Methods of safer sex
HIV InSite Knowledge Base Chapter
December 2003; Content reviewed January 2006
Sexual contact is the most common route of HIV transmission. By December 2001, 51% of all HIV infections among adolescents and adults reported to the U.S. Centers for Disease Control and Prevention (CDC) were sexually transmitted (35% by male homosexual contact, 11% by heterosexual contact in females, 5% by heterosexual contact in males).Worldwide, heterosexual transmission is the most common route of HIV infection. Given the importance of sexual transmission in the HIV epidemic, many HIV prevention strategies have focused on identifying and promoting safer-sex practices. As the name implies, these practices are thought to be “safer” than other sexual practices in that they help reduce (but do not necessarily eliminate) the risk of transmitting HIV from one sexual partner to another.
Clinicians and health educators often have the unique opportunity to discuss topics of an intimate nature in a professional setting. With this privilege comes the responsibility to be respectful and nonjudgmental. In some cases, the goal of safer-sex education may be to help someone minimize risk to him- or herself; in others, it may be to help someone minimize risk to others. The goal of teaching safer sex is to provide not only information, but also counseling to help individuals or groups to make the most appropriate choices for risk reduction.
Not everyone will open a discussion about safer sex with a health care provider. For example, some people may not ask about safer sex because they do not perceive themselves to be at risk. Others may be too embarrassed to open the discussion. It is incumbent on health care providers to perform HIV risk assessment as an integral part of the medical history, and to provide HIV prevention counseling as an integral part of patient education and anticipatory guidance. Risk assessments and appropriate counseling should be performed periodically to facilitate not only initiation, but also ongoing maintenance, of risk-reduction behaviors.
Development of effective antiretroviral therapy (ART) has resulted in optimism for many HIV-infected patients. As efforts to develop even more effective treatments and preventive vaccines continue, it is critical to continue aggressive prevention efforts as a vital component of the battle against HIV. Although ART can result in dramatic reductions in HIV viral load, it is not a cure for HIV disease; thus prevention should still be the first line of defense. In addition, although theoretical models have suggested that ART may combat the HIV epidemic on a population level, models that assumed steady or increased levels of safer-sex practices were more likely to predict reduction in new HIV infections than models that assumed decreased levels of safer sex.ART may reduce, but cannot be expected to eliminate, the potential for an infected individual to transmit HIV to an uninfected individual.Therefore, even individuals receiving effective ART should, at a minimum, initiate and maintain prevention practices with uninfected persons or persons of unknown HIV status. In addition, ART is available only for a small proportion of the world’s HIV-infected population. Thus, prevention remains the main line of defense for these individuals.
This chapter reviews the evidence that has led to the development of safer-sex guidelines, and concludes with specific recommendations for safer-sex practices.
Evidence for Sexual Transmission of HIV
Isolation of HIV in Body Fluids
Researchers can consistently culture or otherwise detect HIV not only in blood, but also in semen and cervical secretions of infected persons. Infectious HIV exists in saliva,tears, and urine ; however, it has only been recovered from these fluids at extremely low titers. In addition, no report has documented cases of HIV transmission by these fluids. Hence, saliva, tears, and urine are highly unlikely sources of HIV transmission.
Infectious HIV has also been isolated in breast milk, and transmission from HIV-infected mothers to nursing infants has been well documented.Breast milk is not commonly encountered during sexual intercourse. However, should individuals accidentally or intentionally come in contact with HIV-infected breast milk during sex, care should be taken to avoid mucosal contact.
Epidemiologic Studies and Case Reports
Epidemiologic evidence in support of male-to-male, male-to-female, and female-to-male sexual transmission of HIV infection is abundant. The risk of HIV infection among women who have sex with women appears to be largely attributable to other risk factors (sex with men, injection drug use). Female-to-female sexual transmission per se is uncommon, with rare case reports of possible HIV transmission by this route.A 2003 case report suggested that sexual practices that can expose sex partners to each other’s blood, such as the shared use of sex toys or vaginal penetration with hand (“fisting”), are a possible route of female-to-female sexual transmission.
