Background: Despite high rates of human immunodeficiency virus/sexually transmitted infection (HIV/STI) among commercial sex workers and international concern that male clients may constitute a critical bridge population for HIV/STI transmission, little empirical data exist within the United States to characterize men who purchase sex or to assess their sexual risk and HIV/STI infection.
Methods: The study involves the analysis of a community-based survey of men aged 18-35 years attending urban health centers (n = 1515) to assess the prevalence of engagement in sex purchasing during the past year and to evaluate relations with self-reported HIV/STI diagnosis and symptoms across this same period.
Results: More than 1 in 12 (8.7%) men reported exchanging drugs, money, or a place to stay for sex with a female partner in the past year. Such behavior was associated with additional sexual risk taking and emerged as an independent predictor of self-reported HIV/STI diagnosis [adjusted odds ratio (ORadj) = 2.99; 95% confidence interval (CI): 1.51 to 5.94] and STI symptoms (ORadj = 2.57; 95% CI: 1.57 to 4.22) in the past year in analyses adjusted for alternate HIV/STI risk sources.
Conclusions: Sex purchasing is a common form of HIV/STI risk among the population sampled. Men engaging in such behavior are more likely to be HIV/STI infected and, thus, represent a risk to the sexual health of both commercial and noncommercial sex partners. Further research is needed to inform interventions targeted toward male clients of prostituted women.
From the *Department of Society, Human Development and Health, Harvard School of Public Health, Boston, MA; †Department of Social and Behavioral Sciences, Boston University of Public Health, Boston, MA; and ‡Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT.
Received for publication November 20, 2007; accepted March 27, 2008.
Correspondence to: Michele R. Decker, ScD, Department of Society, Human Development and Health, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA (e-mail: email@example.com).
Heterosexual commercial sex involving male clients and prostituted women and girls is widely recognized for its role in the spread of the human immunodeficiency virus (HIV) epidemic in developing nations.1-3 Research devoted to this topic has predominantly focused on female sex workers, with findings of extensive sexual risk in this context and high rates of human immunodeficiency virus/sexually transmitted infection (HIV/STI).4,5 In contrast, male clients have remained largely invisible within research and programmatic efforts to stem spread of HIV/STI. A small but growing body of research in nations facing commercial sex-driven HIV epidemics demonstrates high rates of inconsistent condom use,6-12 concurrent sexual partnering,6,13 and HIV/STI infection3,4,6 among male clients of prostituted women.
This body of work has prompted increasing recognition of male clients as a critical bridge population by which infection may spread to both commercial and noncommercial (eg, wives and steady female partners) sex partners.1,6,13,14 Such studies have also served to highlight the need for investigation of men's patterns of commercial sex involvement to inform efforts to contain the spread of HIV/STI from high-risk individuals to the general population. For example, recent population-based evidence points to a rapid rise in British men's commercial sex contacts15 and elevated HIV/STI rates based on such behavior in this setting.15,16 Thus, investigation of men's sex purchasing patterns beyond the developing nations on which it initially focused is needed.
Despite investigations of US women involved in prostitution,17-19 including a recent population-based study demonstrating a 9% prevalence of sex work among young women,20 little research devoted to male clients has been conducted to date in US settings. That which has been conducted has focused solely on Hispanic migrants, with findings of extensive sex purchasing behavior among migrants during their stay in the United States.21-23 Currently, no empirical data exist to examine the prevalence of men's commercial sex involvement and its associations with HIV/STI among broader US populations as needed to assess its role in the domestic HIV/STI epidemic. Such investigation is particularly critical among populations facing the greatest HIV/STI risk, for example, young, low-income, urban men of color,24-28 to assess, understand, and, if indicated, intervene in men's commercial sex behavior in an effort to contain the spread of HIV/STI within the US.
To begin to address this gap, the current study assesses (1) the past-year prevalence of sex purchasing; (2) demographic and sexual risk correlates of sex purchasing; and (3) associations of sex purchasing with self-reported HIV/STI diagnosis and symptoms among an urban sample of young adult men.
The current study utilizes data collected between January 2005 and December 2006 via an anonymous, cross-sectional survey conducted in collaboration with 3 urban community health centers (CHCs) in Boston serving primarily low-income and minority populations. At each CHC, all English-, Spanish-, or Portuguese-speaking men presenting to the main reception desk (at which all patients check-in for care) were screened for age eligibility (ages 18-35 years) by trained research staff with fluency in these languages. Eligible men indicating an interest in participation were escorted to a private area of the CHC, where verbal consent was obtained to preserve participant anonymity. The survey was administered via an audio computer-assisted survey instrument, a self-administered computer program that allows respondents to listen to the questions aloud via headphones and enter responses directly into a laptop. Upon completion of the 30-minute survey, participants received a list of local social support services and a $20 prepaid debit card as compensation for their time. All study materials were available in English, Spanish, and Portuguese. Of the 3430 men approached for the study, 2229 agreed to participate (65% participation rate). Of the 1711 men (77%) who indicated ever having sexual intercourse, 1515 (89%) reported sexual activity within the past year and provided complete data concerning history of commercial sex purchasing; present analyses are limited to these 1515 participants.
