IV Male sex work in public and community health


Global epidemiology of HIV and other sexually transmitted infections among male

sex workers

Emerging approaches in prevention

Global epidemiology of HIV and other sexually transmitted infections among male sex workers: emerging approaches in prevention and treatment

Peter Salhaney, Katie B. Biello, and Matthew J. Mimiaga

This chapter provides an overview of the global epidemiology of HIV and other sexually transmitted infections (STIs) among male sex workers, with an emphasis on sexual risk behavior, as well as psychosocial and structural factors that increase the likelihood of HIV’s spread. It discusses access to HIV prevention and treatment along with effective biomedical and behavioral interventions to reduce HIV acquisition and transmission among this group. Finally, it highlights new areas for exploration and knowledge to be gained. It is important to keep in mind that there are various types of male sex workers, including Internet escorts, street workers, masseurs, and dancers, and each type may have considerable differences in sexual risk behaviors, which may influence epidemiological data across different contexts and world regions. For example, male sex workers who solicit clients on the Internet may have a different risk profile from those whose work is predominantly street-based. Similarly, individuals who self-identify as male sex workers and tor whom sex work is their primary source of income may differ significantly from men who do not identify as sex workers and who exchange sex only intermittently or informally. We use the term male sex worker (MSW) throughout this chapter to refer broadly to men who engage in transactional sex with other men tor money, goods, drugs, or other items of value.

Global epidemiology of HIV and other sexually transmitted infections among male sex workers

According to the United Nations AIDS (UNAIDS) approximately 38 million people are living with HIV/AIDS infection globally, of whom 1.7 million were newly infected in 2019 (UNAIDS, 2020). Amid these cases, male sex workers (MSWs) represent a largely understudied population at particularly elevated risk tor HIV and other sexually transmitted infections.

Owing to the lack of routine epidemiological data collected on MSWs worldwide, there is considerable variation in regional estimates of HIV and ST1 incidence and prevalence within this group.

Studies using convenience sampling consistently show a high burden of HIV among MSWs, with prevalence rates exceeding that ot female sex workers (FSWs) and men in the general population (Friedman, Guadamuz, & Marshal, 2011). We performed a literature review of seven electronic databases, national surveillance reports, and conference abstracts tor reports of MSWs published between 2004 and 2013. Drawing from 66 selected studies, representing 31,924 MSWs in 28 countries, pooled biological assay-confirmed HIV prevalence was 10.5 percent (95 percent confidence interval [Cl] = 9.4 to 11.5 percent). The highest pooled HIV prevalence was in sub-Saharan Africa (31.5 percent, 95 percent Cl = 21.6 to 41.5 percent), followed by Latin America (19.3 percent, 95 percent Cl = 15.5 to 23.1 percent), North America (16.6 percent, 95 percent Cl = 3.7 to 29.5 percent), and Europe (12.2 percent, 95 percent Cl = 6.0 to 17.2 percent) (see Figure 18.1). Men who engaged in transactional sex had an elevated burden of HIV compared with the overall male population (probability [PR]= 20.7, 95 percent Cl = 16.8 to 25.5) (Oldenburg, Perez-Brumer et al., 2014).

In a similar meta-analysis examining the prevalence ot HIV among MSWs in 2015, the rate ranged from 5 to 31 percent, much higher than in the general population (Baral et al., 2015). A study in Cote d’Ivoire, one ot the West Atrican countries most severely affected by HIV/A1DS, found that among 96 MSWs, 50 percent were living with HIV, 12.8 percent with gonorrhea, and 3.2 percent with chlamydia infections (Vuylsteke et al., 2012). Cross-sectional national surveillance data ot MSWs attending STI clinics in the Netherlands from 2006 to 2012 found that 18.1 percent of STI clinic encounters included a diagnosis ot at least one bacterial STI (Fournet et al., 2015). Similarly elevated rates of HIV and other STI diagnoses have been demonstrated by studies conducted in Canada (Weber et al., 2001), Thailand (Toledo et al., 2010), Brazil (Cortez, Boer, & Baltieri, 2011), Vietnam (Nguyen, Nguyen, Le, & Detels, 2008), and Nigeria (Vu et al., 2013), as well as Europe (Belza, 2005; Sethi et al., 2006), Australia (Callander et al., 2015), and Latin America (Segura et al., 2010).

Reports ot higher HIV prevalence among men who have sex with men (MSM) and who engage in sex work versus MSM who do not engage in sex work have not been entirely

Pooled HIV prevalence by country from 66 studies reporting biologically confirmed HIV prevalence with a sample size of >50

Figure 18.1 Pooled HIV prevalence by country from 66 studies reporting biologically confirmed HIV prevalence with a sample size of >50.

Source: Oldenburg, Perez-Brumer et al., 2014.

consistent across studies, likely as a result of different sampling methods. Similarly, in different world regions, the magnitude of this relationship varies with local cultural, political, economic, and structural factors, particularly those that enable or restrict the practice of sex work or same- sex practices. For example, Callander (2017) outlined how HIV and ST1 rates among MSWs are influenced by the local rates of infection overall: if infection rates are elevated in a country overall, rates are also likely to be high among MSWs in that population.

