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Epidemiology and Prevention

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*,†,¶

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: August 1, 2013 - Volume 63 - Issue 4 - p 522-531
doi: 10.1097/QAI.0b013e3182968d39
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Abstract

INTRODUCTION

Male condoms decrease the per-contact probability of male-to-female (MTF) transmission of HIV by about 95%.1 Increasing public health calls to focus on the “feminization of the HIV pandemic,” and theoretical work on gender, women, and HIV,2 point to the need for more nuanced analyses of negotiation of male condom use, recognizing the important role of gendered power dynamics. Condom use within commercial sex transactions has typically been framed as the responsibility of sex workers (SWs), with research overwhelmingly aimed toward identifying SWs at high risk for condom nonuse and implementing behavioral interventions (eg, education and counseling) to increase condom use. Influenced by the “risk environment” framework, which conceptualizes that individual HIV risk is mediated by environmental factors exogenous to the individual,3 a growing body of research has acknowledged the importance of structural factors in shaping SWs’ vulnerability to HIV, including poverty and unstable housing, structural violence, and government policies surrounding the regulation of sex work.4–8

In the context of these structural factors, clients of SWs play a substantial and frequently unacknowledged role in determining the use of condoms for the prevention of HIV and other sexually transmitted infections (STIs) within commercial sex transactions. Negotiations for condom use between SWs and clients are situated within the interpersonal social environment of SWs and are influenced by a number of factors exogenous to individual SWs (eg, sex work environment and client-related factors). Client reticence to condom use is widespread, with men resisting condom use even when they are aware they may face their own increased potential risk of acquiring HIV/STIs. Offers to SWs by clients for sex acts without condoms in exchange for financial incentives are common.9–11

Although SWs may face opposition and pressure to not use condoms by clients in the context of structural inequities, it is important to acknowledge SWs’ agency and the complex negotiation process within transactions. SWs often have to make difficult microlevel decisions regarding their health and safety in the face of financial pressures and structural inequities and face pressure to agree to sex without a condom in exchange for a higher fee.9,10 Although most SWs who understand the personal risks would rather use condoms, some SWs may be prepared to make a trade-off in terms of their own health and safety.

Although qualitative research has elucidated the complex relationships between economic incentives related to sex work and risk environments of HIV and violence,10,12,13 quantitative studies are rare and largely focused on SWs who use drugs.9,14 Other studies have focused on economic costs to women when they practice safer sex (eg, the amount women could lose by using condoms) or have presented theoretical economic models describing how compensation for sex work is linked with future health and social costs (eg, stigma, forgone marriage opportunities, social exclusion, risks to health, and safety and well-being).15–18 The objective of our study was, therefore, to identify the associations between social, drug use, sex work, environmental-structural, and client-related factors and being offered and accepting more money after clients’ pressure for sex without a condom among a large sample of SWs in Vancouver, British Columbia. These relationships are examined in the context of Canada’s quasi-criminalized approach to sex work; in most of Canada, including British Columbia, although sex work per se is legal, many of the activities surrounding sex work are criminalized (which apply equally to male, female, and transgender sex workers and include communicating/soliciting for the purposes of prostitution; owning and operating a brothel/bawdy house; and living off the avails of prostitution), making the practice of sex work nearly impossible without breaking laws. To our knowledge, our study is the first to examine these relationships, which are critical in the understanding of how condom nonuse can be addressed in public health interventions.

METHODS

Survey Design and Sample

Beginning in January 2010, youth and adult women (14 years+) were enrolled in a longitudinal cohort known as “An Evaluation of Sex Worker’s Health Access” (AESHA). This study is based on substantial community collaborations (eg, sex work agencies and service providers) existing since 2005 and is monitored by a Community Advisory Board with representatives from 15+ agencies. Using time-location sampling,19 women who exchanged sex for money within the last 30 days (SWs) were recruited through outreach to outdoor sex work locations (ie, streets and alleys), indoor sex work venues (ie, massage parlors, microbrothels, and in-call locations), and independent/self-advertising SWs (eg, online and newspapers) in Metropolitan Vancouver. Our eligibility is inclusive of transgender individuals (MTF) who identify as women, based on our previous work20 and community guidance, because MTF transgender individuals work in similar spaces as the female SW population and access the same services as the female SWs (directed toward self-identifying women and transgender inclusive). Interviews were conducted in places where women felt comfortable (ie, 3 office site locations across Vancouver; within indoor sex work venues). As executed previously, outdoor sex work “strolls” and indoor venues were identified through a participatory mapping exercise conducted with current/former SWs20 and continuously updated by the outreach team. The study holds ethical approval through Providence Health Care/University of British Columbia Research Ethics Board. All participants receive an honorarium of $40CAD at each bi-annual visit for their time, expertise, and travel.

