On the road: Croatian truck drivers, commercial sex and HIV/AIDS

The primary aims of this study were to examine Croatian truck drivers' sexual contact with sex workers, estimate the frequency of condom use, and assess knowledge of HIV/AIDS within this population. The research was conducted from June 14 to September 16, 2005 at customs offices and accompanying parking lots in four Croatian cities. The sample consists of 69 truck drivers. Information about sexual behavior and condom use were gathered by using a semi-structured interview. Knowledge of HIV/AIDS, measured with a self-administered questionnaire, was found to be low. Six respondents (8.7%) had correctly answered all 13 questions. By contrast, 73% of drivers considered themselves well informed about HIV/AIDS, indicating that most drivers overestimate their knowledge. The majority of respondents (n=62) assumed that most of their colleagues engage in sexual contact with sex workers while on the road, although only one third of respondents reported that they personally have paid for sex. All of the respondents who reported engaging in sexual contact with sex workers stated that they always use condoms. Fear of being infected with a sexually transmitted infection was reported as the main reason for condom use.     

Prevalence of HIV,Syphilis, HCV and Their High Risk Behaviors among Migrant Workers in Eastern China

Objective

The goal of this study was to understand the knowledge about AIDS, identify the correlates and determine the prevalence of HIV infection, syphilis, HCV among migrant workers in Zhejiang, China.

Methods

A cross-sectional study using face-to-face anonymous questionnaire interviews was conducted and blood samples were collected for HIV, syphilis and Hepatitis C infection screening.

Results

17,377 (92.8%) of 18,730 migrant workers approached were interviewed. Among 17,377 participants, the HIV/AIDS knowledge rate was 66.2%. A total of 12,694 (73%) of the participants reported having ever had sexual intercourse, with 30.1% of single participants reporting having had sexual intercourse. Among those respondents with sexual experiences, 7.5% admitted they had two or more sexual partners and 4.9% reported having had sex with casual (unpaid) partners in the previous 12 months, whilst 3.7% had paid for sex. More than half of those who had paid for sex (59.4%) had not used a condom every time in their sexual acts with the sex workers. Multiple logistic regression analysis indicated that high risk sexual behavior (defined as sex with a casual or commercial sex partner without using a condom consistently) was associated with being divorced or widowed (P<0.05 for single); male gender; shorter duration of stay in Zhejiang; working in factory, market or domestic service (P<0.05 for odd job); having a province of origin inside Zhejiang; and drug use. The prevalence of HIV and HCV infections were 0.02% (95% CI: 0.01%–0.06%) and 0.40% (95%CI: 0.31%–0.51%), respectively. The prevalence of syphilis among those who were sexually active was 0.55% (95% CI: 0.43%–0.70%). Risk factors for syphilis included shorter duration of stay in Zhejiang, ethnic minority status, being divorced or widowed and having had multiple sex partners.

Conclusions

Much greater efforts are needed to promote safer sex, and programs for the control of syphilis need to be tailored for migrant workers in China.     

HIV/AIDS and Croatian migrant workers

Due to their geographical mobility and long periods of separation from intimate partners, migrant workers are at increased risk for a variety of sexually transmitted infections (STIs) including HIV/AIDS. This study sought to investigate patterns in HIV/AIDS related knowledge, attitudes and sexual behaviour in migrant workers in Croatia. In 2003, 566 male migrant workers were recruited during regular required medical examinations and surveyed at seven locations throughout the country. Each participant was asked to complete a self-administered KABP (sexual knowledge, attitudes, beliefs and practices) questionnaire. The average age of respondents was 38.2 years and the majority worked as seafarers (77.3%) and construction workers (20.5%). Only 18.5% of respondents were able to correctly answer all 13 questions assessing knowledge of HIV/AIDS. Seafarers reported higher levels of knowledge than did construction workers. The average respondent reported having had two sexual partners in the last 12 months, with slightly over half of the respondents (55.3%) reporting condom use at their last intercourse with a casual partner. One fifth of the respondents (20.3%) who reported having had intercourse with a sex worker during the last year reported not using condoms at last intercourse. The number of sexual partners was correlated with age, marital status, faith in God, and personal HIV risk assessment. Attitudes toward condom use, co-workers' HIV/AIDS concerns and the duration of migrant status (within the last two years) were shown to be significant correlates of condom use at last intercourse with a casual partner. The effect of HIV/AIDS related knowledge on analyzed behaviors did not reach statistical significance. Inadequate patterns of migrant workers' condom use, gaps in knowledge about HIV transmission and modes of protection, as well as widespread ignorance regarding available anonymous HIV testing found by this study suggest a critical need for expert intervention to avert the potential for an increase in new HIV/AIDS cases. A coordinated, systematic campaign for HIV/AIDS prevention among Croatian migrant workers should focus on increasing peer communication about HIV/AIDS, especially among younger migrant workers, and on reducing the frequency of sexual risk taking.     