Notwithstanding this variation, a recent systematic review and meta-analysis of 33 studies in 17 countries, comparing MSM who engaged in transactional sex with those who did not incorporating^ = 78,112 MSM) showed that, overall, transactional sex was associated with a statistically significant elevation in HIV prevalence (odds ratio [OR] = 1.34, 95 percent Cl = 1.11 to 1.62). This increase was most pronounced in Latin America (OR = 2.28, 95 percent Cl = 1.87 to 2.78) and sub-Saharan Africa (OR = 1.72, 95 percent Cl = 1.02—2.91) (Oldenburg, Perez-Brumer, Reisner, & Mimiaga, 2015). In Sydney, Australia, investigators found an HIV prevalence of 6.5 percent among MSWs, which was greater than the prevalence among FSWs (0.4 percent) but less than the prevalence among MSM who did not report engaging in sex work (23.9 percent) (Estcourt et al., 2000). These comparisons, however, should be interpreted with caution, as these were not probability samples, and the three groups ranged in size from 94 (MSWs) to 3,541 (MSM). In the same study, the prevalence of genital warts, the most commonly reported STI, was higher among MSWs than MSM who were not sex workers (12.2 percent) and FSWs (4.6 percent) (Estcourt et al., 2000). A separate analysis conducted in China also found that “money boys”—a term analogous to MSW—had a lower HIV prevalence (4.5 percent) than MSM not reporting sex work (7.0 percent) but a higher prevalence than the general population (0.04 percent) (Liu et al., 2012; UNAIDS, 2015a). As in the study by Estcourt et al. (2000), readers should take into consideration the fact that these analyses did not use probability sampling. Together, these findings suggest that MSWs consistently remain at elevated risk for HIV and other STIs compared to the general population, FSWs, and most MSM who do not engage in sex work. There are, however, regional differences in HIV incidence and prevalence, related to unique context-specific factors, that are essential to informing HIV treatment and prevention interventions for MSWs worldwide.

Sexual behavior, sex partners, and negotiating safer (or riskier) sex with clients

Biological, psychosocial, and structural factors play a meaningful role in HIV and STl-related risktaking behaviors among MSWs. The biological risks associated with HIV transmission through condomless anal intercourse overlap for both MSWs and other MSM (Baggaley, White, & Boily, 2010). Having another STI can also increase the risk of acquiring HIV if exposed; thus, it is common for HIV to be diagnosed with a co-occurring STI (Rodriguez et al., 2002). According to the Centers for Disease Control and Prevention, individuals infected with an STI are two to five times more likely to acquire HIV after unprotected sexual exposure than people who are not infected with an STI (CDC, 2018), because ulcerations on the genitals and other parts ot the body, often produced by syphilis and herpes simplex virus, become vulnerable entry points for HIV infection. Similarly, chlamydia and gonorrhea cause inflammation, which amplifies the concentration of cells in genital secretions to which HIV can successfully bind (Ward & Ronn, 2010).

Behavioral risks for HIV taken by MSWs typically include having multiple concurrent sexual partners (Beyrer et al., 2012) and greater numbers of condomless anal or vaginal sex acts with both male and female clients (Baral et al., 2015; Nerlander et al., 2017; Rietmeijer, Wolitski, Fish— bein, Corby, & Cohn, 1998). Commonly reported factors related to condom negotiation include physical or emotional attraction to the client, the type of sex (oral versus anal), and the length or steadiness of the client—sex worker relationship (Ballester-Arnal, Gil-Llario, Salmeron-Sanchez, & Gimenez-Garcia, 2014; Shinde, Setia, Row-Kavi, Anand, & Jerajani, 2009). For example, a study in Spain found that nearly all MSWs (99.6 percent) reported using a condom during anal intercourse, but only 76.8 percent used a condom during oral sex (Ballester-Arnal et al., 2014). These behaviors extend the risk for HIV and ST1 transmission to others; specifically, MSWs are more likely than their non—sex worker MSM counterparts to engage in condomless sex with their primary male and female partners (Elwood, Williams, Bell, & Richard, 1997; Estcourt et al., 2000; Rietmeijer et al., 1998). Further findings from Bacon and colleagues (2006) estimated that 42 percent ot seropositive MSWs in San Francisco were unaware of their HIV infection, suggesting that many MSWs may unknowingly be transmitting HIV to both clients and nonpaying partners, making them a particularly important “bridge” population on whom interventions should be focused (Elwood et al., 1997; Estcourt et al., 2000; Rietmeijer et al., 1998).

Across much ot the literature, inconsistent condom use by MSWs appears to be motivated by socioeconomic need, as MSWs are often offered more money if they agree not to use a condom with a paying client (Mimiaga, Reisner, Tinsley, Mayer, & Safren, 2009). One study conducted in India found that more than two-thirds of MSW participants reported being offered more money if they would not use a condom with a client, and 74.2 percent of those MSWs had accepted the proposition; the investigators also found that 86.0 percent of MSWs had not used a condom during their most recent paid sexual encounter (Biello, Thomas et al., 2017).

The degree of risk for acquiring HIV and other STls from sex work encounters varies widely depending on the context. For example, in 2009, a research team found that while most MSWs in the United States were offered more money by clients for condomless sex, street- based MSWs were far less likely to refuse such offers compared with Internet-based escorts (Mimiaga et al., 2009). Additionally, the street-based MSWs were more likely to engage in riskier sexual behaviors for more money out of financial desperation, and they more commonly exchanged sex for drugs, as well, reporting a higher frequency than Internet escorts of crack and cocaine use in the past 12 months. Such differences in risk-taking behavior between street- based and Internet-based MSWs are consistent across the literature (Minichiello et al., 2000; Morse, Simon, Bans, Balson, & Osofsky, 1992; Parsons, Koken, & Bimbi, 2004; Rietmeijer et al., 1998). However, Smith and Seal (2008) found that Internet escorts had a higher probability of participating in risk-taking behaviors with their casual sex partners or clients, owing to the fact that most Internet-based escorts in their sample primarily used sex work on a “part time” basis to supplement other sources of revenue (Smith & Seal, 2008). These subgroup distinctions should be factored heavily into the effective design and implementation of public health interventions that will meet the unique needs of MSW subgroups.