Questionnaires and Measures

Following informed consent, at baseline and each semiannual follow-up visit, participants completed questionnaires by trained interviewers (both SW and non-SW interviewers), which elicited responses relating to sociodemographics, sex work patterns/client experiences, work environments, occupational violence and interactions with policing, characteristics of noncommercial or regular partnerships, violence and trauma, and drug use. Participants also completed a nurse-administered questionnaire that elicited responses relating to overall physical, mental, and emotional health, sexual and reproductive health, and HIV testing and treatment. As part of the nursing visit, SWs were also provided with extensive pre- and posttest counseling, testing for HIV, hepatitis C virus, and STIs, and referral for care and support services. Biolytical INSTI rapid tests were used for HIV screening, with reactive tests confirmed by blood draw for western blot. Urine samples were collected for gonorrhea and chlamydia, and blood was drawn for syphilis, Herpes simplex virus-2 antibody, and hepatitis C virus. Treatment was provided for symptomatic STI infections by an onsite nurse, and free serology and Papanicolaou testing were also available for those in need, regardless of study enrollment.

Outcome

Two outcomes were included: (1) being offered more money for sex without a condom and (2) accepting more money for sex without a condom, by both regular and 1-time clients; both outcomes were assessed in a 6-month timeframe. Participants were considered to have positive (yes) responses for each outcome if their responses included “always,” “usually,” “often,” and “sometimes,” as opposed to “never” (no). The outcome variables were dichotomized because, conceptually, women who reported being offered or accepting more money more frequently than never could potentially be exposed to HIV/STIs.

Explanatory Variables

The relationships between the study outcomes and a number of explanatory variables were explored. All factors were self-reported, and most factors, with the exception of age, sexual minority status, and ethnicity, were reported on for the last 6 months. Table 1 provides a full list of explanatory variables. These included individual-level variables that capture effects within the social environment. For example, these include age, reporting being a sexual minority (lesbian, gay, bisexual, transgender, transsexual, 2-spirit versus heterosexual, and nontransgender), and ethnicity (Indigenous/Aboriginal ancestry, including First Nations and Métis, Inuit and visible minority, primarily comprised of Asian new immigrant/migrant SWs, versus Caucasian/white). These also included drug use and sex work-related factors (eg, noninjection and injection drug use; exchanging sex while high), client-related factors (eg, violence by clients), and environmental-structural variables [eg, main place of soliciting for clients (independent, including self-advertised, online, phone/texting; indoor, including bars, brothels, massage/beauty parlors, dance/strip clubs; versus outdoor/public, including streets and outdoor public spaces)].

T1-17
TABLE 1-a:
Social, Drug Use, Sex Work, Structural-Environmental, and Client-Related Factors of SWs in Vancouver, Canada, According to Whether or Not They Were Offered More Money for Sex Without a Condom
T2-17
TABLE 1-b:
Social, Drug Use, Sex Work, Structural-Environmental, and Client-Related Factors of SWs in Vancouver, Canada, According to Whether or Not They Were Offered More Money for Sex Without a Condom

Analysis

In bivariate analysis, categorical variables were compared using the χ2 test and the Fisher exact test, whereas continuous variables were compared using Wilcoxon rank-sum test. A 2-part modeling approach was used. First, using multivariable logistic regression, we fitted an explanatory model for the relationship between the explanatory variables and the outcome “being offered more money for sex without a condom.” Then, for SWs who had been offered more money for sex without a condom, we fitted a multivariable logistic regression explanatory model for the relationship between the explanatory variables and the outcome “accepting more money for sex without a condom.” Odds ratios (ORs), adjusted odds ratios (AOR), and 95% confidence intervals (95% CIs) were presented. As in previous research,21,22 a backward stepwise technique was used in the selection of covariates for an explanatory model. This modeling approach is well-suited for understanding which factors/explanatory variables best explain a high probability of our outcomes, being offered more money for sex without a condom and accepting more money for sex without a condom. The final model was selected by minimizing Akaike Information Criterion in a stepwise manner, with selection starting with a model including only a constant and adding predictor 1 at a time. At each step, the effect on Akaike Information Criterion is checked by removing a previously added variable, with a lower value suggesting a better fit. Missing data were dropped before model selection. Unadjusted (bivariate) ORs, AOR (multivariable), 95% CIs, and P values were reported. All statistical analyses were performed using SAS software version 9.2.23