All items were self-reported. Past-year history of commercial sex purchasing was assessed via a single item “Have you given drugs, money or a place to stay in exchange for sex with a girl or woman in the past year?” A single item also assessed participants' HIV/STI diagnosis history, specifically “Have you ever been told by a medical professional that you have a sexually transmitted disease (chlamydia, herpes, gonorrhea, HIV, genital warts)?,” with a follow-up question pertaining to such diagnosis within the past year. With recognition of high risk for undiagnosed STI among young men,29 a secondary measure of past-year STI was also used, consisting of 5 common STI symptoms, “burning when you urinate or pee,” “discharge from your penis,” “warts or pimples around penis or scrotum,” “warts or pimples around anus,” and “open sores on penis or scrotum.” Participants endorsing any of the 5 items were classified as past-year STI symptomatic. Although limited in precision, syndromic assessment of STI tempers the potential confounding introduced by reliance on clinical STI test results,29 as individuals may seek such testing based on risk perception.30 Covariates assessed included demographics (age, race, Hispanic ethnicity, nativity, education, and relationship status) and additional sexual risk behaviors (past-year multiple partnering and past-year concurrent sexual partnering); all were assessed via single items. To reduce ambiguity regarding men's role in condom nonuse, the current study assessed men's unwillingness to use a condom in the past year, defined as participant indication via a single item that they had “made a girl/woman have sex without a condom when she wanted to use one” in the 12 months before the survey.
Prevalence estimates were calculated for past-year commercial sex purchasing for the total sample and by demographic factors and sexual risk behaviors. Differences in sex purchasing behaviors based on these factors were assessed via χ2 test; significance for all analyses was set at P < 0.05. Prevalence estimates were calculated for past-year HIV/STI diagnosis and STI symptoms for the sample and by past-year history of commercial sex purchasing. Adjusted logistic regression models were constructed to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the associations of past-year commercial sex purchasing with HIV/STI diagnosis and STI symptoms in the past year using respondents indicating no past-year commercial sex purchasing as the referent group. Logistic regression models were adjusted for age, race, Hispanic ethnicity, relationship status, multiple past-year sex partners, unwillingness to use condoms in the past year, and recent concurrent sexual partnering. All statistical analyses were conducted using SAS Version 9.
Past-Year Prevalence of Sex Purchasing and Associations With Demographics and Sexual Risk Behaviors
Approximately 1 in 12 (8.7%) participants traded drugs, money, or a place to stay in exchange for sex with a female partner in the past year (Table 1). A χ2 test revealed several differences in the past-year prevalence of this behavior based on demographic characteristics and sexual risk factors. The oldest participants were most likely to report engagement in commercial sex purchasing, with 12.6% of men in the 29- to 35-year age category purchasing sex in the past year (P < 0.001). Racial/ethnic differences were detected in past-year sex purchasing with non-Hispanic Black men demonstrating the highest prevalence of past-year commercial sex contact (11.2%; P = 0.006). Immigrant men were less likely than nonimmigrant men to report commercial sex purchasing in the past year (5.5% vs 9.8%, P = 0.008). No differences in past-year sex purchasing were detected based on education level or current relationship status. Sex purchasing was strongly associated with other sexual risk behavior; men with a recent history of multiple sex partnering (6 or more partners in the past year) were more likely to purchase sex in the past year relative to those with fewer sexual partners during this period (18.0% vs 6.5%, P < 0.001). Similarly, men indicating unwillingness to use a condom and concurrent sexual partnering within the past year were more likely to engage in commercial sex than those not indicating such behavior (39.0% vs 5.4%, P < 0.001; and 17.7% vs 3.7%, P < 0.001, respectively).
Past-Year HIV/STI History and Symptoms and Relations With Sex Purchasing
Across the total sample, 4.1% of participants self-reported an HIV/STI diagnosis within the past year, and 11.3% reported STI symptoms during this same period (Table 2). The χ2 tests revealed differences in HIV/STI diagnosis and symptoms based on past-year commercial sex purchasing behavior. HIV/STI diagnosis in the past year was reported by 16.8% of men with a past-year sex purchasing history compared with 2.9% of men not reporting this behavior (P < 0.001). Such men were also more likely to report recent STI symptoms; just under one third (31.8%) of men who had purchased sex in the past year reported STI symptoms during this timeframe, as compared with only 9.3% of nonpurchasing men (P < 0.001).
Logistic regression analyses adjusted for demographic factors (age, race/ethnicity, immigrant status, relationship status, and education) and past-year sexual risk behavior (multiple partnering, unwillingness to use a condom, and concurrent sex partnering) demonstrated that men's sex purchasing in the past year was a significant independent predictor of HIV/STI diagnosis within the past year (AOR = 2.99; 95% CI: 1.51 to 5.94). Such behavior also emerged as a significant independent predictor of STI symptoms within the past year (AOR = 2.57; 95% CI: 1.57 to 4.22).