Factors potentiating HIV and sexually transmitted infection risk among MSWs

Over the past decade, research on sexual and gender minorities has suggested that psychosocial problems may represent intertwined “syndemics” (Mimiaga et al., 2015; Mustanski, Garofalo, Herrick, & Donenberg, 2007; Reisner et al., 2009; Stall et al., 2003). The term syndemic was first developed to describe the co-occurring and mutually reinforcing epidemics of substance use, violence, and AIDS in poor urban communities, and it emphasizes how disadvantageous social conditions interact to adversely affect health outcomes within marginalized communities. There is a substantive body of literature revealing that MSWs disproportionately face psychosocial problems such as depression, substance abuse, childhood sexual abuse, and intimate partner violence

(Burnette et al., 2008; Panchanadeswaran et al., 2008). A study from the northeastern United States found that 41 percent of MSWs had experienced childhood sexual abuse, a rate that is considerably higher than in the general male U.S. population (Mimiaga et al., 2009). Furthermore, several studies in the United States and Australia have highlighted the elevated frequency of illicit drug use among MSM who engage in transactional sex compared to those who do not (Biello, Oldenburg et al., 2017; Underhill et al., 2014; Weber et al., 2001). In an analysis of twenty metropolitan U.S. cities, Nerlander and colleagues (2017) found that 22.6 percent of men who reported engaging in transactional sex had injected drugs at some time, compared with only 5.4 percent of men who had not. Similar trends were identified related to the use of noninjection drugs, including crack cocaine (26.7 percent versus 3.2 percent) and methamphetamine use (24.2 percent versus 5.3 percent), in the past 12 months (Nerlander et al., 2017).

In addition to these psychosocial burdens, MSWs also experience structural and socioeconomic marginalization (Marshall et al., 2010), lower educational attainment (Weber et al., 2001), and incarceration (Nerlander, Shannon, Kerr, Zhang, & Wood, 2017), as well as stigma, poverty, and discrimination (Underhill et al., 2015). The literature that is only beginning to emerge on the lived experiences of MSWs beyond their risk for acquiring HIV reveals that MSWs often perceive or experience high rates of discrimination when receiving health care (Brookfield, Dean, Forrest, Jones, & Fitzgerald, 2019; Crowell et al., 2017; Jones, Dean, Brookfield, Forrest, & Fitzgerald, 2018; Lazarus et al., 2012; Oldenburg, Biello, Colby, Closson, Mai et al., 2014; Scorgie et al., 2013). Male sex workers may face discrimination related to their sexual identity, sex work, HIV status, or other associated factors (e.g., homelessness, low literacy, mental health, and substance use). A recent meta-analysis of 22 qualitative papers addressing barriers to accessing sexual health services for MSWs found that stigma was the predominant obstacle identified in all but one of the studies (Brookfield et al., 2019). The spectrum of reported stigma in health care settings ranged from, in the United States, an unwarranted focus on a persons sex work—related history (Xavier et al., 2013), to disregard for patient confidentiality, ridicule (Scorgie et al., 2013), and even, in sub-Saharan Africa, the refusal of care (Okanlawon, Adebowale, & Titilayo, 2013).

For MSWs, feeling stigmatized and criminalized, and fearing disclosure of their identity, can create overwhelming barriers to accessing health care. Because of the personal nature of discussing one’s sexual activity', health care—related stigma can lead individuals to avoid such undesirable experiences, distrust their medical providers, and choose not to disclose certain sex work—related behaviors (Underhill et al., 2015). Notably, these negative coping strategies may mean MSWs receive improper health guidance, incomplete risk assessments and risk reduction counseling, only partial disease screening, and prescriptions for medications that are not specific to their health needs. It is well documented that stigmatization makes individuals less likely to seek care, thereby delaying opportunities for testing, diagnosis, and treatment and increasing the likelihood of poor health outcomes overall (Boynton & Cusick, 2006; King, Manran, Bowling, Moracco, & Dudina, 2013; Kriisi et al., 2014; Lazarus et al., 2012; Restar et al., 2017; Scambler & Paoli, 2008; Scorgie et al., 2013; Callander, 2017). Male sex workers in Lebanon reported avoiding HIV testing because they knew that they would lose their employment at a brothel it they were found to be infected (Aunon et al., 2015). Because of such consequences, when faced with barriers to care or experiences of stigma, many MSWs rely on health services provided in nonconventional settings. One report in the United States found that the primary sources of HIV testing for MSWs were research studies, drug rehabilitation centers, needle exchange programs, street-based outreach, and correctional institutions. That same study found that, compared with their non—sex worker MSM counterparts, MSWs reported lower rates of non-HIV ST1 testing, less access to insurance coverage, and higher rates of unmet health care needs (Underhill et al., 2014).

Stigma as a barrier to health care access is often multilayered and interwoven with other structural, cultural, and legal influences. Interviews with MSWs from Lebanon and Kenya have highlighted the pervasive impact ot deeply rooted cultural conservatism on perpetuating damaging social norms regarding sexuality, gender diversity, and sex work, which has ultimately impeded the coverage of targeted, evidenced-based HIV prevention strategies tor this group (Aunon et ah, 2015; Okal et ah, 2009). As a consequence of these gaps, MSWs in Lebanon and Kenya reported limited knowledge of HIV-related risks and particularly low participation in HIV testing; instead, they relied heavily on other MSWs for social support and access to sexual health- related resources. Both studies concluded that truly effective outreach strategies seeking to facilitate access to HIV/STI information and services must be spearheaded by peer educators (i.e., men who have previously or are currently engaged in sex work) (Aunon et ah, 2015; Okal et ah, 2009). Research in Malaysia involving qualitative interviews with key stakeholders who worked with MSWs—health ministry officials, religious leaders, and people living with HIV—support these findings, underscoring how cultural and structural norms can affect sexual health promotion efforts among individuals who engage in transactional sex (Barmania & Aljunid, 2016).