Sex Workers Perspectives on Strategies to Reduce Sexual Exploitation and HIV Risk: A Qualitative Study in Tijuana,Mexico

Globally, female sex workers are a population at greatly elevated risk of HIV infection, and the reasons for and context of sex industry involvement have key implications for HIV risk and prevention. Evidence suggests that experiences of sexual exploitation (i.e., forced/coerced sex exchange) contribute to health-related harms. However, public health interventions that address HIV vulnerability and sexual exploitation are lacking. Therefore, the objective of this study was to elicit recommendations for interventions to prevent sexual exploitation and reduce HIV risk from current female sex workers with a history of sexual exploitation or youth sex work. From 2010–2011, we conducted in-depth interviews with sex workers (n = 31) in Tijuana, Mexico who reported having previously experienced sexual exploitation or youth sex work. Participants recommended that interventions aim to (1) reduce susceptibility to sexual exploitation by providing social support and peer-based education; (2) mitigate harms by improving access to HIV prevention resources and psychological support, and reducing gender-based violence; and (3) provide opportunities to exit the sex industry via vocational supports and improved access to effective drug treatment. Structural interventions incorporating these strategies are recommended to reduce susceptibility to sexual exploitation and enhance capacities to prevent HIV infection among marginalized women and girls in Mexico and across international settings.     

The HIV epidemic among men who have sex with men—behaviour beats science

More than three decades after the emergence of HIV/AIDS, more than 30 million people worldwide still live with the disease. In the West, those most at risk are men who have sex with men owing to a combination of social factors and, ironically, improved healthcare.The acquired immune deficiency syndrome (AIDS) pandemic that started more than 30 years ago remains one of the greatest public-health concerns worldwide: in 2009, it was estimated that 33.3 million individuals were infected with human immunodeficiency virus (HIV), with 2.6 million new infections globally (see graphic; [1]). Even in the affluent countries of North America, Australia, New Zealand and Western and Central Europe, the numbers of people infected with HIV have grown over the past two decades. Although the availability of efficient diagnostics and highly active antiretroviral therapy (HAART) have drastically improved life expectancy and quality of life—at least in those parts of the world where both are available and affordable—HAART does not cure the disease. Moreover, despite massive research efforts, there is no efficient vaccine on the market to protect against infection with HIV.Given the lack of either a vaccine or a cure, the main public-health intervention to halt the pandemic is to prevent viral transmission in the first placeGiven the lack of either a vaccine or a cure, the main public-health intervention to halt the pandemic is to prevent viral transmission in the first place. In fact, the transmission of HIV is not as efficient as other, more resistant blood-borne viruses such as hepatitis B and hepatitis C viruses (HBV and HCV), and it requires direct contact of blood or semen from an infected person with the blood system of the exposed person. This feature puts certain groups at greater risk of transmission: heterosexuals with many sexual partners, including sex workers, men who have sex with men (MSM—a technical term used by health professionals to avoid forcing individuals to define themselves in a specific sexuality), people who inject drugs, newborns of HIV-infected mothers, blood recipients and healthcare workers. Yet, the risk of infection differs for each of these groups. There is also a geographical dimension to the risk, as different parts of the world have unique epidemiological characteristics, reflecting biological, behavioural and socio-economic factors. In many parts of Africa and Asia, for example, the most susceptible groups are heterosexuals and sex workers; in Eastern Europe, people who inject drugs are mainly affected; and in western countries, the most vulnerable population are MSM, followed by heterosexual migrants from areas where HIV is endemic [2].