Number and Selection of Sexual Partners
Results from early epidemiologic studies of HIV infection in homosexual men revealed that sexual activity with many different partners carries a high risk of HIV infection. Many of the published reports of heterosexual transmission present no detailed data regarding this risk factor, presumably because the researchers examined transmission from HIV-infected persons to their monogamous sexual partners.Researchers who did specifically analyze this issue were unable to demonstrate an association between number of sexual partners and risk of HIV infection, perhaps because the median number of partners was relatively low in these studies (1-4 partners in 5 years).
Early research on selection advised that the choice of a partner was the most important determinant of transmission of HIV during a sexual encounter.Current research has shifted emphasis from an explicit concern with absolute numbers of sexual partners to a model that situates an individual’s selection of sexual partners in the context of the population seroprevalence, the likelihood that an individual has been tested for HIV, the likelihood that the test result was accurate, the likelihood of infection through insertive or receptive oral, vaginal, or anal sex, and the degree to which condom use reduces the probability of transmission during these acts. The model shows that individuals can reduce their risk by choosing a partner who has tested HIV negative, choosing a safer-sex act, using a condom, or some combination of these factors. For heterosexuals, whose population prevalence was modeled at 1%, choosing one risk-reduction behavior substantially reduced the absolute risk of HIV infection. However, for men who have sex with men (MSM), whose population prevalence was modeled at 10%, the choice of only one risk reduction behavior did not significantly lower the absolute risk of HIV infection. As these models draw their assumptions from the epidemiology of HIV in developed-country settings, the applicability of their conclusions to high-prevalence heterosexual epidemics in the developing world seems limited. It is therefore important in high-prevalence settings to continue to encourage risk reduction behaviors that include both safer sex practices and HIV testing.
When both sexual partners are HIV positive, it is still reasonable to consider safer-sex practices to reduce the likelihood of infection from other sexually transmitted diseases, such as herpes, gonorrhea, chlamydia, syphilis, and hepatitis B and C viruses.
Case reports have confirmed that HIV-positive individuals can acquire different strains of HIV through sexual exposure.Acquisition of a new strain of HIV in an individual who is already HIV-infected is known as superinfection. There is not yet a clear understanding of the probability of superinfection at the individual or population level, nor do we fully understand its impact on the long-term health of HIV-infected individuals. Superinfection may cause acute viral syndrome, and transmission of drug-resistant strains may reduce options for future ART, suggesting a role for continued vigilance and safer-sex decision making by HIV-infected individuals even when both partners are infected.
Risk Associated with Specific Sexual Practices
Epidemiologic investigations of HIV transmission provide substantial evidence that some sexual practices are associated with a high risk of HIV transmission, whereas others are not.
Heterosexual intercourse is presumed to be the most common mode of HIV infection worldwide. Studies of male-to-female and female-to-male transmission provide strong epidemiologic evidence that heterosexual transmission of HIV does occur via penile-vaginal intercourse.Vaginal sex during menstruation may increase the risk of transmission from an infected female to an uninfected male,but probably does not increase the risk of transmission from an infected male to an uninfected female.
The efficiency of heterosexual transmission of HIV and per-act risk of infection are the subjects of debate in the epidemiologic literature. Early epidemiologic studies on heterosexual transmission in Western countries established that male-to-female transmission in the vagina was significantly more likely than female-to-male transmission from the vagina, with estimates in three studies ranging from 1.9,2.3,and 8.0 times greater efficiency of male-to-female transmission. Per-act infectivity in two studies was found to be low: 0.0005 and 0.0009 for male-to-female transmission, and 0.0003 and 0.0001 for female-to-male transmission. However, studies conducted in developing countries have estimated that per-act transmission probabilities are greater by a factor of 10 for both male-to-female and female-to-male transmission.
Although the greater efficiency of male-to-female versus female-to-male transmission has also been observed in developing countries, a systematic review of the literature found a greatly enhanced efficiency of female-to-male transmission in the high-prevalence epidemics of Asia and sub-SaharanAfrica. The ratio of male-to-female summary mean transmission rates in the developing world compared to the rate in Western countries was 2.9, whereas for female-to-male transmission this ratio was 341. Women in some developing countries may be more infectious due to higher prevalence of sexually transmitted infections (STIs) and untreated HIV disease, although the authors state that evidence for the relative importance of these factors is unclear. The greater susceptibility of men in developing countries is also difficult explain, and may include a low prevalence of male circumcision, poor genital hygiene, a high prevalence of genital ulcer disease, and a high prevalence of unprotected sex with women having a high probability of being HIV infected.