The criminalization ot sex work also has direct implications for how vulnerable MSWs are to HIV and other STIs. Globally, there is a lack of legislation and formal policy to protect sex workers from violence at the hands of law enforcement, primary partners, and sex work clients (UNAIDS, 2010). Shannon and Csete (2010) have reasoned that restricting legal protections reinforces sex workers’ disempowerment and tear of violence, creates barriers to negotiating safe sex practices and seeking out health services, and thereby increases the risk of poor sexual health outcomes. Emerging data have also revealed that legalizing or decriminalizing sex work is imperative to addressing the HIV epidemic among people who engage in transactional sex because it would improve access to regular sexual health services (HIV and STI screening and treatment, preexposure prophylaxis [PrEP], postexposure prophylaxis [PEP], and antiretrovirals [ARVs] tor HIV treatment), provide protection for sex workers when they are attempting to negotiate condom use with clients, and prevent further violence or abuse (Abel, Fitzgerald, & Brunton, 2009; Kerrigan et al., 2006; Kriisi et al., 2014; Shannon & Montaner, 2012; Shannon et al., 2015; UNAIDS, 2016). By mitigating individual fears of incarceration or legal hassles, eliminating legal constraints on sex workers would allow HIV prevention programs to be implemented more widely and effectively (Baral, Logie, Grosso, Wirtz, & Beyrer, 2013). In fact, a 2017 ecological analysis of data from 27 European countries found that HIV prevalence was much lower among sex workers in countries where sex work was fully or partially legal, compared with countries where sex work remained criminalized (Reeves et al., 2017). Overall, a 2015 report estimated that sex work decriminalization and comprehensive legal protections could prevent 33 percent to 46 percent of new HIV infections among sex workers and their clients over the next decade (Beyrer et al., 2015). By lifting social, cultural, and legal barriers, public health officials would also be able to better promote proper health care utilization, work toward improving the overall health of sex workers, and further prevent acquisition and transmission ot HIV and other STIs between sex workers and their partners and clients (Steen, Chersich, & de Vlas, 2012).

Access to HIV prevention and treatment and to antiretroviral therapy

Expanded access to antiretroviral therapy among the general population through governmental and programmatic services, community organizations, and research entities has led to significant improvements in the overall health and well-being of people living with HIV. The benefit of consistent adherence to ART treatment is twofold: it protects one’s immune system from the spread of the virus, and it reduces the individual’s viral load and thus the likelihood of transmission through sexual activity and injection drug use (Lundgren et ah, 2015; Schaecher, 2013). The advantages offered by ART are contingent on linkage to care shortly after HIV diagnosis, prompt initiation of antiretroviral medications, optimal adherence to the prescribed regimen, and ongoing retention in HIV care (Gardner, McLees, Steiner, del Rio, & Burman, 2011; Mugavero, Amico, Horn, & Thompson, 2013). The HIV care continuum has been developed to visualize and quantify the spectrum of engagement in HIV-related health care: testing and diagnosis, linkage to care, retention in care, delivery of ART, and achievement of viral suppression. While HIV care-continuum data are available tor the general population and certain high- risk groups, including MSM overall, there is a dearth of statistical evidence related to MSWs. Given this, we have drawn on data from FSWs to highlight where potential risks may exist for their male counterparts.

A 2015 report from the Joint United Nations Programme on HIV/AIDS (UNAIDS) found that the proportion of FSWs who reported receiving an HIV test, with a result, in the past 12 months ranged widely by country, from 1.1 to 5.9 percent in Egypt, Vanuatu, and Afghanistan, to as high as 100 percent in Djibouti, Ireland, Sao Tome and Principe, and Singapore (UNAIDS, 2015b). Another review of 52 low- and middle-income countries found that, in 2010, the median percentage of FSWs who had both been tested for HIV in the past 12 months and also knew their results was 49 percent (Bekker et ah, 2018). In an attempt to measure global linkage to ART, a meta-analysis of 39 studies of FSWs living with HIV in Asia, Africa, North America, and South America found that a reported history of ever having taken ART was higher among FSWs in high-income countries (80 percent) than those in low- and middle-income countries (36 percent) (Mountain et ah, 2014). This inequity in ART access exists within nations as well. According to UNAIDS (2019b), in Zimbabwe, 84.0 percent of all people living with HIV reported receiving ART, compared with 78 percent of FSWs living with HIV. In Pakistan, the rate of access to HIV care is even lower, with antiretroviral treatment reportedly received by 12 percent of those among the general population living with HIV and just 5 percent of FSWs with HIV (UNAIDS, 2019a).

As previously discussed, the lack of access to HIV treatment and deficient uptake of ART are results of the overlapping challenges facing sex workers who are living with HIV, including societal stigma, little to no legal protection for sex work, and tear of serostatus disclosure without consent. Although there are virtually no data specific to MSWs, it could be speculated that rates of HIV-care access and follow-through are even lower among MSWs compared with FSWs, given that men are less likely than women to attend health care visits and given the added stigma faced by MSWs for engaging in same-sex behaviors (Baker et al., 2014; Bertakis, Azari, Helms, Callahan, & Robbins, 2000; Wang, Hunt, Nazareth, Freemantle, & Petersen, 2013). To our knowledge, the only examination of the HIV care continuum among MSWs was conducted in Peru in 2017 by Bayer and colleagues, with a group of 209 MSWs. Their study found that, among the 34 MSWs in the study who tested positive for HIV (16.3 percent of the sample), 76 percent had attended at least one HIV-related appointment, only 59 percent were currently in care, 50 percent were actively taking ART, and only 32 percent had been on ART for six months or more. The primary reason reported tor nonmaintenance in HIV care was the difficulty of managing multiple clinical visits over an extended period of time (Bayer et al., 2017).