Science & Society Series on Sex and Science

Sex is the greatest invention of all time: not only has sexual reproduction facilitated the evolution of higher life forms, it has had a profound influence on human history, culture and society. This series explores our attempts to understand the influence of sex in the natural world, and the biological, medical and cultural aspects of sexual reproduction, gender and sexual pleasure.Public-health programmes intended to prevent the transmission of HIV therefore have to address these groups individually. Such measures require education and the involvement of at-risk populations, and recommendations must be based on a thorough understanding of the social, economic and other factors that determine disease risk among certain groups of people. For instance, one of the most efficient measures to decrease the risk of HIV infection among people who inject drugs is to offer clean syringes and needles,and safe places to use them. One of the most efficient ways to prevent HIV transmission during sexual intercourse is the use of condoms. But, the answers are not always as simple; human behaviour is complex and even irrational at times. This paper outlines the main causes of the HIV epidemic among MSM in western countries, highlights specific behavioural factors that increase exposure to HIV and discusses how these can be addressed in public-health programmes.AIDS was first identified and described in the USA in June 1981 [3]. Following reports from Los Angeles and New York City about clusters of otherwise healthy Caucasian MSM who developed Kaposi''s sarcoma and fatal Pneumocystis carinii (jirovecii) pneumonia, the US Centers for Disease Control and Prevention (CDC) conducted an epidemiological investigation and identified a man they referred to as ‘patient zero'': a flight attendant working for Air Canada named Gaëtan Dugas, who had numerous male sexual partners in North America. Dugas might not have been the first person who was infected with HIV, but the first one who was identified with the disease.​disease.Open in a separate windowSee full size illustration: http://staging-www.nature.com/embor/journal/v13/n11/full/embor2012152i1.htmlIt was a combination of a general liberal attitude towards sex that was prevalent among MSM, unprotected anal sex and having multiple sexual partners that allowed HIV to spread quickly among the gay community in the early 1980s. Owing to the overwhelming impact on MSM in the early years of the AIDS epidemic—when many MSM saw close friends, partners and lovers die—gay communities adopted a range of practices to reduce the risk of infection successfully by changing sexual behaviours. Regretfully, these achievements did not last; many other developed countries also recorded a resurgence in the number of MSM newly diagnosed with HIV/AIDS since the mid-1990s [4]. The main reason for the re-emergence of the disease was the come-back of risky sexual behaviours, triggered by wider social and cultural changes, greater social acceptance for gay men and, somehow unpredictably, the introduction of more efficient drugs [5].The most important risk factor for exposure to HIV among MSM remains sexual practices. As the rectal mucosa is more fragile than the vaginal or oral, anal sex increases the risk for transmitting HIV and other sexually transmitted infections (STIs). The frequency of risky sexual practices between MSM seems to be increasing [6], which would go some way to explaining the resurgence of AIDS.Another main factor for the resurgence of AIDS among the gay communities in western countries is, ironically, the efficiency of HAARTIn addition, gay communities have a relatively liberal attitude towards sex and partnership. The way they form partnerships may differ from many heterosexuals: the sexual contact is more instantaneous and spontaneous, and sexual intercourse may take place early in a relationship [7]. Relationships between some MSM may be more flexible, and concurrent sex with casual partners during a relationship is generally more tolerable [8,9]. Concomitancy and age-mixing of sexual partners has a strong influence on the dynamic of HIV transmission if an infected man is unaware of his infection owing to the asymptomatic nature during the first years of HIV infection, or because he has not been tested for HIV [10]. Early sexual debut is another reason for greater exposure to HIV, as MSM would have more partners during their lifetime.Social changes have also played a role in increasing the HIV transmission rate among MSM. Since the 1990s, homosexuality and gay lifestyle have become much more accepted in many western societies. This increasing tolerance and acceptance has enabled many MSM ‘to get out of the closet'', that is to disclose their sexual orientation and have fulfilling lives. It has also encouraged entrepreneurs to tap into this customer base by offering services and establishments specifically for MSM including cafés, bars, clubs, restaurants, hotels and bath houses, all specifically intended for the purpose of meeting other men. This sexually liberal climate, along with the venues to meet other gay men, has amplified the risk of having sex with an HIV-infected partner.Similarly, the rise of internet-dating sites has increased the ease with which new partners can be found. New sexual practices and behavioural norms are quickly diffused between cultures, with possible international importing of HIV and other STIs. The internet, which is affordable, immediate and discrete, has become the most popular way of searching for other MSM. Most gay-related internet sites are free and guarantee anonymity until participants find the preferred fit and disclose their personal details or picture. The discrete nature of the web also allows MSM who are still ‘in the closet'' or ‘on the down low'' to search for sexual partners. This electronic meeting place might modify the sexual risk, as it exposes users to a diverse pool of men and increases their ability to search and negotiate for sexual practices [11]. The anonymity also allows MSM to search explicitly for unprotected anal sex [12]. MSM who originate from low-resource countries and migrate to developed countries might not be familiar with the risk of unprotected sex and may also be excited about the sizeable and versatile MSM community in the hosting country [12]. A combination of insufficient knowledge about HIV/AIDS, coupled with their interest in experiencing gay life, may increase the risk for those migrants to become infected with HIV.