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From:         jayhawk@anon.nymserver.com
Date:         1998/04/25


PREVALENCE OF HIV IN SEX WORKERS AND RISK TO CUSTOMERS: A BRIEF REVIEW

by JayHawk

	This newsgroup has been filled with conflicting information on
the risk of contracting human immunodeficiency virus (HIV) from a sex
worker.  Some individuals tell you that the incidence of HIV in sex
workers is negligible, whereas newspapers cite statistics that over
50% of all prostitutes have AIDS.  Since I have access to MEDLINE, I
conducted a search for every study that links HIV to prostitution,
either to workers or customers.  A total of 94 papers were listed
(although some were mis-hits that were not relevant).

	Here is, what I believe to be, an objective presentation of
the facts as they appear in the medical/scientific literature.  I have
done my best to convert medical terminology into lay person language.
I have only included references that deal with female prostitution;
male prostitutes have an understandably higher risk of HIV.  Of
interest is the nearly complete lack of published studies in the U.S.
In the discussion below, risk is generally expressed as the "odds
ratio."  Odds ratio is essentially your risk relative to everyone
else; therefore, an odds ratio=1 is no increased risk; an odds
ratio=10 is 10 times the risk of the general population.


PROPORTION OF HIV IN SEX WORKERS IS COUNTRY-DEPENDENT

	Outside of Africa, the incidence of HIV in sex workers is
reasonably low, generally about the same as in the population as a
whole, even in developing nations, although the incidence does vary by
region.

	In Europe, HIV incidence is low.  In Vienna, where prostitutes
are registered and regularly screened for various STDs, in 1986 only
0.8% of 839 prostitutes were HIV+, and all of these were either
i.v. drug users or were the sexual partner of an i.v. drug user (Kopp
and Dangl-Erlach, 1986).  In a group of 88 prostitutes in Seville,
Spain, 2.5% of the non-intravenous drug abusers and 20% of the
intravenous drug abusers were HIV+ (Calderon et al., 1991).  Van
Haastrecht et al. (1993) studied 201 non-drug using female prostitutes
in the Netherlands and 213 male clients of female prostitutes.  HIV
prevalence was low: three prostitutes (1.5%) and one client (0.5%)
were infected. All three HIV positive prostitutes originated from
AIDS-endemic countries, and came to the Netherlands only recently.  In
another group of 32 non-drug using female prostitutes in Amsterdam,
the Netherlands, no cases of HIV were reported, and this group
consistently used condoms during sex.  In contrast, 24% of a group of
25 transsexual/transvestite prostitutes were HIV positive, and this
group frequently reported a lack of condom use during receptive anal
sex (Gras et al., 1997).  Even in a population of drug-injecting
prostitutes in Glasgow, the prevalence of HIV was only 2.2% (Taylor et
al., 1993).  This confirmed an earlier survey of 197 street
prostitutes in Glasgow which found that 2.5% were HIV+, and all of
these were women who also injected drugs.  The study estimated that
about 1150 women worked on the streets in Glasgow, and that 71% were
also i.v. drug users (McKeganey et al., 1992).  A large survey of 896
prostitutes in 9 European countries revealed an HIV prevalence of 5.3%
(Anonymous, 1993).  The majority of cases was seen in intravenous drug
users: 31.8% of drug users vs. 1.5% of non-drug users were HIV+.
Bulgaria is a major site for recruitment of prostitutes for work
throughout Europe.  Of 200 prostitutes surveyed, 8 (4%) were less than
15 years old and 32 (16%) more than 25 years old. Most of the women
came from rural villages and had no history of drug use.
Approximately 43% of women has evidence of one or more STDs
(Tchoudomirova et al., 1997), although data on HIV incidence is not
available. Lack of condom use and previous ulcerative sexually
transmitted disease were associated with HIV infection in both drug
users and non-users.  One interesting finding is that use of
petroleum-based lubricants was a significant risk factor (odds ratio
=15.2) in non-drug users; this may reflect a bias for individuals who
participate in anal sex (Anonymous, 1993).