Interventions focused on sexual risk reduction

Despite the fact that MSWs are disproportionately burdened by HIV and other STIs owing to their high-risk sexual activity, few behavioral interventions have been adapted to directly address the unique challenges MSWs face. This scarcity' may be overshadowed by the extensive research focused on MSM who do not engage in transactional sex and on FSWs. The complex nature of the environment in which MSWs operate (transient, stigmatized, hidden) makes it nearly impossible to effectively tap into this population via traditional avenues of outreach. The most effective designs for behavioral intervention have incorporated interpersonal, biomedical, community', and structural approaches.

Formative research with MSWs in various global contexts has offered insight into which components are best included when tailoring interventions for MSWs. Recent findings from qualitative interviews with 32 MSWs in Boston suggested that key project elements to effectively promote behavioral change should integrate trauma-informed care for mental health, substance abuse treatment, accessible H1V/STI testing, readily available condoms and informational materials, support groups for those experiencing social isolation, and skills building for risk reduction with sexual partners (Mimiaga et al., 2009; Reisner et ah, 2008). These recommendations highlight the need for broad, multifaceted interventions to meaningfully address the unique contextual barriers to care for MSWs (Ballester-Arnal et ah, 2014; Baral et ah, 2015; Vuylsteke, Das, Dallabetta, & Laga, 2009).

Behavioral interventions to reduce risk for HIV

As mentioned, there are few sexual risk reduction programs for MSWs and even fewer evaluations of the projects’ utility. One intervention model makes use of peer-led outreach and education, in which a program-trained MSW or former MSW disseminates HIV- and STI-related information, promotes safer sexual behaviors, and facilitates links to care through referrals to sexual and social services. The effectiveness of this particular peer-led model tor MSWs has varied by' study. In New York City, for example, the paradigm demonstrated a significant reduction in the number of condomless anal sex (CAS) acts between MSWs and their clients (Miller, Klotz, & Eckholdt, 1998). Similarly, for 425 MSWs in Mombasa, Kenya, peer-based outreach considerably improved HIV knowledge and STI-prevention behaviors, including increased condom use with both pay'ing and nonpaying male partners (Geibel, King’ola, Temmerman, & Luchters, 2012). A seven-module version of this intervention, called Harm Reduction and Sexual Health Promotion, was evaluated among 919 young MSWs in Vietnam. Results of the pre-post assessment found significant improvements in HIV- and STI-related knowledge, as well as intentions to attend a doctors visit and to disclose same-sex behaviors to medical providers (Clatts, Goldsamt, Yu, & Colby, 2016). While the peer-led model has shown some success, there is concern that the initial efficacy eventually dwindles and the educational focus diffuses. To counteract these possibilities, peer outreach should be supplemented with behavioral interventions that are brief and that directly target individual actions, activities, and skills (McCamish, Storer, & Carl, 2000).

One group of researchers recently aimed to develop a behavioral intervention specifically for MSWs in Chennai, India (Thomas et al., 2017). First, the researchers collected in-depth qualitative feedback from 40 interviews with MSWs, and four focus groups with 35 key' informants who had expert knowledge of the local MSW community, to inform the design of an HIV- prevention program. Participants discussed the need for content beyond basic HIV educational and psychological support, emphasizing a focus on psychological distress, alcohol-related risk, and sexual communication skills (Thomas et al., 2017). Respondents also raised concerns about confidentiality, privacy, and scheduling on implementation of the program. As in other parts of the world, MSWs in India increasingly rely on the use of mobile phones for sex work solicitation, and they endorsed a combination of in-person and mobile phone—delivered sessions as well as mobile phone messaging. Integrating mobile phone technology helped to mitigate some of the challenges associated with face-to-face counseling, such as execution, confidentiality, and resource consumption (i.e., time and money), while also proving to be both feasible and useful for MSWs (Thomas et al., 2017).

These findings served as the basis for a theoretically driven, manualized intervention program incorporating mobile phones for MSWs in the U.S. northeast (Mimiaga et al., 2019). This intervention was recently tested in a randomized, controlled pilot trial to examine participant acceptability, procedural feasibility, and preliminary efficacy in reducing sexual risk tor HIV. Male sex workers (и = 100) were equally randomized into (1) a behavioral HIV prevention program integrating in-person and mobile phone—delivered HIV risk reduction counseling, plus daily personalized text messages used as motivating “cognitive restructuring” cues for reducing CAS acts, or (2) a standard of care (SOC) comparison condition (Mimiaga et al., 2019). The intervention was both feasible (98 percent retention at six months) and acceptable (>96 percent of all intervention sessions attended); all intervention participants rated the project as “acceptable” or “very acceptable.” A reduction in the reported number of CAS acts by MSWs with paying male clients in the preceding month was seen in both study groups, but MSWs who received the intervention reported a faster rate of decline from the baseline (B) to both the three-month (B = -1.20; 95 percent Cl = —1.68, —0.73; p < 0.0001) and six-month assessment visits (B = —.44; 95 percent Cl = —3.35, —1.53; p < 0.00001), compared with men in the SOC group. Specifically, at three months, participants in the intervention condition reported 1.43 CAS acts (standard deviation [SD] = 0.29) with paying male clients in the previous month, compared with 4.85 (SD = 0.87) in the SOC control group (p = 0.0003). Furthermore, at six months, the intervention-condition participants reported 0.24 (SD = 0.09) CAS acts with male clients in the previous month, compared with 2.79 (SD = 0.79) in the SOC control group (p < 0.0001) (Mimiaga et al., 2019). These preliminary findings are encouraging, and they suggest that similar behavioral HIV-prevention interventions tor MSWs could be adapted and implemented more globally.