…the chances that an HIV-negative MSM finds himself engaged in sexual contact with an HIV-infected partner are higher than 15 years agoCorresponding with the increased number of sexual partners and the greater risk during sexual intercourse, MSM are also exposed to other STIs, especially if they are already infected with HIV. Increasing incidence of syphilis, as well as outbreaks of primary and secondary syphilis among MSM, has been reported during the past decade from developed countries [13,14]. Primary syphilis might manifest in a ‘chancer''—a sore—which is a possible port of entry for HIV. Additionally, the immunological reaction to STIs includes the migration of macrophages and lymphocytes to the affected organs. These cells are also the target of HIV, and thus one STI increases the chances of infection with further STIs or HIV. Over the past years, several outbreaks of lymphogranuloma venereum (an uncommon STI), presenting proctitis (inflammation of the rectum), and genital ulcers with inguinal adenopathy (inflammation of the lymph nodes in the groin) have been reported [15]. The asymptomatic nature of some STIs, along with the limited success of the risk-reduction strategies practiced by MSM, might explain the increased incidence of STIs among gay men [16,17]. Among HIV-infected individuals, genital infections with common STI pathogens have been associated with increased HIV viral load in semen, thus negating the benefit of HAART [18].Another important factor for the resurgence of AIDS among the gay communities in western countries is, ironically, the efficiency of HAART, which has converted AIDS from a death sentence into a manageable chronic medical condition. As the perceived threat of HIV/AIDS diminishes and direct experience with death disappears, some MSM may be more inclined to take higher risks. Before the introduction of HAART in the mid-1990s, most MSM had direct experience of the devastating effects of HIV/AIDS on friends and loved ones. It is important to note that HAART reduces the viral load in HIV-infected persons to undetectable levels in the blood and thereby decreases the risk of infecting partners. However, studies have documented the persistence of HIV virions and infected cells in semen of HIV-infected MSM treated with HAART [19]. Most physicians, therefore, do not recommend unprotected sex for HAART-treated HIV/AIDS patients, although the risk of HIV transmission has been significantly reduced.…public-health measures to reduce the prevalence of HIV among MSM should focus on the behavioural and psychosocial factors that increase the risk of infectionAs such, HAART has profoundly changed the impact of HIV/AIDS: people who live with HIV/AIDS who adhere to their drug regimen are usually asymptomatic and seem healthy. The non-fatal prognosis for AIDS, the large communities of HIV-infected MSM who live apparently healthy lives and the greater social acceptability of the disease have together reduced the perceived threat of HIV/AIDS.The success of HAART has affected sexual behaviour, a phenomenon called ‘AIDS optimism''. First, as HIV-infected MSM feel healthy and their sex-drive is preserved, they have a normal sex life and seek sexual partners, similarly to HIV-negative MSM. Second, before HAART and during its introduction in the 1990s, people living with HIV/AIDS could be recognized either by their cachectic posture or by the lipodystrophic features of their cheekbones and limbs due to loss of subdermal fat—a side-effect of the first generation of protease inhibitors. HIV-negative MSM could therefore decline sexual contact or insist on safer sex practices. However, modern HAART has diminished side-effects and HIV-infected men are usually unrecognizable. MSM may wrongly consider their sexual partners to be HIV-negative and might have unprotected sex. Third, some MSM may be aware of the availability of post-exposure prophylaxis as an additional use of ART, and might have unprotected sex then request the treatment, which is available up to 72 hours after sex [20]. These men may not be aware that post-exposure treatment has not been proven to be efficient in humans in randomized clinical trials. Finally, young MSM, who have not witnessed the devastation of AIDS, may no longer feel threatened by the disease and might engage in unprotected sex. The advanced manageability of HIV, as portrayed in the media and advertisements sponsored by the pharmaceutical industry, may further disinhibit their sexual behaviour.Moreover, the success of HAART and decades of public-health recommendations to practice safe sex may have led to ‘AIDS fatigue''. Some MSM may become desensitized to safe-sex messages and might develop a negative emotional response to HIV issues. As the number of newly diagnosed HIV-positive MSM is increasing, some will also remain unaware of their infection and may ignore safe-sex practices. Thus, the chances that an HIV-negative MSM finds himself engaged in sexual contact with an HIV-infected partner are higher than 15 years ago. Some public-health professionals argue that the uptake of HIV tests among MSM has more to do with the increased acceptance of their lifestyle than an increasing infection rate; thus the high HIV rates recorded are no more than epidemiological fallacy. However, even if this assumption is true, it neither explains the rapid dynamic of HIV transmission among MSM communities, nor the increased syphilis infection rates. Additionally, ART-resistant strains of HIV have emerged, which complicates treatment and prolongs the transmission period. The prevalence of primary or transmitted drug-resistant HIV strains in North America and Western Europe is as high as 26% [21].…it crucially requires the involvement and engagement of the gay community themselves to maintain effective and acceptable interventionsDrug abuse is another relevant risk factor. Even if the percentage of intravenous drug users among MSM may not differ compared with the percentage among heterosexuals, it creates a twofold risk of acquiring HIV: by blood-to-blood transmission when sharing needles and syringes, and by semen-to-blood exposure when having sex. Some males who inject drugs may also engage in sex with other males, although they are heterosexuals, to finance their addiction.MSM are generally aware of their risk of acquiring HIV and of the importance of condom use. Yet, they have developed alternative strategies to prevent possible HIV exposure that involve evaluating their partners and the environment in which they meet more carefully, and then taking calculated risks [22]. One such strategy used is called ‘negotiated safety'', in which both men disclose to each other their HIV status before they have sexual intercourse and may decide to perform unprotected anal sex if they are both negative. The efficacy of this strategy depends on the time at which they were tested, their honesty and being safe if performing sex outside the primary sexual relationship. The second strategy is ‘sero-sorting'', when MSM restrict unprotected anal intercourse only to partners they believe to be concordant [23]. MSM negotiate and try to identify signs that might indicate that a partner could be HIV-positive, such as special physical features—being cachectic or lypodystrophic—the venue and context in which they meet, and when visiting the home of a partner, taking a quick look in their drawers or in the bathroom closet to search for HAART tablets (‘sero-guessing''). Another strategy is called ‘strategic positioning'', which is the use of sero-status to determine sexual roles in which MSM may perform only oral sex or take the active role in anal sex. However, these risk reduction strategies, widely used by MSM, offer only limited protection from HIV [24].The recommended use of condoms during anal sex can fall by the wayside after recreational drug use. Drugs such as alcohol and methamphetamine, which are commonly used at clubs, discos and other venues, lower social barriers and increase sociability. MSM using such drugs are therefore more