Strong evidence exists that being the receptive partner in unprotected penile-anal intercourse is associated with a high risk of HIV infection. Transmission of HIV to the receptive partner probably occurs as a result of the deposition of HIV-infected semen on traumatized rectal mucosa. More recently, studies have suggested that exposure to infected pre-ejaculate through anal intercourse may also carry a high risk of transmission. Unprotected receptive anal intercourse (URAI) has been consistently described as an independent risk factor for HIV infection among MSM.One recent study estimated the per-act risk of HIV infection from URAI with a partner who is HIV-positive at 0.82% (82 in 10,000) and with a partner of unknown serostatus at 0.27% (27 in 10,000).
Several investigators found that receptive penile-anal sex is also a risk factor for male-to-female transmission. Others failed to find this association among heterosexual couples.Of the latter studies, however, three had small sample sizes, which may have made a relationship between anal sex and HIV infection impossible to detect. It is probable that unprotected anal sex between serodiscordant heterosexual partners carries a similar per-act risk as it would between MSM, with greater risk incurred by the receptive female partner.
Whether being the inserting partner in unprotected penile-anal sex is an independent risk factor for HIV infection is not well understood. Most early studies did not demonstrate a statistically significant association between this practice and HIV infection among MSM.This was not taken as evidence that the behavior was free of risk.One recent study has estimated the per-act risk of unprotected insertive anal sex with an HIV-positive or unknown status partner at 0.06% (6 in 10,000).This risk, although 4-14 times less than that estimated for URAI, remains considerable. The lack of more complete information on the risk of unprotected insertive anal sex reflects the research community’s attention to the riskier activity URAI, rather than any consensus that unprotected anal sex has been determined to be of low risk to the insertive partner.
Rectal Douching and Rectal Fisting
Studies of transmission among MSM have revealed that rectal douching increases the risk of HIV infection. A similar association between fisting (penetration of the anus with the hand) and HIV infection was observed in some studies, but not others.One presumptive mechanism for transmission via these practices is that they disrupt the mucosal barrier of the rectum and thus facilitate entry of HIV into the bloodstream during subsequent exposure to infected body fluids. In a large multicenter cohort study of MSM, the investigators devised a composite variable called “rectal trauma,” composed of enema usage, receptive fisting, report of blood around the rectum, and evidence of scarring, fissure, or fistula on examination.They found that higher rectal trauma scores correlated with increased risk of HIV infection.
Oral-penile contact (fellatio) is not an efficient route of HIV infection. Estimating precise per-act risk is difficult because so few people practice oral sex to the exclusion of other, higher-risk sexual activities. Nonetheless, the risk of infection from oral sex is believed to be extremely low. Early male-to-male transmission studies consistently failed to demonstrate an increased risk of HIV infection associated with the practice of oral-penile sex.A more recent study of MSM confirmed earlier findings, and further estimated that on a population level, the risk of HIV infection among MSM that is attributable to oral sex is extremely low. Most studies of male-to-female and female-to-male transmission also failed to show any increased risk of HIV infection associated with oral-penile sex. A cohort study among heterosexual serodiscordant couples at an STI clinic in Spain found no seroconversions attributable to oral sex, supporting the conclusion that HIV transmission via oral-penile sex between heterosexuals was extremely low.
Oral-penile contact is not completely risk free, however. A study of per-contact risk of infection to the receptive partner found that the probability of infection was 0.06% with a known HIV-positive partner and 0.04% with partners of unknown status. Although these are low probabilities, the authors suggest that oral-penile sex may play a larger role in the epidemic among MSM as more men adopt these behaviors as risk reduction measures. Several case reports have implicated oral-penile contact as a source of male-to-male transmission.The most convincing of these reports described a homosexual man who seroconverted despite having had only oral-genital contacts (and no anal-genital contacts) for at least 5 years preceding the estimated date of seroconversion. In one study of heterosexual transmission, repeated oral sex was associated with transmission of HIV from men with AIDS to their spouses, although competing risks also showed significant associations in this study. Because so few people practice oral-penile sex to the exclusion of other sexual practices, it is very difficult to recruit and retain subjects for epidemiologic studies of the HIV risk associated with this practice. Only one study was able to do this ; another examined monogamous serodiscordant couples whose only unprotected sexual activity was oral sex. No serocoversions were observed in either study. Despite the case reports, the epidemiologic evidence suggests that unprotected oral-penile sex is a low-risk activity.