Another promising approach tested in the Philippines was a brief community mobilization program that included HIV and STI education, interactive training on proper condom use, instructions on seeking out community resources, and both individual and group goalsetting exercises (Urada et al., 2016). This project was uniquely grounded in a human rights framework, with a focus on mediating risks relevant to sex workers (i.e., rape, violence) and raising sex workers’ awareness and understanding of the laws protecting them against abuse and discrimination. Among 87 sex workers (27 men and 60 women), pre-post test scores revealed significant increases in scores across all domains assessed (each rated out of 10): HIV knowledge (pre-test score 3, post-test score 7), STI knowledge (2 pre, 5 post), human rights knowledge (3 pre, 6 post), intentions to use condoms consistently with causal partners (4 pre, 10 post), and intentions to get tested for HIV (6 pre, 8 post) (Urada et al., 2016).

Contingency management, another behavioral-change model, provides monetary incentives for achieving a targeted health behavior and has been shown to be an acceptable and feasible means of supporting HIV-risk reduction among MSWs (Galarraga et al., 2014; Landovitz et al., 2015; Mitchell et al., 2018). For example, MSWs in Mexico City were given economic incentives for having negative (uninfected) test results for HIV and other STIs at periodic clinical visits. This study demonstrated lower rates of HIV and STI diagnoses among MSWs assigned to the intervention group compared with those in the control group, suggesting that financial compensation may be effective in promoting harm-reduction behaviors among MSWs (Galarraga, Fletcher, Shoptaw, & Reback, 2014).

Recent research has revealed that MSWs also engage in adaptive behavioral strategies to decrease their vulnerability to HIV. For example, an analysis of23 MSWs in Vietnam found that the men experienced both felt and enacted social stigma related to sex work, which increased their susceptibility to HIV and other STIs by way of riskier sexual behaviors, as the literature has indicated. In response to such shame and discrimination, the MSWs employed stigma- management techniques aimed at concealing their involvement in sex work, such as controlling communication with nonpaying sexual partners and seeking increased social support from family and friends (Closson et ah, 2015). Other risk-reduction strategies used by MSWs in this sample included engaging in oral or manual sex instead of anal sex, selecting male clients whom they perceived to be lower-risk clients, and reducing their overall number of partners by choosing to work with repeat transactional sex clients (Mimiaga et ah, 2013).

Treatment as prevention

Biomedical approaches that use antiretroviral drugs to treat HIV have been groundbreaking in addressing the HIV epidemic. The PARTNER study, which examined HIV-positive partners taking ART in couples where the other partner is HIV negative, has concluded. Final results subsequently confirmed that individuals living with HIV who are on effective ART, adhere to their medication regimen, and have an undetectable level of HIV in their blood are unable to transmit the virus to others (Rodger, Cambiano, Bruun, Vernazza, Collins, Degen et ah, 2019; Rodger, Cambiano, Bruun, Vernazza, Collins, Van Lunzen et ah, 2016). This method, known as treatment as prevention (TasP), serves as both primary and secondary prevention tor HIV-acquired individuals and their sexual partners (Hollingdrake et ah, 2019; Rodger et ah, 2016; Saag et ah, 2018; WHO, 2012). As previously established, access and adherence to ART are vital to the success of TasP, yet they remain suboptimal among disenfranchised populations, including MSWs.

To facilitate linkage to care and treatment uptake, certain initiatives have been promoted, including “test and treat,” in which individuals who test positive for HIV immediately receive ART, regardless of their CD4 cell count or viral load. Early treatment, on a biological level, promotes viral suppression while simultaneously improving retention in HIV-related care at a structural level (Mugavero et ah, 2012). In 2009, investigators in South Africa used mathematical modeling and estimated that combining test-and-treat strategies with other prevention methods would reduce the worldwide prevalence of HIV to 1 percent by 2059 (Granich et ah, 2009). Though the test and treat model may ultimately reduce HIV transmission and improve HIV-related outcomes, it does not address the roots of stigma, discrimination, and other structural barriers that prevent MSWs from seeking out health care services in the first place, which is why it must be supplemented with concurrent behavioral and structural interventions to meet the needs of MSWs and other marginalized populations.


In addition to biobehavioral approaches employing antiretroviral drugs tor treatment, preexposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) have also proven to be effective in stemming HIV transmission among high-risk groups (Fonner et ah, 2016; Grant et ah, 2010). Since the approval of PrEP by the FDA in 2012, narrowly focused health communications and marketing strategies have primarily targeted gay and bisexual cisgender men, leading to deficient awareness of PrEP among MSM who do not identify as gay or bisexual (i.e., many MSWs) and other at-risk groups, including transgender women. Thus, despite the fact that both medication regimens are highly efficacious (>90 percent reduction in risk), knowledge and uptake of PrEP and PEP remain low. Findings from a study across 20 major U.S. cities found that out of 585 MSM who reported exchanging sex for money or drugs, only 20.5 percent had ever heard of PrEP (Nerlander et ah, 2017). Furthermore, this statistic has been globally consistent: 21.7 percent of MSWs sampled in Kenya were familiar with PrEP, and none had ever taken it (Restar et ah, 2017). Similarly, among 31 MSWs in Providence, Rhode Island, only 19.4 percent had ever heard of PrEP (Underhill et ah, 2015).

