Gay bathhouses and sex clubs (hereafter, simply “clubs”) have contributed to and served as sites for HIV prevention from the early days of the AIDS epidemic,1-3 and they continue to do so without deleterious effects on their businesses.4,5 Although data from probability samples of men leaving clubs show that risk behavior inside the clubs themselves is atypical,6-9 clubs do attract men who engage in such behavior. High-risk men who have sex with men (MSM) are more likely than their peers to go to clubs,10 and more than half of all nontesting high-risk MSM go to clubs.11 Clubs are an ideal environment in which to target this otherwise hard-to-reach population with appropriate prevention interventions. Recent research has focused on the challenges of implementing HIV testing programs in clubs,12-15 whereas other studies have shown that men at clubs will avail themselves for testing when it is available on site7,16-18 and that such in-club testing has been associated with a reduced risk behavior for more than a 3-month period.19,20 The scientific literature indicates a wide range of HIV prevention programs, and services have been initiated in clubs to try to reach men at risk with important HIV prevention services and information.4,7,14,16-21 To determine the extent to which HIV prevention is implemented in clubs across the United States, we interviewed club managers. This article presents the findings from that study.
The study population included all clubs operating in the United States and listed in the Damron Men's Travel Guide 2004 (a gay resource directory for the United States) or www.cruisingforsex.com (at the time, the most comprehensive Web listing of places for men to meet men for sex). Lists of establishments in these resources were inclusive of a variety of places where men meet for sex. We operationally defined a club as any listed business that provided a space where anonymous sex was permitted between male patrons, that had a permanent location, and that operated at least 3 days a week.
Managers of these clubs served as key informants, providing data about the clubs they manage. To recruit these managers, we followed procedures used in a similar survey of clubs conducted from October 1996 to February 1997.4 A letter introducing the study was addressed to the general manager of each club and mailed at least a week before the initial telephone contact; attempts to complete direct contact with a club owner or manager followed and continued until a representative of the club verbally declined study participation. During the subsequent initial direct contact, the interviewer described the study, answered any questions, and determined whether the general manager or whether someone else (eg, a manager who oversees the HIV prevention activities at the club) should be the respondent. Participation was voluntary, and the participants gave verbal consent. The telephone interview lasted from 1.5 to 2.5 hours. Interviewers used a computer-assisted telephone interview system. The questionnaire was developed from the formative work on HIV prevention services in clubs in New York, Los Angeles, and San Francisco and was reviewed in advance by 3 club managers. The interview included items requesting detailed data about the specific club's size and amenities, its rules and regulations, its prevention programs (including education and information, condom and lube distribution, and on-site testing programs for HIV/sexually transmitted infection), and the barriers to and facilitators for providing HIV testing services. All procedures and protocols were approved by the Institutional Review Board at the University of California, San Francisco.
We identified 94 gay sex establishments in the United States, of which 77 met the eligibility criteria (ie, provided space where sex was permitted, had a permanent location, and operated at least 3 days a week). We completed interviews with representatives of 53 clubs, a response rate of 70.1%.
These businesses used various terms to describe themselves, including bathhouse (43.4%), health club (34.2%), sex club (13.2%), and sauna (5.7%); the remaining respondents did not know or preferred not to say (2.8%). Clubs varied widely in their size, as indicated by the range in the number of rentable rooms (22-129; mean = 55.0, median = 55.0) and lockers (34-400; mean = 127.6, median = 100.0), although 1 club offered neither rooms nor lockers to rent. In general, clubs that offered rooms to rent were larger, and the more rooms and lockers available to rent, the larger the club.
About half the venues (50.9%) permitted sexual behavior among patrons in the public areas; 22 (81.5%) of these 27 clubs purposely kept the lighting levels lower in the public areas intended for sex. About 4 (41.5%) in 10 clubs had rules about safer sex (eg, it was the only type of sex permitted inside the club), and most of those (77.3%) asked patrons to agree in writing to follow the rules, usually at each visit (68.4%). All clubs had rules prohibiting the use of drugs (including alcohol), and a majority (60.4%) did a bag check at entry. A few clubs (6.3%) prohibited on-premise use of “poppers” (ie, alkyl nitrites, inhaled for recreational purposes), but more than half (56.6%) sold them. Methamphetamines and alcohol were most frequently reported as the substances causing the largest problem at a club (29.9% and 16.1%, respectively).