Oral-genital sex, both oral-penile and oral-vaginal, can transmit STIs other than HIV with varying degrees of efficiency. Receptive oral-penile sex carries the risk of pharyngeal gonorrheal infection for both men and women, and insertive oral-penile sex, although carrying only extremely low, hypothetical risk of HIV infection to the insertive partner, carries a demonstrable risk of urethral gonorrheal infection. Other risks of receptive oral-genital sex include small probabilities of human papillomavirus and hepatitis C transmission. Insertive oral-penile sex is an efficient route for the transmission of herpes simplex virus (HSV). The damage that many STIs cause to mucosa can conceivably increase the likelihood of transmission of HIV through oral sex, although this risk has not been quantified.
The risk of HIV transmission through oral-vaginal sex (cunnilingus) has received less attention than oral-penile sex. There have been case reports of female-to-male and female-to-female transmission of HIV infection via oral-vaginal sex. One study found an association between oral-vaginal sex and female-to-male transmission of HIV, although competing risks also showed significant associations in this study. As with oral-penile sex, conducting an epidemiologic study that can examine oral-vaginal sex in the absence of competing HIV risk behaviors is difficult, and no such studies have been reported. However, all studies that have controlled for competing risk behaviors have concluded that oral-vaginal sex is extremely low risk.
Although oral-anal contact is not an independent risk factor for HIV infection based on data from male-to-male transmission studies, it may be a marker for other high-risk sexual practices. Univariate analysis showed an increased risk of HIV infection associated with oral-anal sex. This association was no longer statistically significant once the authors controlled for other high-risk behaviors.Oral-anal sex has been shown to be a route of transmission for hepatitis A and B, and parasitic infections such as giardiasis and amebiasis.
Methods to Prevent Sexual Transmission of HIV
Barrier Methods and Microbicidal Agents
Male Condoms: Permeability to Viruses
Several laboratory experiments were conducted to test the ability of latex condoms to provide an effective physical barrier against HIV. Condoms were tested by placing a solution containing HIV inside the condoms, and culture medium (free of HIV) outside the condoms. No leakage of HIV across latex condoms was demonstrable.
Similar studies tested the permeability of latex condoms to other sexually transmitted viruses. Latex condoms are impermeable to HSV and hepatitis B virus.
Studies in vitro provided evidence that condoms made of natural membranes do not provide a consistently effective physical barrier against a number of viruses. Leakage of HIV occurred across lambskin condoms in one of two studies. Hepatitis B virus and HSV also leak across natural skin condoms.
In the 1990s, polyurethane condoms were introduced in both “male” and “female” varieties (the female condom will be discussed below). Polyurethane condoms, like those made of latex, effectively contain viruses in vitro.Additional benefits of the polyurethane condom include use by persons with latex allergies, and anecdotal reports of increased tactile sensitivity through the barrier relative to latex.
Epidemiologic Evidence for Condom Efficacy
Several transmission studies demonstrated a statistically significant negative association between condom use and risk of HIV infection,whereas others did not. Determining the true extent to which condoms reduce risk is difficult because investigators have used various scales for describing condom use. For example, in one investigation, condom use was reported as “never/not always” versus “always.”In another investigation, condom use was reported as “routine use during vaginal intercourse.” It is generally accepted by the medical and public health communities that when used properly, latex and polyurethane condoms can significantly reduce the risk of sexual transmission of HIV. Condoms are therefore recommended as an important HIV prevention measure.
Reasons for Condom Failure
As the results of HIV transmission studies indicate, being made of material impermeable to HIV in a laboratory (ie, latex or polyurethane) is not sufficient to ensure that condoms will provide complete protection during real-life usage. Condoms can fail to provide complete protection for a variety of reasons, including failure to use them consistently, failure to use them properly, condom breakage, and condom slippage. Studies of latex condom performance during human use reported breakage and slippage rates varying from 1.46% to 18.60%.Use of thicker condoms for anal sex and having more personal efficacy (technical skill) and experience (number of episodes of prior use) in using condoms were associated with lower failure rates. In addition, laboratory evidence suggests that improper use of latex condoms (eg, applying an oil-based lubricant) can make condoms more susceptible to breakage.