inclined to have sex with an unknown partner and might not use a condom, as their judgment is impaired. This risky combination of drug use during sexual contact is called ‘party and play'' on internet sites for MSM who are searching for a partner [25].The result is that in the post-HAART era, MSM still remain the group most at risk of acquiring HIV, with substantial evidence for continuing HIV transmission. It has been estimated that more than 40% of HIV-positive young MSM are involved in risky sexual behaviour, despite their awareness of their infection [26,27]. Behavioural, emotional, psychological, environmental and epidemiological factors all act synergistically to increase risk-taking when it comes to sexual practices, thus exacerbating HIV incidence in MSM. These factors might be even more dominant among HIV-positive MSM, driving them to perform unprotected anal sex. They face specific psychosocial factors such as the need to be loved and cared for, a different meaning of sex as an emotional connection and a decreased desire for intimacy after their diagnosis, owing to mixed feelings of shame and guilt [24].By contrast, HIV-infected MSM who receive HAART and achieve undetectable viral load in their blood usually reduce the risk of transmitting the virus to their sexual contacts, and probably engage less in risky sexual behaviour than those who are not on ART [28]. One explanation is that they frequent HIV clinics more often and are therefore more aware of the need to use condoms, and receive positive self-care advice. Some studies have shown that many HIV-positive men are also engaged in both sero-sorting and strategic positioning, probably to avoid HIV transmission to members of their social and sexual networks [29].…the success of HAART and decades of public-health recommendations to practice safe sex might have led to ‘AIDS fatigue''Some HIV-infected MSM therefore prefer to contact sero-concordant HIV-positive partners to experience unprotected anal intercourse, free from the worry of infecting a negative partner, or the embarrassment of having to disclose their HIV status to a negative partner, exposing themselves to the stigma attached to HIV. These perceived benefits seem to outweigh the perceived risks of contracting another strain of HIV, potentially drug-resistant, or STIs.Lacking an efficient vaccine or cure for AIDS, public-health measures to reduce the prevalence of HIV among MSM should focus on the behavioural and psychosocial factors that increase the risk of infection. Effectively, this means educational and outreach campaigns to address risky sexual behaviour and to promote the use of condoms and other protective strategies. These interventions should involve all relevant parties: non-governmental and governmental organizations, health providers, public-health experts and gay-related agencies. The message about the continuing risks and dangers of HIV/AIDS should go through multiple routes to address as many men as possible through the internet, media, clubs, bars and public spaces, to reinforce consistent condom use and other risk-reduction strategies, and to promote early diagnosis and treatment.Such campaigns should address both HIV-negative and HIV-positive men, but with a different focus on the needs of each. HIV-negative MSM should be informed about the possible routes of HIV transmission, the importance of using condoms, improving negotiation skills and other risk-reduction strategies to protect themselves and their partners. Innovative interventions could also attempt to associate the strong motivation of MSM for masculinity with the use of condoms. Additionally, frequent HIV testing in MSM-friendly clinics and community settings should be encouraged to detect new infections as early as possible. HIV-infected MSM should be instructed with safe-sex recommendations and prescribed HAART to reduce seminal viral load. Intervention in this group should address the unique psychological, social and medical status of each patient. As pointed out above, it crucially requires the involvement and engagement of the gay community themselves to maintain effective and acceptable interventions.Health educators must also respect the needs, wishes and behaviour of MSM when addressing them about the risk of HIV/AIDS, and making recommendations about safe-sex practices. Although condoms are indeed efficient at preventing HIV transmission, they might nonetheless be the ‘incorrect'' instrument in the ‘wrong'' place for many people. Condom use breaks the intimacy and spontaneity of sex and reduces the pleasure. Although we hope that we can convince a young, HIV-positive MSM to use condoms, this might not be a realistic goal. As such, addressing the risks requires a sensitive, ‘down-to-earth'' approach that respects gay culture and the dynamic of finding partners, as well as training physicians to provide counselling for MSM in a friendly and confident way.Reducing the use of illicit drugs in both HIV-infected and uninfected MSM is another priority, although in some cases drugs are used to cope with the stress related to living with HIV. Appropriate interventions for HIV-infected MSM must therefore include stress-reduction techniques, psychological services and counselling about the negative effects of substance use. Another public-health priority is to promote the disclosure of HIV status as part of the ethics related to using gay-dating sites. As the perceived threat of HIV has diminished owing to the success of ART and the non-fatal medical prognosis of HIV/AIDS, noticeable messages should be more positive and reflect contemporary gay life, using gay-related and non-gay-related venues frequented by MSM, such as gyms, airports, shops or tourist resorts.To address the problem and slow or halt the pandemic requires focused, evidence-based measures that respect biological, emotional and social aspects in a holistic approach…In conclusion, HIV prevalence among MSM remains high and, given the increase in survival of HIV-infected individuals and the high rate of new infections, this hyper-endemic state is likely to be sustained in developed countries [14]. To address the problem and slow or halt the pandemic requires focused, evidence-based measures that respect biological, emotional and social aspects in a holistic approach [24], taking into account psychological stressors, drug habits, discrimination and the quest for intimacy. It is also important to increase the sensitivity of health providers towards the special needs of MSM, to conduct open and non-judgemental discussions with their patients. A supportive medical environment can encourage MSM to adhere to periodical HIV testing, HBV and hepatitis A virus immunizations and, possibly, to comply with condom use [19]. Finally, due to the similarities in MSM behaviours in industrialized countries, a closer collaboration is required between researchers from countries that have large MSM communities. We are entering the fourth decade of the AIDS epidemic, and despite awareness among MSM of their greater vulnerability to HIV and the introduction of new medical interventions, the rate of new infections continues to rise disproportionately. It is time for new interventions.? Open in a separate windowZohar MorOpen in a separate windowMichael Dan     