Despite minimal awareness of PrEP among MSWs, research reveals that, upon learning of its efficacy, these men are generally interested in and willing to use PrEP tor HIV prevention. For example, during individual interviews, Underhill and colleagues found that among 31 MSWs in Providence, 20 (64.5 percent) were interested in taking PrEP, compared with 12 (48 percent) of 25 MSM who did not engage in sex work (Underhill et ah, 2015). In a study in Vietnam, nearly all (95.4 percent) of the 281 MSW participants indicated they would be willing to take PrEP, although the percentage dropped substantially when participants were asked whether they would take PrEP given potential side effects (Oldenburg, Biello, Colby, Closson, Nguyen et ah, 2014). Out of 12 MSWs in Puerto Rico in 2016 who had heard of PrEP, 9 expressed high levels of interest in taking the medication (Giguere et ah, 2016). The year prior, among 40 people in Canada who inject drugs and engaged in transactional sex, 70 percent also reported that they would consider taking PrEP in the future (Escudero et ah, 2015). The most common reasons stated by MSWs for a lower interest in and nonuptake of PrEP are concerns about side effects, a lower perceived risk tor HIV, lower socioeconomic status (income, education, employment), less engagement with health services, lack of health insurance, and not identifying as gay or bisexual (Biello, Oldenburg et ah, 2017; Giguere et ah, 2016; Oldenburg, Biello, Colby, Closson, Nguyen et ah, 2014; Underhill, Guthrie et ah, 2018; Underhill, Morrow et ah, 2015). However, among 300 MSWs in Vietnam, those who had previous contact with a peer educator were approximately twice as likely to be interested in taking PrEP than those who did not have contact with a peer educator (OR = 2.01, 95 percent Cl =1.22 to 3.31). These results suggest that peer education may play a key role in informing MSWs about PrEP and promoting other risk-reduction practices (Oldenburg, Biello, Colby, Closson, Nguyen et ah, 2014).

In modeling the potential impact of PrEP, a team in Peru estimated that by providing PrEP to 20 percent of MSWs in the capital city of Lima, approximately 3.4 percent of HIV infections within that population could be avoided over the course of ten years (Gomez et ah, 2012). Given the low use of condoms and elevated number ot sex partners among MSWs, increasing the acceptability of PrEP and PEP among this population would be a transformative addition to current risk-reduction practices. To the best of our knowledge, only one behavioral intervention has been developed and tested specifically to increase PrEP uptake among MSWs, in Providence, Rhode Island, where approximately 80 MSWs were randomized to receive either

  • (1) a strength-based case management intervention implemented by nonclinical staff (including motivational interviewing, appointment and transportation assistance, and problem solving), or
  • (2) SOC referrals to the local PrEP clinic. Participants randomized to the case-management arm were 2.6 times as likely to initiate PrEP within two months of baseline compared to those in the SOC arm (57 percent versus 22 percent, p = .002; relative risk = 2.64, 95 percent Cl = 1.34 to 5.20) (Biello et ah, 2019). Overall satisfaction with the intervention was also very high. Thus, promotion and facilitation ot PrEP among MSWs remains an important element ot future HIV risk-reduction studies.

HIV self-testing

Recognizing the lack of access to and engagement in HIV testing and counseling, public health officials have strived to establish innovative strategies that promote the availability and accessibility ot preventative sexual health resources. One method that has been adopted in many countries is HIV self-testing (HIVST), wherein individuals collect their own biological specimen (oral fluid or blood) and perform a rapid HIV test on the sample themselves (Napierala Mavedzenge, Baggaley, & Corbett, 2013). This high-impact, low-cost option may allow MSWs to overcome substantial barriers to HIV testing, such as concerns about confidentiality and stigma. A growing number of studies conducted with MSM and FSWs have found that HIVST is highly acceptable, but there are concerns about user error, lack of professional counseling, and poor test accuracy (Lippman et al., 2018; Marley et al., 2014; Ortblad et ah, 2018; Witzel, Rodger, Burns, Rhodes, & Weatherburn, 2016). Additionally, very tew projects have explored the opinions and feasibility of HIVST among MSWs. In a small sample of cisgender male and transgender female sex workers in Puerto Rico, 91.6 percent said they would “likely” or “definitely” use rapid HIVST (Giguere et ah, 2016). Some participants believed that HIVST offered an opportunity for sex workers to self-test with their clients; however, others feared such discussions would complicate exchanges with clients or even trigger violence toward sex workers (Giguere et ah, 2016). Still, HIVST has the potential to reach MSWs who are reluctant to be tested tor HIV and who would otherwise not seek out or have access to HIV testing services. Because empirical evidence is still limited, effective HIV self-testing programs for MSWs must continue to comprehensively monitor for quality assurance (i.e., adequate training and proper use), laboratory confirmation of test results, and rapid linkage to the counseling and care that are necessary for individuals testing, both positive (HIV-acquired) and negative (HIV-uninfected) (Napierala Mavedzenge et ah, 2013).