More than half of the clubs (58.5%) had a designated employee responsible for oversight of club prevention activities, with about a quarter of these employees (25.9%) dedicating 50% or more of their work time to managing prevention activities. Table 1 summarizes the range of prevention activities and the proportion of clubs engaging in each prevention activity. All the venues made free condoms available to all patrons, and nearly all displayed educational posters in public areas and had informational pamphlets available for patrons; a few clubs also offered other outreach services, but special events that focused on risk reduction and counseling services were not as prevalent. Almost all the clubs promoted HIV testing (at a minimum, providing information about where to get tested), and 40 of 53 offered HIV testing on site (ie, inside the “paid” area of the club).
Of the clubs offering on-site HIV testing, 14 had more than 1 group providing testing at the club; 7 clubs had 2 different groups offering testing, 3 clubs had 3 groups, and 4 clubs had 4 groups. Table 2 summarizes key features of the 65 testing programs implemented inside the 40 clubs that offered testing on site. Those programs had been offering testing on average for 5.6 years (median = 4.5 years; range ≤1-25 years). At the time of the study, they operated on average 3.7 days a month (median = 4.0 days, range = 1-12 days), constituting 13.6 hours of testing (median = 12.0 hours, range = 2-48 hours), serving 26.4 clients per month (median = 16.0, range = 2-100). Of the 62 programs that offered HIV testing, 37 (59.7%) delivered test results inside the club, and of those, 10 (27.0%) delivered results solely inside the club. Of the 41 programs (63.1%) that offered testing for sexually transmitted infection, 20 (48.8%) delivered results inside the club.
Clubs across the United States continue to provide a wide range of HIV prevention efforts. Rather than resist HIV prevention,22 club managers seemed to promote and engage actively in it. Our telephone survey found that most clubs have assigned a specific employee to manage prevention activities and that on-site testing programs were more likely to have been initiated by the clubs themselves than by any other single group of stakeholders. Although condom and information distribution remain the primary prevention activities, many clubs reported additional prevention efforts, including outreach programs, counseling services, and special events that focused on HIV prevention and testing. In fact, when compared with a similar study conducted in 1996-1997,4 the percentage of clubs offering HIV testing programs has almost doubled.
The data presented described the extent to which prevention programs were offered in clubs across the country. Further research is needed to determine the efficacy of prevention activities (such as where condoms are distributed in the club), to develop best-practices standards for service programs (such as on-site HIV testing), and to identify the facilitators that lead clubs to engage in prevention and the barriers that stifle such engagement. Providing answers to these questions can help direct future prevention efforts by focusing resources on effective programs and assisting public health officials and service providers in exploiting facilitators and minimizing barriers for clubs to engage in prevention. Although local jurisdictions have instituted many different policies to establish particular approaches to prevention in clubs, little or no research has been conducted to determine whether any of them are effective or more appropriate than other approaches.23 Studies of how these policies alter club environments in ways that might decrease risk behavior (eg, always using a condom for anal sex) or increase protective behavior (eg, testing by high-risk MSM) are required to better understand how these environments can facilitate prevention efforts that will reach the highest-risk segment of the MSM population.
The following limitations should be kept in mind when interpreting the results of this study. All data were provided by 1 key informant at each site, without any observational or secondary source verification. It is possible that different information may have been provided had a different key informant been interviewed. It also is possible that we received refusals from clubs that were not providing prevention efforts. Finally, the information on HIV testing programs is limited, as the program providers were not interviewed.
In summary, nearly all the businesses engaged in HIV education and prevention. We found that free condom distribution was a universal characteristic of prevention in clubs, followed closely by such educational efforts as posters and pamphlets. Most clubs provided on-site HIV testing. The absence of studies evaluating these prevention efforts remains a concern and an obstacle for efficient use of the resources. Nevertheless, these data suggest that HIV prevention in clubs is perceived by most managers as a necessary part of doing business. The willingness of these clubs to promote HIV prevention suggests that the business aspect of venues that serve at-risk populations is not necessarily an impediment to intervening in these venues.
The authors acknowledge the club owners and managers, without whose cooperation the survey could not be conducted. They also wish to recognize the efforts of the survey team, specifically Justin Bailey, Paul Cotten, Robert Siedle-Khan, Alberto Curotto, Gabriel Ortiz, and Joseph Morris.
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