When polyurethane condoms were introduced, questions were raised almost immediately as to their safety compared to latex condoms. In general, it was asserted that polyurethane condoms were more prone to breakage and slippage, and this delayed the approval by the U.S. Food and Drug Administration (FDA) of one brand of polyurethane condom. Although the FDA eventually determined that the polyurethane condom was safe for consumer use in 1995, six epidemiologic studies have since addressed this question.Three of the six studies found equivalent low rates of breakage and slippage between the two condom types ; one study found polyurethane condoms to have higher breakage but equivalent slippage rates compared to latex condoms ; one study found higher breakage and higher slippage rates with polyurethane condoms ; and the one study that addressed only breakage found higher rates with polyurethane condoms. It should be emphasized that the breakage and slippage rates of polyurethane condoms are not unacceptably high, and using polyurethane condoms is still considered safer sex practice for those people unable or unwilling to use latex condoms.
All studies on condom efficacy in theUnited Stateswere conducted with heterosexual couples performing vaginal sex. It is believed that condom failure rates may be higher for anal sex. Condoms designed for specifically for anal intercourse are available in Europe, but there is little data on their performance versus commonly available latex or polyurethane male condoms.
The female condom, made of two flexible polyurethane rings and a loose-fitting polyurethane sheath, is approved for contraception and HIV prevention in heterosexual intercourse. The female condom prevents leakage of HIV in laboratory testing.In studies of acceptability, between 50% and 73% of women respondents liked female condoms as much or better than male condoms.Acceptance was somewhat less among their male partners, with only 44% reporting they liked the female condom as much as or better than the male condom. Nonetheless, as a female-controlled method, the female condom represents an important advance in HIV prevention.
Researchers have explored whether polyurethane female condoms can be reused. Given their much higher per-unit costs versus male condoms, this question is particularly relevant for women in resource-poor environments. One study has shown that the structural integrity of female condoms is not significantly damaged in up to five uses if disinfected in diluted household bleach and water (1 part bleach to 4 parts water) for not more than 30 minutes, washed in diluted dishwashing liquid or bar soap and water, and air dried or dried carefully by hand. The condoms should always be inspected for holes and tears before reuse, and discarded if any are observed. However, the authors caution that the safest way to use female condoms is to use them only once and then discard them.
Although female condoms are not approved for anal use, some MSM have nonetheless begun to use them for anal sex. The large size and polyurethane composition have been reported anecdotally by MSM to increase sensitivity for the insertive partner compared with latex male condoms. The one study on their use by MSM found that 57% of men reported problems with the condom, including rectal bleeding by the receptive partner.Anecdotal evidence suggests that removing the inner ring, lubricating the inside, placing the condom over the erect penis, lubricating the outside, and then entering the receptive partner eliminates some discomfort and trauma. As with vaginal use, care should be taken that the outer ring of the condom does not enter the rectum. It is important to keep in mind that safety and efficacy have not been demonstrated in anal use, and that female condoms are neither recommended nor approved for this purpose.
Latex dental dams can be placed over the labia and genitalia, or over the anal area, for protection during cunnilingus (oral-vaginal sex) and anilingus (oral-anal sex). These latex squares can be purchased at condom specialty stores and some drugstores (available in different flavors), or similar barriers can be made by cutting a latex condom or a latex glove. The efficacy of these methods has not been studied.
Table 1 summarizes practical instructions for the use of barrier methods.
Effective topical anti-HIV agents that women could use with or without their sexual partner’s knowledge would be of great benefit. Nonoxynol-9 (N-9), a detergentlike molecule once thought to be a leading candidate in the search for vaginal microbicides against HIV,is no longer recommended. Studies of the in vivo efficacy of N-9 have shown that N-9 reduces the risk of HIV transmission in some cases but not in others. A recent meta-analysis of vaginal N-9 studies found that there is no evidence that N-9 prevents HIV infection in women, and confirmed former research findings that had found a significantly elevated risk of genital lesions and ulcers associated with N-9 use.
Several other vaginal microbicides are being studied in animal and clinical trials.Available results do not yet support making specific recommendations.
Why is ‘AIDS and prostitution’ an issue?
This topic is significant for several reasons:
- High rates of HIV have been found amongst individuals who sell sex in many different and diverse countries. Even where HIV prevalence is low amongst this group, it is usually higher than the rate found amongst the general adult population.