RESULTS

Of 510 SWs who completed baseline, 490 SWs provided valid responses to the outcome being offered more money for sex without a condom and were included in the analyses. The sample had a median age of 35 years (interquartile range [IQR]: 28–42 years) and a median age at first sex work of 20 years (IQR: 15–30 years). Overall, 120 (24.5%) reported identifying as a sexual minority. The sample included 190 individuals (38.8%) of Indigenous/Aboriginal ancestry, 124 (25.3%) were visible minorities (of these, 97.5% East Asian, namely Chinese; 2.5% other visible minority), and 176 (35.9%) Caucasian/white. Of note, Aboriginal SWs were highly overrepresented in our sample relative to the general Canadian population of women and girls (3%).24 Overall, 266 (54.3%) reported soliciting for clients independently, 127 (25.9%) in indoor sex work places and 347 (70.8%) in outdoor sex work places, highlighting the substantial overlap in terms of sex work solicitation environments. Of the 490 respondents, 356 (72.6%) reported being offered more money for sex without a condom by clients in the last 6 months, with 75/302 (19.2%) reporting accepting more money after client demand (54 missing or 11.0%). Overall, 11.4% of SWs in the sample were HIV-positive and prevalence of STIs (including chlamydia, gonorrhea, and active syphilis) was 10.4%.

Offered More Money

Variables associated with being offered more money for sex without a condom in bivariate analysis (P < 0.05) are detailed in Table 1. In multivariable analysis, significantly higher odds of being offered more money for sex without a condom were found for SWs who had, in the last 6 months: used speedballs (AOR: 6.93, 95% CIs: 1.60 to 29.94); higher average numbers of clients per week (AOR: 1.03, 95% CIs: 1.01 to 1.06, a 3% increase in the odds of the outcome for each 1-client increase); difficulty accessing condoms (AOR: 2.72, 95% CIs: 1.09 to 6.77); and had clients who visited other SWs (AOR: 2.72, 95% CIs: 1.09 to 6.77) (Table 2).

Accepted More Money

Variables associated with accepting more money for sex without a condom in bivariate analysis (P < 0.05) are detailed in Table 3. In multivariable analysis, significantly higher odds of accepting more money for sex without a condom were found for SWs self-reporting as a sexual minority (AOR: 2.72, 95% CIs: 1.35 to 5.46) and who had, in the last 6 months: experienced client violence (AOR: 2.18, 95% CIs: 1.10 to 4.34); were displaced (ie, moved to another place) by security (AOR: 2.01, 95% CIs: 0.95 to 4.26); and had higher intensity of crystal meth use (daily, AOR: 2.58, 95% CIs: 0.39 to 17.17; less than daily, AOR: 2.95, 95% CIs: 1.27 to 6.87; versus none). Significantly reduced odds of accepting more money for sex without a condom was found for older SWs (AOR: 0.96, 95% CIs: 0.93 to 1.00, a 4% decrease in the odds of the outcome for each 1-year increase) and SWs who solicited for clients indoors (versus outdoor/public places; AOR: 0.15, 95% CIs: 0.04 to 0.54) (Table 2).

T3-17
TABLE 2:
Multivariable Associations Between Social, Drug Use, Sex Work, Structural-Environmental, and Client-Related Factors of SWs in Vancouver, Canada, and Being Offered and Accepting More Money for Sex Without a Condom
T4-17
TABLE 3-a:
Social, Drug Use, Sex Work, Structural-Environmental, and Client-Related Factors of SWs in Vancouver, Canada, According to Whether or Not They Accepted More Money for Sex Without a Condom
T5-17
TABLE 3-b:
Social, Drug Use, Sex Work, Structural-Environmental, and Client-Related Factors of SWs in Vancouver, Canada, According to Whether or Not They Accepted More Money for Sex Without a Condom

DISCUSSION

Our study confirms the high demand by clients for unprotected sex among SWs in an urban Canadian setting. Overall, nearly three quarters of hidden street and off-street SWs reported being offered more money for sex without a condom by clients within the last 6 months, with one fifth reporting accepting more money according to client demand. We identified a number of social, drug use, sex work, environmental-structural, and client-related factors associated with being offered and accepting more money after clients’ pressure for sex without a condom among a large sample of SWs in Vancouver, British Columbia.

