Client Demands for Unsafe Sex: The Socioeconomic Risk Environment for HIV Among Street and Off-Street Sex Workers

Deering, Kathleen N. PhD*,†; Lyons, Tara PhD*,†; Feng, Cindy X. PhD; Nosyk, Bohdan PhD*,§; Strathdee, Steffanie A. PhD*,‖; Montaner, Julio S.G. MD*,†; Shannon, Kate PhD*,†,¶

JAIDS Journal of Acquired Immune Deficiency Syndromes:
doi: 10.1097/QAI.0b013e3182968d39
Epidemiology and Prevention
Abstract

Objective: Among sex workers (SWs) in Vancouver, Canada, this study identified social, drug use, sex work, environmental-structural, and client-related factors associated with being offered and accepting more money after clients’ demand for sex without a condom.

Design: Cross-sectional study using baseline (February 2010 to October 2011) data from a longitudinal cohort of 510 SWs.

Methods: A 2-part multivariable regression model was used to identify factors associated with 2 separate outcomes: (1) being offered more money for sex without a condom in the last 6 months; and (2) accepting more money, among those who had been offered more money.

Results: The sample included 490 SWs. In multivariable analysis, being offered more money for sex without a condom was more likely for SWs who used speedballs, had higher average numbers of clients per week, had difficulty accessing condoms, and had clients who visited other SWs. Accepting more money for sex without a condom was more likely for SWs self-reporting as a sexual minority and who had experienced client violence and used crystal methamphetamine less than daily (versus none) and less likely for SWs who solicited mainly indoors for clients (versus outdoor/public places).

Conclusions: These results highlight the high demand for sex without a condom by clients of SWs. HIV prevention efforts should shift responsibility toward clients to reduce offers of more money for unsafe sex. Programs that mitigate the social and economic risk environments of SWs alongside the removal of criminal sanctions on sex work to enable condom use within safer indoor workspaces are urgently required.

Author Information

*BC Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, British Columbia, Canada;

Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada;

School of Public Health, Faculty of Medicine, University of Saskatchewan, Saskatoon, Canada;

§Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada;

Department of Medicine, Faculty of Medicine, University of California, San Diego, CA; and

School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada.

Correspondence to: Kate Shannon, PhD, Department of Medicine, School of Population and Public Health, University of British Columbia and Gender and Sexual Health Initiative, British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard St, Vancouver, BC, Canada V6Z 1Y6 (e-mail: gshi@cfenet.ubc.ca).

Supported by operating grants from the US National Institutes of Health (Grant R01DA028648) and by Canadian Institutes of Health Research Grant HHP-98835. K.N.D. is supported by the Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research. J.S.M. is supported by an Avante Garde award from US NIH (Grant DP1DA026182). K.S. is supported by US NIH (Grant R01DA028648) and the Canadian Institutes of Health Research.

The authors have no conflicts of interest to disclose.

K.N.D. made key contributions to the conceptual and analytic design of the study and drafted the manuscript. T.L., B.N., S.S., and J.S.G.M. made key conceptual contributions and reviewed the manuscript. C.F. performed statistical analysis and reviewed the manuscript. K.S. made key contributions to the conceptual and analytic design of the study and takes responsibility for the accuracy of the data.

Presented at 21st Annual Canadian Conference on HIV Research, April 19–22, 2012, Montreal, Canada, and at XIX International AIDS Conference, July 22–27, 2012, Washington, DC.

Received December 13, 2012

Accepted March 13, 2013

© 2013 by Lippincott Williams & Wilkins