- Sex workers usually have a high number of sexual partners. This means that if they do become infected with HIV, they can potentially pass it on to multiple clients.
- Preventing HIV infections amongst those involved in the sex trade has been proven to be an instrumental part of many countries’ fight against AIDS. We discuss this issue in our HIV prevention and sex workers page.
‘Prostitutes’ or ‘sex workers’?
Although the word ‘prostitution’ can be used to describe the act of selling sex, it can also mean ‘using a skill or ability in a way that is considered shameful’. It seems to include a moral judgement, by implying that individuals who sell sex are involved in a practice that is corrupt and so are themselves unworthy. A far more neutral and respectful alternative is the term ‘sex work’.
This issue may not matter so much in the context of everyday conversations or casual debates, but in serious discussions on the topic it is important that words are chosen carefully. Since this article seeks to discuss the issue of HIV and sex work in an open and non-judgemental way, we refer to sex workers rather than prostitutes.
The term ‘sex worker’ refers to a wide array of people who sell sex, and who work in a variety of environments. They include women, men and transgender people and people who may work either full time or part time, in brothels, or bars, on the street or from home for example.
What role do sex workers play in the global AIDS epidemic?
Sex workers, along with other marginalised groups such as men who have sex with men and injecting drug users, are often labelled a ‘high risk group’ in the context of HIV and AIDS. But the debate about sex workers’ wider role in the global AIDS epidemic often polarises opinion. Some argue that sex workers are being wrongly portrayed as ‘spreaders’ of HIV, while others claim that HIV transmission through paid sex is ‘driving’ the epidemic.
In truth, the situation differs vastly between different countries and regions. While HIV prevalence is high amongst sex workers in some areas, in others it is relatively low, and they seem to play a fairly minor role in the spread of HIV. For instance, in most parts of Western Europe and North America, HIV transmission through paid sex is not considered to be a major issue. In other regions, however, notably parts of Asia, large numbers of sex workers are living with HIV, and this is influencing the overall pattern of the AIDS epidemic.
The factors that put sex workers at risk vary between countries. In some places, sex workers commonly use drugs and share needles. The overlap between sex work and injecting drug use is linked to growing HIV epidemics in a number of countries throughout Eastern Europe and Asia.1
As well as regional differences between sex workers, the picture is further blurred by a general lack of information on this group. Sex workers are a marginalised and often criminalised population, and are therefore very difficult to track and monitor.2 They can therefore be hard to reach with HIV prevention programmes.
Some people argue that labelling sex workers as a ‘high risk group’ is used an excuse to further stigmatise sex workers by those who are morally opposed to their profession:
“Apart from the stigma already attached to [sex workers], society has further marginalised them as core transmitters of the HIV infection. It fails to understand and recognise that they are but links in the broad networks of heterosexual transmission of HIV. And that they constitute a community that bears and will continue to bear the greatest impact of the HIV epidemic.” Meena Seshu, SANGRAM (a project working with sex workers in India)3
The clients of sex workers are often referred to as a ‘bridge’ population for the transmission of HIV, meaning that they act as a link between high risk groups and the general population. Many women do not report using condoms with their husbands and may therefore be at risk of HIV infection if their partners frequent sex workers. This is particularly true for wives of migrant workers who travel long distances and spend an extended period of time away from home. High HIV prevalence amongst the male clients of sex workers have been detected in studies across the world.4 5 6 7
HIV and sex work around the world
According to the Commission on AIDS in Asia ‘men who buy sex are the single-most powerful driving force in Asia’s HIV epidemics’.8 There are an estimated 10 million sex workers in Asia, and 75 million male clients.9
Historically, the AIDS epidemic in India was first identified amongst sex workers and their clients, before other sections of society became affected.10 High HIV infection rates among sex workers continue to be detected in India. The government estimates that 5% of sex workers nationally are infected with HIV, which is fifteen times higher than the overall HIV prevalence.11 What is more, sex workers in some areas have a much higher HIV prevalence, such as 18% in the state of Maharashtra, and 13% in Manipur.