Kunyenga, "real sex," and survival: assessing the risk of HIV infection among urban street boys in Tanzania

This article examines possible avenues of HIV infection among urban street boys in Tanzania. In doing so, it questions the ways that AIDS researchers have defined and approached the phenomenon of "survival sex" in East and Central Africa. The article specifically examines the boys' sexual networks, sexual practices, and attitudes regarding their own sexual behavior, including their perceived risk of HIV/AIDS infection. Seventy-five street boys aged eight to 20 from the city of Mwanza were interviewed. Results suggest that almost all street boys are involved in a sexual network in which homosexual and heterosexual behavior occurs. Homosexual practices are rooted in a complex set of behaviors and ideologies known as kunyenga, which is a situated aspect of life on the streets and helps maintain the boys' strong dependence on one another. A key aspect of the boys' sexual careers involves a decrease in kunyenga activity as they approach the age of 18 and an increase in heterosexual encounters after the age of 11. There appears to be a critical period between these ages in which heterosexual and kunyenga activities overlap. It is suggested that boys between these ages represent a potential bridge for HIV/AIDS infection between the general population and the relatively enclosed sexual network of street boys.     

National cross sectional study of views on sexual violence and risk of HIV infection and AIDS among South African school pupils

Objective To investigate the views of school pupils on sexual violence and on the risk of HIV infection and AIDS and their experiences of sexual violence.Design National cross sectional study.Setting 5162 classes in 1418 South African schools.Participants 269 705 school pupils aged 10-19 years in grades 6-11.Main outcome measure Answers to questions about sexual violence and about the risk of HIV infection and AIDS.Results Misconceptions about sexual violence were common among both sexes, but more females held views that would put them at high risk of HIV infection. One third of the respondents thought they might be HIV positive. This was associated with misconceptions about sexual violence and about the risk of HIV infection and AIDS. Around 11% of males and 4% of females claimed to have forced someone else to have sex; 66% of these males and 71% of these females had themselves been forced to have sex. A history of forced sex was a powerful determinant of views on sexual violence and risk of HIV infection.Conclusions The views of South African youth on sexual violence and on the risk of HIV infection and AIDS were compatible with acceptance of sexual coercion and “adaptive” attitudes to survival in a violent society. Views differed little between the sexes.     

A Qualitative Exploration of Barriers to Condom Use among Female Sex Workers in China

Background

Sex workers in China continue to engage in unprotected sex acts that put them at risk for contracting HIV (Human Immunodeficiency Virus) and other STIs (Sexually Transmitted Infections). The purpose of this study was to explore women’s work history, the context of sex work, condom use, HIV testing services, and potential barriers to condom use in a sample of FSWs (female sex workers) in Guangzhou, China.

Methodology/Principal Findings

In-depth, semi-structured, face-to-face interviews were conducted with 24 FSWs in Guangzhou, China. Informants were recruited using a purposive sampling technique. Qualitative data were coded and analyzed using NVivo 8.0. The majority of respondents were internal economic migrants who had entered the sex industry in pursuit of greater financial reward. Most women in the study were married or had steady boyfriends, and were young, with secondary education and limited knowledge about HIV and STIs. Most were not satisfied with their current living conditions and expressed a desire to leave the sex industry. Women reported that they were more likely to use condoms during sex acts with commercial partners than with non-commercial partners. The potential stigma of being seen as a sex worker prevented many from accessing HIV testing. Three key factors put these FSWs at risk for HIV and STIs: unreasonable trust toward clients, stereotypes and assumptions about customers, and financial incentives.

Conclusions/Significance

These findings suggest that social and economic factors play an important role in shaping sexual decision-making among female sex workers in Guangzhou. We argue that greater insight into and attention to these factors could enhance the success of HIV prevention efforts.     

Female sex worker social networks and STI/HIV prevention in South China

Background

Reducing harm associated with selling and purchasing sex is an important public health priority in China, yet there are few examples of sustainable, successful programs to promote sexual health among female sex workers. The limited civil society and scope of nongovernmental organizations circumscribe the local capacity of female sex workers to collectively organize, advocate for their rights, and implement STI/HIV prevention programs. The purpose of this study was to examine social networks among low-income female sex workers in South China to determine their potential for sexual health promotion.

Methods/Principal Findings

Semi-structured interviews with 34 low-income female sex workers and 28 health outreach members were used to examine how social relationships affected condom use and negotiation, STI/HIV testing and health-seeking behaviors, and dealing with violent clients. These data suggested that sex worker''s laoxiang (hometown social connections) were more powerful than relationships between women selling sex at the same venue in establishing the terms and risk of commercial sex. Female sex workers from the same hometown often migrated to the city with their laoxiang and these social connections fulfilled many of the functions of nongovernmental organizations, including collective mobilization, condom promotion, violence mitigation, and promotion of health-seeking behaviors. Outreach members observed that sex workers accompanied by their laoxiang were often more willing to accept STI/HIV testing and trust local sexual health services.

Conclusions/Significance

Organizing STI/HIV prevention services around an explicitly defined laoxiang social network may provide a strong foundation for sex worker health programs. Further research on dyadic interpersonal relationships between female sex workers, group dynamics and norm establishment, and the social network characteristics are needed.     

Factors Associated with Risky Sexual Practices among Female Sex Workers in Karnataka,India

Introduction

The objectives of this study are to develop a summary measure of risky sexual practice and examine the factors associated with this among female sex workers (FSWs) in Karnataka, India.

Materials and Methods

Data were drawn from special behavioral surveys (SBS) conducted in 2007 among 577 FSWs in two districts of Karnataka, India: Belgaum and Bangalore. FSWs were recruited using the two-stage probability sampling design. FSWs'' sexual practice was considered risky if they reported inconsistent condom use with any sexual partner and reported experience of one of the following vulnerabilities to HIV risk: anal sex, alcohol consumption prior to sex and concurrent sexual relationships.

Results

About 51% of FSWs had engaged in risky sexual practice. The odds of engaging in risky sex were higher among FSWs who were older (35+ years) than younger (18–25 years) (58% vs. 45%, Adjusted Odds Ratio (AOR): 2.0, 95% confidence interval (CI): 1.2–3.4), who were currently married than never married (61% vs. 51%, AOR: 4.8, 95% CI: 2.5–9.3), who were in sex work for 10+ years than those who were in sex work for less than five years (66% vs. 39%, AOR: 2.6, 95% CI: 1.6–4.2), and who had sex with 3+ clients/day than those who had sex with fewer clients (67% vs. 38%, AOR: 3.7, 95% CI:2.5–5.5).

Conclusion

FSWs who are older, currently married, practicing sex work for longer duration and with higher clientele were more likely to engage in risky sexual practices. HIV prevention programs should develop strategies to reach these most-at risk group of FSWs to optimize the effectiveness of such programs.     