Community-based programs

In response to structural challenges when seeking or navigating health care services where sex work is criminalized, many MSWs have collaborated with local stakeholders on peer-driven, community-based efforts to address health disparities. For example, the Sex Workers’ Rights Advocacy Network (SWAN) is a group in Central and Eastern Europe and Central Asia that advocates tor the human rights of male, female, and transgender sex workers and is led by sex workers who sit on the network’s steering committee and advisory board (www.swan net.org). In Myanmar, the Targeted Outreach Project (TOP) began in 2004 and has been implemented in 18 cities across the country, reaching more than 62,000 sex workers annually (Ditmore, 2012). TOP establishes drop-in centers where sex workers can go for peer support and access to free health care, without the stigma they often experience. Local sex workers in each city' (known as “community educators”) lead their respective sites by offering empowerment, advocacy, and emotional support tor their communities (Ditmore, 2012). Project Weber/ RENEW is a peer-led nonprofit organization for male, female, and transgender sex workers in Rhode Island. Weber/RENEW provides sexual health resources (HIV and STI testing, safer sex materials), harm reduction (clean needle exchange, overdose prevention programs), and substance-abuse recovery support for its members (www.weberrenew.org). A recent review of 22 global “community empowerment—based” programs led by sex workers in India, Brazil, and the Dominican Republic were found to be significantly associated with national reductions in HIV and STI diagnoses as well as increases in consistent condom use with clients. Of significant importance to these findings is that the effectiveness of many of the programs was moderated by structural barriers, including funding constraints, criminalization of sex work, and pervasive stigma, discrimination, and violence toward sex workers (Kerrigan et al., 2015). Thus, high levels of social, financial, and political support are needed to implement such community-based programs in a comprehensive way.

Cost considerations and access to prevention and treatment

With the emergence of improved treatment options, HIV/A1DS is now viewed as a manageable chronic condition in most developed countries. Yet the condition requires long-term and costly medical management, support services, and prescription drugs. Data from the United States reveal that the lifetime medical cost for an individual living with HIV in 2017 was, on average, $379,668 (CDC, 2017). Conversely, an analysis by Schackman et al. (2015) found that the average lifetime cost tor high-risk individuals who remain uninfected was approximately $96,700 per person, corresponding to a savings of approximately $280,000 per person for each infection averted. Preventative biomedical drugs such as PrEP cost more than $2,000 per month out of pocket in the United States (Adamson, Carlson, Kublin, & Garrison, 2017). Without health care coverage, many MSWs may not be able to afford these drugs. The costs of other medications, food, and housing must also be considered. Taken as a whole, these high costs represent substantial financial barriers to accessing services for both HIV-infected and uninfected MSWs.

Financial limitations vary by country, state, and type of health care system. For example, in Norway, which has a government-funded national health care system, costs for HIV care and prevention services are covered, leaving citizens with little to no out-of-pocket costs (PEI, 2017). In Canada, there is a great deal of interjurisdictional heterogeneity of drug costs, which are primarily dependent on one’s geographical location (Gogolishvili, 2019; Yoong, Bayoumi, Robinson, Rachlis, & Antoniou, 2018). For example, while the governments of Alberta, British Columbia, Northwest Territories, Nunavut, and Prince Edward Island offer universal coverage of ART for all residents living with HIV, other provinces, such as Quebec, collect a yearly income-based premium tor the same medications (Yoong et al., 2018). In Australia, there are similar inconsistencies across both inter- and intrajurisdictions. For example, the Northern Territory and Western Australia provide free HIV and sexual health services, such as ART (Wilkinson et al., 2015). Within jurisdictions, one study found that copays for ART were free of charge at a major sexual health clinic in Victoria but cost money in more rural parts of Victoria (Wilkinson et al., 2015). In the United States, access to treatment and prevention varies by state and type of insurance. For example, low-income MSWs who lack private health insurance and meet certain eligibility criteria may qualify for Medicaid, the federal- and state-funded health insurance program. Compared with the rest of the country, U.S. states in the South have been more restrictive in their coverage of services and their eligibility criteria, requiring that people with HIV must also meet a disability requirement to qualify for such programs (Adimora, Ramirez, Schoenbach, & Cohen, 2014). Even for those who do qualify, benefits and coverage in southern states are generally substandard compared with other parts of the country (Kates, 2011). Limited insurance policies and coverage of sexual health services are directly linked to elevated rates of HIV and STIs; in the United States, the South accounts for more than half (52 percent) of new diagnoses nationwide, and the region has the highest rates of chlamydia, gonorrhea, and syphilis (CDC, 2018; Workowski & Berman, 2011). And regardless of the state or the insurance plan, insurance deductibles and copays in the United States remain significant barriers to accessing prevention options and treatment compliance (Eaddy, Cook, O’Day, Burch, & Cantrell, 2012; Underhill et al., 2014; Wohl et al., 2017; Yehia et al., 2015).

Gaps in the literature and future directions

As we have made clear, MSWs remain largely overlooked by public health efforts in the context of the global response to HIV/AIDS and STIs. Most of the emerging data from systematic surveillance of HIV/AIDS and STIs is limited to nonprobability samples, but these studies overall reveal that MSWs continue to experience unique biological, behavioral, and structural challenges that increase their risk for poor sexual health outcomes. Given the inherent heterogeneity of this population, health and governmental officials must seek to generate and implement innovative HIV and STI treatment and prevention approaches for MSWs. As highlighted throughout this chapter, a multilevel methodology is necessary to optimize the effectiveness of such programs. Future studies should aim to develop and test novel behavioral interventions tailored to the specific needs of MSWs. Moreover, such interventions should be integrated with biomedical approaches that address the complex psychosocial factors and risk-taking behaviors of MSWs. To comprehensively address the sexual health disparities among MSWs, it is essential to concentrate on key structural factors, including the decriminalization of sex work, the reduction of sex work—related stigma and discrimination, and increasing access to services such as mental health, sexual health, and substance abuse treatment. Local and federal agencies would benefit from including MSWs in strategic planning and developmental efforts aimed at improving access to and participation in HIV treatment and prevention. Ultimately, committed advocacy, funding, surveillance, programmatic efforts, and research are central not only to public health but also as a foundation for social justice and human rights.


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Male sex work and behavioral health

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