High HIV rates were also first identified amongst sex workers in Thailand, although the Thai government were faster to act on this problem. In the early 1990s, they implemented the now famous ‘100% condom programme’, enforcing mandatory condom use in commercial sex establishments throughout Thailand, which helped to significantly reduce the spread of HIV. A similar programme has also significantly reduced HIV prevalence Cambodia since it began in 2001 (from 44% in 1998 to 8% in 2003 among sex workers older than 20 years).12 However, although HIV prevalence among female sex workers in Thailand has dropped to 2.8%, male sex workers are a traditionally overlooked group with a much higher HIV prevalence (14%).13 Unfortunately sex workers who work outside of formal commercial sex establishments like brothels or karaoke bars in Thailand are not reached by the ‘100%’ condom programme and there are concerns that HIV prevalence among this group is rising.14
The overlap between sex work and injecting drug use is of increasing concern in Asia, in particular in southern India, Pakistan, Indonesia and Vietnam.15 In Vietnam, more than a third of injecting drug users surveyed said they had bought sex in the previous 12 months, but only about a fifth said they consistently used condoms with their sexual partners.
HIV prevalence among female sex workers in sub-Saharan Africa varies widely but in some countries it is more than 20 times higher than the HIV prevalence of the general population. This is particularly the case in West Africa, where HIV prevalence is much lower among the general population than in Eastern and Southern Africa, but where more than a third of sex workers are reported to be living with HIV.16 As many as a fifth of men in West Africa had visited sex workers in 2007 which means that they can act as a potential ‘bridge’ for HIV transmission to the rest of the population, either through their wives or other sexual partners.17
Although the impact of sex work on rate of new HIV infections varies widely in sub-Saharan Africa, it impacts significantly on the HIV/AIDS epidemics of a number of countries in this region. In Ghana, for example, female sex workers, their clients and the sexual partners of clients made up a third of all new HIV infections in 2009, 10% of all new HIV infections in Uganda, and 14% of HIV infections in Kenya in the same year.18
Male and transgender sex workers (MTSW) in the region often engage in sex work for financial reasons and are at high risk of HIV infection. Criminalisation of homosexuality and marginalisation drive male sex work underground and make it extremely difficult to access MTSW with HIV/AIDS prevention initiatives. A study of male sex workers in Mombasa, Kenya found that less than half of male sex workers surveyed consistently used condoms with their male clients.Low condom use among MTSW in particularly worrisome because of the increased risk of HIV transmission associated with anal sex. Male sex workers are also found to have low condom use rates with their female clients.
“Twenty-three of my friends died of AIDS. Nineteen trans women and 4 women, all sex workers. None of them got ARVs. It was the fear of discrimination and abuse from the doctors that kept them from getting medication”. – A transexual sex worker from Windhoek, South Africa
The Caribbean‘s thriving sex industry serves both local clients and tourist and features prominently in the AIDS epidemics of certain countries such as Haiti and Jamaica, where HIV prevalence among sex workers is 5.3 percent and 4.9 percent respectively. Also in Guyana, the HIV prevalence among sex workers is very high at 16.6 percent.Male sex workers in the Dominican Republic have been identified as particularly high risk, because of the secret nature of their work and lack of prevention programmes aimed at this group. The epidemic among male sex workers in the country is being driven by both high unemployment rates in rural areas, which has encouraged migration to urban areas, and the profitable sex tourism industry.
A handful of countries in the region have established HIV prevention campaigns aimed at sex workers; in Haiti, for example, a non-governmental organisation called FOSREF offer sex workers HIV testing and counselling services, treatment for sexually transmitted infections and vocational training (for example in cooking, dance, beauty or information technology) that provide alternatives to sex work. In general, though, organisations that work with sex workers are being overlooked in the Caribbean, and this is holding back the region’s fight against AIDS.
Information about the role of sex workers in Latin America’s AIDS epidemic is sparse, and shows a varied picture. A study released in 2006, which analysed sex workers in nine South American countries over a thirteen-year period, concluded that “consistently low HIV seroprevalences were detected among female commercial sex workers in South America, particularly in the Andean region”.
However, HIV prevalence among sex workers is high in Honduras (10%), Guatemala (4%) and El Salvador (3%).High rates of injecting drug use are common among sex workers in Central America, particularly on major drug trafficking routes. This is a major issue where HIV prevalence is high among female sex workers who inject drugs (12% in the Mexican border cities of Tijuana and Ciudad Juarez) as there is a significant risk of HIV infection being passed to male clients of sex workers and then into the wider population. This is particularly true because female sex workers who are injecting drug users in this area have been found to be more likely to engage in unprotected sex (often for more money used for buying drugs).
