections in the population. The direct method has been improved over a number of years since first used in 1994, as further data became available such as the inclusion of newly available behavioural survey data both from the National Survey of Sexual Attitudes and Lifestyles (Natsal 2000) and community surveys of men who have sex with men (MSM). These data were used to re-estimate numbers of people unaware of their infection and provided ethnic breakdowns within behavioural categories. The total population was divided into 10 mutually exclusive behavioural categories relevant to HIV risk in the UK-for example, MSM and injecting drug users. Estimates of the population size within each group were derived from Natsal 2000 and National Statistics mid-year population estimates. The total number of undiagnosed HIV infections was calculated by multiplying the undiagnosed HIV prevalence for each group, derived from the Unlinked Anonymous HIV Prevalence Monitoring Programme surveys (UAPMP), by the population size. These estimates were then added to the prevalent diagnosed HIV infections within each group derived from the national census of diagnosed HIV infections, the Survey of Prevalent HIV Infections Diagnosed (SOPHID). The estimates were then adjusted to include all adults in the UK. Because undiagnosed HIV prevalence estimates were not available for each of the behavioural categories, the UAPMP prevalence estimates were adjusted using available data to provide the best estimates for each group.

RESULTS

It is estimated that 53,000 individuals are infected with HIV in the UK in 2003, of whom 27% were unaware of their infection. Of the total of 53,000, an estimated 26,000 were among heterosexually infected and 24,500 among MSM.

CONCLUSION

The direct method uses an explicit framework and data from different components of the HIV surveillance system to estimate HIV prevalence in the UK, allowing for a comprehensive picture of the epidemic.