Women's lives and sex: Implications for AIDS prevention

Preliminary findings from the Women and AIDS program, a research grants program of the International Center for Research on Women in Washington, D.C. that supports 17 studies in developing countries worldwide, provide a glimpse into the complex interaction between women's social and economic status and risk of HIV infection. In many settings, the cultural norms that demand sexual fidelity and docile and acquiescent sexual behavior among women permit — and sometimes even encourage —early sexual experimentation, multiple partnerships, and aggressive and dominating sexual behavior among men. Drawing upon the findings from the program, the paper analyzes how such cultural norms, together with women's social and economic dependency, can limit a woman's ability to negotiate safer sex with her partner; restrict her access to information and knowledge about her body; force her to sometimes barter sex for survival; increase her vulnerability to physical violence in sexual interaction; and compromise her self-esteem. The findings highlight the limitations of the current HIV/AIDS prevention strategy for reducing women's risk of HIV, and underline the urgency for an approach to prevention that is grounded in the realities of women's lives and sexual experiences — an approach that recognizes the relationship between the dynamics of gender relations, sexual behavior, and HIV risk.     

Effects of public health educational campaigns and the role of sex workers on the spread of HIV/AIDS among heterosexuals

This paper presents a sex-structured model for heterosexual transmission of HIV/AIDS in which the population is divided into three subgroups: susceptibles, infectives and AIDS cases. The subgroups are further divided into two classes, consisting of individuals involved in high-risk sexual activities and individuals involved in low-risk sexual activities. The model considers the movement of individuals from high to low sexual activity groups as a result of public health educational campaigns. Thus, in this case public health educational campaigns are resulting in the split of the population into risk groups. The equilibrium and epidemic threshold, which is known as the basic reproductive number (R0), are obtained, and stability (local and global) of the disease-free equilibrium is investigated. The model is extended to incorporate sex workers, and their role in the spread of HIV/AIDS in settings with heterosexual transmission is explored. Comprehensive analytic and numerical techniques are employed in assessing the possible community benefits of public health educational campaigns in controlling HIV/AIDS. From the study, we conclude that the presence of sex workers enlarges the epidemic threshold R0, thus fuels the epidemic among the heterosexuals, and that public health educational campaigns among the high-risk heterosexual population reduces R0, thus can help slow or eradicate the epidemic.     

Core groups and the transmission of HIV: learning from male sex workers

A growing and substantial body of research suggests that female sex workers play a disproportionately large role in the transmission of HIV in many parts of the world, and they are often referred to as core groups by epidemiologists, mathematical modellers, clinicians and policymakers. Male sex workers, by contrast, have received little attention and it is not known whether it is helpful to conceptualize them as a core group. This paper draws upon ethnographic research documenting social and sexual networks in London and looks at the position of five male sex workers within a network comprising 193 men and seven women (as well as 1378 anonymous sexual contacts and 780 commercial contacts). In so doing, it suggests that there is no evidence to show that male sex workers are more or less likely to acquire or transmit HIV in the course of commercial sex compared with other types of sexual relationships. In addition, men engaging in non-commercial sex all reported having unprotected sex in a variety of contexts and relationships and there is no evidence to suggest that men who are not sex workers play less of a role in the transmission of HIV. In short, these data suggest that it would be inappropriate to conceptualize male sex workers as a core group. This is not to suggest that public policy should continue to overlook male sex workers. New and inventive approaches are required to reach out to a vulnerable but diverse group of men, selling sex for a variety of reasons; even if these men are no more vulnerable to acquiring and/or transmitting HIV than other men and women that form part of their network.     

"She drank his money": survival sex and the problem of violence in taverns in Gauteng province,South Africa

This article examines the practice of "survival sex" in the taverns of Soweto and Hammanskraal area, South Africa. Women who engage in survival sex do not self-identify as commercial sex workers, and the community does not identify them as such. Those who structure HIV prevention programs should not confound such women with commercial sex workers, because effective intervention may vary between the two groups. Violence against women who engage in survival sex in taverns is common, as it is argued that, when a woman accepts beer from a man, she is obliged to exchange sex (because she has "drunk his money"). The South African government should prioritize the reduction of violence as a way to reduce HIV transmission, as, in the context of violence, women do not have the option of negotiating safer sex.     

Prostitution and risk of HIV: male partners of female prostitutes.

OBJECTIVE--To describe risk behaviours for infection with HIV in male sexual partners of female prostitutes. DESIGN--A cross sectional study. SETTING--Genitourinary medicine clinic, St Mary''s Hospital, London. SUBJECTS--112 self identified male sexual partners of female prostitutes: 101 who reported commercial sexual relationships only, five who reported non-commercial relationships only, and six who reported both commercial and non-commercial relationships. MAIN OUTCOME MEASURES--Reported risk behaviours for infection with HIV. RESULTS--Of the 40 men who had had previous HIV tests or were tested during the study, two (5%) were infected with HIV. Of the men who would answer the questions, 34/94 reported having sex with other men, 2/105 reported using injected drugs, 8/105 had a history of blood transfusion, 14/108 reported a past history of gonorrhoea, 44/102 reported paying for sex abroad, and 8/92 said that they had also been paid for sex. Of the 55 men who reported paying for vaginal intercourse in the past year, 45 (82%) said that they had always used a condom. In contrast, of the 11 non-paying partners of prostitutes, only two (18%) reported ever using a condom with their partners. CONCLUSIONS--Men who have sex with female prostitutes cannot be assumed to be at risk of infection with HIV only by this route: homosexual contact may place them at greater risk. Despite the heterogeneity among male sexual partners of prostitutes, patterns of use of condoms were uniform when they were considered as a reflection of the type of relationship a man had with a female prostitute rather than a consequence of an individual''s level of risk.     