More frequent drug use (eg, use of speedballs and noninjection crystal methamphetamine) was strongly associated with being offered or accepting more money for sex without a condom. These findings are consistent with other studies, which have suggested that clients looking for unprotected sex may seek out SWs who are particularly vulnerable to coercion, including women who are experiencing acute withdrawal and the immediate need to use drugs.9,13,25 Despite this relationship and demonstrated quantitative linkages between sex work income earned and money spent on drugs,14 it may be surprising that some measures of drug use were not associated with accepting more money because of client demand. These results may reflect how SWs with increased drug use vulnerability sometimes provide sexual services in direct exchange for drugs instead of financial incentives13 or may suggest that SWs agree to other higher-risk sex acts (eg, anal sex) after client demand in exchange for increased earnings.

The relationship between experiencing physical or sexual violence by clients and accepting more money for sex without a condom supports research suggesting a link between violence and HIV risk among sex workers.26 Violence against SWs in many settings is high, as evidenced by a recent systematic review on the factors shaping risk environments for violence among SWs globally (ranging from 50% to 75% lifetime to 32% to 55% in the last year) and has been linked to reduced condom use by clients.27 During experiences of direct violence, including physical assault and rape, condom use is unlikely. Fear or threat of violence can result in SWs’ heightened reluctance to insist on condom use and to agree to use condoms in exchange for an increased fee to avoid client violence as a safety measure.13 Inequitable gender-based power relations that favor male clients within environments of repeated and sustained “everyday” occupational violence (eg, by clients, police, and pimps/managers) and in the context of criminalization of indoor sex work spaces and public communication limit the agency of women and transgender women to negotiate condom use.13

Our results suggest potential routes of increased HIV risk to SWs through difficulty accessing condoms and having clients with other SWs as sex partners. SWs who experience difficulty accessing condoms may also experience heightened police harassment, lessening their control over negotiations with clients.13,28 Finally, our results suggest that SWs working in indoor settings (eg, massage/beauty parlors; managed indoor spaces/brothels are less likely to accept more money based on client demand relative to SWs who work in more dangerous, outdoor, and street-based public settings). Multiple studies have suggested working outdoors places women at greater risk for exposure to violent predators and clients and can result in difficulty accessing safer sex and harm reduction services and increased vulnerability to clients’ demands.5,6,29 Women who work in indoor settings can have more control over negotiations with clients regarding sexual transactions and can charge increased fees, potentially reducing the need to agree to clients’ demands for unsafe sex.13,30

Our study also suggests key social factors that can help identify SWs who may be particularly vulnerable to HIV/STIs. Sexual minority SWs experience additional and unique forms of stigma and marginalization, including homophobia and transphobia.31–33 Stigma, gender discrimination, homophobia, and transphobia, which shape the risk environment for HIV through social pathways, factor into power relations between SWs and clients and may result in less negotiating power for sexual minority SWs. For example, many transgender SWs face high rates of physical and sexual violence,34,35 which may compromise negotiation of condom use with clients. Further, marginalization and economic vulnerabilities have also been shown to be instrumental in sexual minority SWs’ ability to negotiate HIV risk behaviours,36 including client condom use,34 suggesting increased economic pressure to accept more money for sex without a condom. Our results also suggest that, because the median age at initiation of sex work initiation in our sample was 20 years (IQR: 15–30 years) whereas the median age was 35 years (IQR: 28–42 years), older women with longer duration in sex work may be more experienced in negotiations with clients or more comfortable refusing demands for higher fees. Moreover, research also suggests that youth may be particularly at risk for economic pressures and differential power relations favoring older male partners, which may affect their vulnerability to client demand for unsafe sex.37,38 Importantly, these results also highlight the potential increased risk of younger SWs to acquiring HIV/STIs from clients. Finally, results suggest that having more clients may result in increased opportunities for encountering coercive clients with a preference for unprotected sex.