Male sex workers in Latin America are at particularly high risk of HIV infection. In Argentina, for example, the HIV prevalence among male sex workers is thought to be 22.8% compared to 1.8% among female sex workers.
Where efforts have been made to target sex workers with information on sexual health, notable changes have been observed. For example, in Guatemala where a sexual health clinic offered counselling, testing and follow-up services over a six month period, a four fold decrease in HIV was noted among sex workers. HIV prevalence among sex workers in Chile and El Salvador is also said to have fallen significantly following the targeting of sex workers with prevention programmes.
Eastern Europe/ Central Asia
The number of sex workers in Eastern European and Central Asian countries has risen in recent years due to social, economic and political changes that have led many to turn to sex work as a means of income. The defining characteristic of this region’s HIV/AIDS epidemic has traditionally been a very high prevalence among injecting drug users. However, there is a clear overlap between injecting drug use and sex work in this region and this is playing a significant role in the spread of HIV as many sex workers are also injecting drug users.35 It is estimated that more than a third of sex workers in the Russian federation inject drugs.36 High levels of needle sharing also place them at high risk of contracting HIV. For example, in St Petersburg nearly half of all sex workers admit to sharing injecting equipment.37
“Nearly half of all sex workers in St Petersburg admit to sharing injecting equipment ”
Prevention initiatives aimed at sex workers in Russia where there is a high rate of injecting drug use among sex workers need to include services that reduce the risk of HIV infection through drug use. One initiative in Saint Petersburg uses ‘mobile points’ or vans to reach sex workers.38 Apart from condoms and voluntary counselling and testing for sexually transmitted diseases, the vans also provide needle exchange services so that sex workers can exchange used needles for sterilised injecting equipment.
Western Europe and North America
There is a lack of recent data available on HIV infections among sex workers in Western Europe, although Western Europe is one of the few parts of the world which includes countries where commercial sex is either legal or controlled (Switzerland, Finland, Germany, Ireland, Austria, Latvia, Hungary, Turkey, and the Netherlands). Overall, the HIV prevalence among sex workers is less than 5%. Levels of HIV infection seem to be low (less than 1%) amongst sex workers who do not inject drugs. However, for those who do inject drugs the risk is often significantly higher. According to a study carried out in three cities in the Netherlands, the HIV prevalence among female sex workers who injected drugs was 13.8%, while it was 1.5% amongst other female sex workers.
In many areas, it also seems that male and transgender sex workers are more vulnerable to HIV than female sex workers. For example, male sex workers in Spain were found to have an overall HIV prevalence of 12% in a study conducted in 19 Spanish cities compared to 1% for female sex workers during the same time period.A study conducted in three cities in the Netherlands found that 18.8% of transgender sex workers surveyed were HIV positive, compared to 5.7% of sex workers in general.
In the United States, the government takes a strong stance against sex work, as demonstrated by its refusal to grant overseas aid to any HIV/AIDS projects that do not ‘explicitly oppose’ the practice. Domestically, sex work is illegal in the U.S. (with the exception of a few counties in the state of Nevada), and very little information is gathered about workers and their clients. As with Western Europe, many of the HIV cases that do occur amongst sex workers in the region are amongst sex workers who also inject drugs.
The way forward
It is clear that sex workers are not ‘universally’ at high risk of becoming infected with HIV, and that the situation varies widely between regions. However, it is also apparent that in many of the countries where AIDS is taking its heaviest toll, large number of sex workers are being affected by HIV, and this is a major issue.
Improving the situation will require greater efforts by governments, groups, and individual members of society to help sex workers. It is particularly important that sex workers gain access to HIV prevention and treatment programmes. Such programmes not only save sex workers’ lives; they can also help to stem the wider impact that HIV is having on societies around the world.
To read a detailed account of what needs to be done, and to find out about some of the most famous examples of campaigns that have reduced the impact of AIDS on sex workers, see our HIV prevention and sex workers page.
Posted on June 2, 2012, in Categorized and tagged AIDS, CDC, Centers for Disease Control and Prevention, HIV, Human sexual activity, MSM, Safe sex, Sexually transmitted disease. Bookmark the permalink. Leave a comment.