Findings from this first US-based investigation of sex purchasing among young, low-income, urban men (a population facing high HIV/STI risk24-28) indicate that more than 1 in 12 men purchased sex from prostituted women and girls in the past year and that men engaging in sex purchasing within the past year were over twice as likely to report HIV/STI diagnosis and symptoms after accounting for alternate HIV/STI risk sources. Men's past-year sex purchasing was also strongly associated with other sexual risk behaviors, presenting clear mechanisms for the contraction and continued transmission of HIV/STI (ie, unwillingness to use condoms and multiple and concurrent sexual partnering in the context of sex purchasing likely facilitate men's infection and spread of HIV/STI). Given these findings and a prevalence exceeding that estimated for other HIV risk behaviors such as injection drug use,31 the current lack of attention to men's sex purchasing behavior may constitute a critical gap in US HIV/STI prevention and intervention efforts.
Current findings are consistent with prior reports across the international literature demonstrating higher rates of both sexual risk behavior and HIV/STI based on men's reports of commercial sex involvement.3,4,7-11,15,16 Thus, the present study adds to the growing body of work indicating that men who seek sex with prostituted women and girls should be considered a high-risk population, given the heightened risk they pose for the spread of HIV/STI to both commercial and noncommercial sex partners (ie, “bridging”). The implications of the current findings are particularly relevant, as the current sample of largely non-Hispanic Black and Hispanic urban young adult men represents demographics of those at highest infection risk within the US HIV/STI epidemic.24-28
Findings provide a basis for future work to clarify appropriate HIV/STI intervention approaches and components targeted to men seeking commercial sex. Current evidence of elevated HIV/STI risk based on men's past-year sex purchasing after accounting for sexual risk sources most often targeted via existing prevention efforts indicates unique HIV/STI risk based on this behavior and suggests the need for specifically addressing men's commercial sex contact within HIV/STI prevention efforts. Currently, no documented programs exist within the United States to address this understudied form of men's sexual risk or to reduce men's sexual risk behavior within this context.
Further qualitative and quantitative investigation is required to understand the mechanisms underpinning the currently identified associations. The high HIV/STI risk consistently demonstrated among women engaged in commercial sex4,5,20,32 suggests that men's elevated HIV/STI prevalence based on their commercial sex involvement may result from higher exposure to infection. Qualitatively unique aspects of commercial sex contacts must also be considered. Prostituted women consistently report forced and coerced sex within prostitution,17,19,33 and clients often expect, demand, and offer more money for unprotected sex,11,34,35 suggesting that men's sexual coercion and violence in this context may also serve a role in facilitating transmission of HIV/STI and thus pose risk to both prostituted women and male clients. This hypothesis is supported by the current finding that men who purchase sex are more likely to be unwilling to use a condom.
Finally, given growing recognition of the role of men's demand for commercial sex in promoting trafficking of women and girls into prostitution,36-38 current findings echo recent calls for greater programmatic and research attention to this high-risk group of men.1,3,13,36-38 Such efforts have the potential of both reducing the transmission of HIV/STI and protecting women and girls from sexual exploitation.
The present findings should be considered in light of several limitations. Cross-sectional analyses do not allow us to determine the relative chronology of sex purchasing in relation to HIV/STI diagnosis and symptoms; however, past-year time periods were selected to maximize the likelihood of their co-occurrence. Longitudinal and qualitative research is needed to clarify the causal and temporal relations among sex purchasing, sexual risk, and HIV/STI infection. All measures were self-reported; measurement error resulting from self-report may have limited the precision of the present estimates. The current assessment of men's sex purchasing was broad; further research may benefit from increased clarity regarding the sex trade currency (ie, sex in exchange for drugs vs money vs other goods). To specify men's role in condom nonuse, the current study utilized a measure of men's unwillingness to use a condom; subsequent studies should assess associations of sex purchasing with additional forms of male-driven HIV/STI risk. Although the current use of a general clinic-based population sample allows for greater generalizability of findings as compared with investigations situated within HIV/STI clinics, such a setting limits the availability of clinical HIV/STI diagnosis assessments. The use of the syndromic assessment, although limited in empirical strength and precision compared with clinical indicators, is included to temper the potential confounding introduced by reliance on self-reported HIV/STI testing results,29 as individuals may seek testing based on perception of risk,30 whereas the syndromic assessment, although imprecise, is likely less sensitive to this potential bias. Further work is needed to assess generalizability of findings obtained from CHCs serving predominantly low-income clients to those representing a broader range of socioeconomic status.
A high level of sex purchasing was identified among the young urban adult men in the current sample, with 1 in 12 men engaging in such behavior over the past year and increased risk of HIV/STI diagnosis and symptoms based on men's transactional sex with women and girls. Given increasing recognition of the role of men's risky sexual behavior in posing HIV/STI risk to their female partners,39,40 and in light of concentration of the US HIV/STI epidemic among young, low-income urban men and women,24,27 the present findings indicate an urgent need to prioritize etiological research to describe and understand the motivations of men engaging in sex purchasing and to develop HIV/STI prevention efforts targeting this understudied form of men's sexual risk.
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