Our study has several limitations. Because sampling frames are difficult to construct for hidden populations, the sample was not randomly generated and may not be representative of all SWs in ours or other settings. To address this, we recruited participants through systematic time-location sampling and targeted outreach to sex work strolls and indoor locations,19 considered the best method of recruitment for mobile/hidden populations and, therefore, helping attract a representative sample. The study design is cross-sectional in nature and, thus, cannot determine causal relationships; however, although it is not possible to confirm the direction of associations, our study results are situated within a number of other studies suggesting relationships between social, drug use, sex work, environmental-structural, and client-related factors and condom use. We had a large sample size for both street and off-street SWs. As with all self-report data, responses may be subject to recall or social desirability bias, and the prevalence of being offered and/or accepting more money for sex without a condom may be higher than reported. However, we had extensively trained interviewers with experience with the sample population, and interviews were conducted in spaces where women were comfortable (ie, indoor work places), facilitating accurate responses.

Our results point to several important structural and policy gaps in HIV programming and related recommendations to support SWs’ agency and ability to refuse clients’ demands for sex without a condom. Although approximately three quarters of SWs reported that clients demanded sex without a condom, it is positive that only one fifth reported accepting clients’ demands (although this may be underreported). Our study, therefore, provides strong evidence of the importance of acknowledging the role of clients in the spread of HIV/STIs. Although there are limited studies on clients of SWs,11,39,40 such studies are a crucial first step in understanding how to reduce demand for unprotected sex with SWs, include clients in HIV/STI programming for SWs, and address client responsibility for safer sex practices. Gaining this understanding is particularly relevant in settings such as Vancouver, where the client population is highly hidden. Increasing calls are being made to develop HIV/STI programs specific to clients,41,42 with some evidence of successful integration of hidden populations of clients demonstrated in international settings using smaller peer based43 and large-scale targeted42,44 approaches. In addition, structural policy changes that reduce economic disempowerment among SWs’ are critical.45 For example, practical interventions could include scaled-up access to SW-driven programs that increase SWs’ financial security, including those that support SWs to engage with regulated and legal banking institutions and those that provide relevant education and training. SWs who wish to remain in sex work and those who wish to exit should be supported. Where relevant, harm reduction and drug treatment modalities, including opiate substitution therapies, should be made available for SWs who use drugs to increase economic empowerment. Safer-environment interventions that are designed for SWs and are tailored for specific sex work environments (ie, mobile outreach46) can help meet the needs of SWs for an adequate no-cost condom supply.

Finally, alongside global calls,47,48 our study adds to a growing evidence base suggesting the potential protective effects of working in indoor spaces and of changes to policies relating to the criminalization and regulation sex work, including punitive sanctions and enforcement-based policing approaches that target public solicitation and prevent the development of safer indoor sex work spaces, to enable condom use in commercial sex transactions. In Ontario, Canada, such sex work laws were recently overturned based on evidence that such laws negatively impact SWs’ health and safety, including HIV risk prevention practices (similar court cases are ongoing in British Columbia, Canada).49,50 Decriminalized environments support SWs to self-regulate industry practices through collectivization processes and reconceptualization of sex work as work, including setting prices and limiting competition, which drive unprotected sex, in addition to maintaining occupational health and safety standards.51 Safer indoor sex workspaces tailored for local social and cultural contexts can enhance SWs’ agency to decline pressure from clients to have unprotected sex through buffers of social support, self-regulation, and organization. For example, nonexploitative managed brothels in designated areas where sex work is tolerated might be appropriate for SWs who prefer a distinction between work and home, whereas a focus on home-based sex work could work better for SWs who feel their safety could be compromised if there is an increased risk of disclosure by traveling to designated areas. Drawing on the experiences and knowledge of SWs is key in identifying the most effective HIV prevention approaches for SWs and addressing upstream factors that shape socioeconomic HIV risk environments.

ACKNOWLEDGMENTS

The authors thank all those who contributed their time and expertise to this project, including participants, partner agencies, and the AESHA Community Advisory Board. They wish to acknowledge Peter Vann, Calvin Lai, Eric Fu, Ofer Amram, Jill Chettiar, Alex Scot, and Kathleen Deering for their research and administrative support.

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Keywords:

condom use; sex workers; Canada; HIV risk; clients

© 2013 by Lippincott Williams & Wilkins