Profile of an HIV Testing and Counseling Unit in Bangladesh: Majority of New Diagnoses among Returning Migrant Workers and Spouses

Introduction

Analysis of data from HIV testing and counseling (HTC) services provides an opportunity to identify important populations for targeting of HIV prevention efforts. Our primary aim was to describe the demographics of clients presenting to HTC in Bangladesh, a low HIV prevalence country. Our secondary aim was to determine the risk factors for HIV positivity among returning migrant workers who were tested.

Methods

We performed a cross-sectional study of data collected between 2002 and 2010 from the first HTC service established in Bangladesh, located in three large cities.

Results

8973 individuals attended HTC services, with 558 (6.2%) of clients testing positive for HIV, including 33 children. The majority of those who tested positive were aged 25–44 (71%), male (70%), and married (68%). Key populations considered at increased risk of HIV, such as female sex workers, people who inject drugs, and males who have sex with males accounted for only 11% of adults who tested positive. Notably, 75% of adults testing positive had a history of migrant work or was the spouse of a migrant worker. In multivariable logistic regression of those with a migrant work history presenting for HTC, we found rural residence, working in the Middle East, and longer duration of migrant work to be independently associated with testing positive, and female gender and higher level of education to be negatively associated.

Conclusions

These data suggest that in Bangladesh, in addition to targeting traditional key populations, HIV prevention efforts should also focus on migrant workers and their spouses.     

High risk populations and HIV-1 infection in China

China is currently experiencing one of the most rapidly expanding HIV epidemics in the world. Although the overall prevalence rate is still low, with a population of 1.3 billion, high-risk factors which have contributed to the HIV/AIDS epidemics worldwide continue to prevail in China, including a high rate of injecting drug use and needle sharing, commercial sex with low rates of condom use, and concurrent sex with both commercial sex workers and non-commercial casual or steady sex partners. In addition, there are increasing "double risk" populations overlapping drug users and sex workers, as well as increasing rates of STDs and HIV among high-risk populations. Sexual transmission, therefore, may serve as a bridge connecting high-risk populations with general populations. There is an urgent need to prevent the spread of HIV from these high-risk populations into the general population of China.     

Creating a new drug service in Edinburgh.

After one year Edinburgh''s Community Drug Problem Service has shown that if psychiatric services offer consultation and regular support for drug users many general practitioners will share the care of such patients and prescribe for them, under contract conditions, whether the key worker is a community psychiatric nurse or a drug worker from a voluntary agency. This seems to apply whether the prescribing is part of a "harm reduction" strategy over a long period or whether it is a short period of methadone substitution treatment. Given the 50% prevalence of HIV infection among drug users in the Edinburgh area and the fact that only half of them have been tested for seropositivity, the health and care of this demanding group of young people with a chaotic lifestyle are better shared among primary care, community based drug workers, and specialist community drugs team than treated exclusively by a centralised hospital drug dependency unit. As the progression to AIDS is predictable in a larger proportion of drug users who are positive for HIV, there is an even greater need for coordinated care between specialists and community agencies in the near future.     

Factors Associated with Inconsistent Condom Use among Men Who Have Sex with Men in Cambodia

Background

Compared to the general population, men who have sex with men (MSM) are at greater risk for HIV and less understood due to their more hidden and stigmatized nature. Moreover, the discrepancy in findings in the literature merits further investigations in MSM populations from different cultures and settings. We therefore conducted this study to explore factors associated with inconsistent condom use among high-risk MSM in Cambodia.

Methods

This cross-sectional study was conducted in 2014 among 367 MSM randomly selected from Battembang and Siem Reap using a two-stage cluster sampling method. A structured questionnaire was used for face-to-face interviews to collect information on characteristics of respondents, HIV testing history, self-perception of HIV risk, substance use, sexual behaviors, mental disorders, and HIV knowledge. Multivariable logistic regression analysis was performed to identify factors independently associated with inconsistent condom use.

Results

On average, 62.3% of respondents reported that they always used condoms over the past three months. The rates varied with types of sexual partners; the proportion of respondents who reported always using condoms was 55.1%, 64.2%, 75.9%, 73.0%, 78.1%, and 70.3%, for sexual partners who were girlfriends, boyfriends, female sex workers, male sex workers, female clients, or male clients, respectively. After adjustment, inconsistent condom use was significantly associated with age of ≥25 (AOR = 1.77, 95% CI = 1.09–2.86), self-rated quality of life as good or very good (AOR = 4.37, 95% CI = 1.79–5.67), self-perception of higher HIV risk compared to the general population (AOR = 2.37, 95% CI = 1.35–4.17), illicit drug use in the past three months (AOR = 5.76, 95% CI = 1.65–10.09), and reported consistent lubricant use when selling anal sex to men in the past three months (AOR = 2.85, 95% CI = 1.07–8.12).

Conclusions

We found risky sexual behaviors to be considerably high among MSM in this study, especially among those who used illicit drugs or were older than 25. HIV education and social marketing should be expanded and specifically designed for MSM to better educate on the increased risk of HIV with unprotected anal sex and illicit drug use as risk factors, and the importance of the use of both condoms and lubricant during anal intercourse.