	The story in Asia is complicated, and data are spotty.  A very
large study conducted in the Philippines evaluated 25,392 prostitutes
working in 64 cities between 1985-87.  The prevalence of HIV was only
0.08%; however, one year later, the rate had increased to 0.23%,
suggesting an increase with time (Hayes et al., 1990).  This was
relatively early in the worldwide spread of HIV, and the frequency may
be higher today.  A majority of women arrested for prostitution in
China had active STD infections at the time of arrest, with gonorrhea
being the most common; however, there was no correlation with HIV
infection and prostitution.  Interestingly, the Chinese government has
either downplayed or twisted these results to suggest an
HIV-prostitution link as part of their campaign to eliminate
prostitution (Gil et al., 1996).  A survey of individuals in Vietnam
(954 from South Vietnam, 945 from North Vietnam) showed that HTLV-I,
HTLV-II, and HIV-1 were primarily limited to i.v. drug abusers.  125
of 954 samples from South Vietnam were HTLV-II positive, but 119 of
these were i.v. drug abusers.  Of the remainder, one was a healthy
control, one was a prostitute, two were children, and two were
patients undergoing hemodialysis.  In contrast, no seropositives to
any of the viruses were detected in the North Vietnamese samples
(Fukushima et al., 1995).  Kihara et al. (1993) reported that of 191
prostitutes working in Tokyo, none were HIV+; however, incidence of
hepatitis C and Treponema pallidum was 11.0% and 16.2%, respectively,
compared to 0% of a matched control group.  The data from Japan and
China should serve as a reminder that there are other things you can
catch from sex workers besides HIV.

	Little data is available for North and South America.  A large
Peruvian female prostitute population was evaluated over a 3-year
period.  On initial evaluation, 3 (0.3%) had HIV-1 antibody, 170
(17.6%) had HTLV-I antibody, 578 (59.8%) had hepatitis B antibody, and
7 (0.7%) had antibody to hepatitis C virus.  The mean annual incidence
of HTLV-I and hepatitis B infection was 1.6% and 4.7%, respectively
(Hyams et al., 1993).

	There are essentially no reports on HIV incidence in sex
workers in the U.S., possibly due to the unwillingness of funding
agencies to support such studies.  One published study reported on HIV
in tuberculosis patients.  Of 183 tuberculosis patients in Los
Angeles, 18% were infected with HIV, and nearly all of these had
sexual risk factors including prostitute contact, multiple sex
partners, and a history of sexually transmitted disease (Barnes et
al., 1996).  Based on these findings, public health officials are now
recommending screening of all tuberculosis patients for HIV infection.

	In some parts of the world, especially Africa, HIV prevalence among
prostitutes is much higher. Among 332 female sex workers in Douala, Cameroon,
34% were HIV-1 seropositive, 3 were HTLV-I seropositive, and only 1 had
specific anti-HTLV-II antibodies (Mauclere et al., 1995).  This was an
increase over an earlier study which reported that of 168 prostitutes working
in Yaounde, Cameroon, 7.1% were HIV+, although 38.3% had Chlamydia trachomatis
(Kaptue et al., 1991).  In a population of Nairobi prostitutes, 71% of women
who did not use condoms seroconverted to HIV+, whereas 46% of condom users
seroconverted (Ngugi et al., 1988).  In southwest Uganda, 3% of the population
at large is HIV+.  A group of 36 Ugandan prostitutes had an HIV prevalence of
25% and 46% were positive for the Treponema pallidum hemagglutination (TPHA)
test for syphilis (Hudson et al., 1988).  In 1987 in Djibouti, only 2% of
prostitutes were HIV+, which is much lower than the incidence reported from
other East African countries, leading the authors to speculate that the
African AIDS epidemic stops at the Horn of Africa (Fox et al., 1989).
However, in a later study, in Djibouti, HIV infection was found to be 36.0% in
street prostitutes and 15.3% in prostitutes working as bar hostesses (Rodier
et al., 1993).  


PROSTITUTION ALONE IS NOT A RISK FACTOR FOR HIV

	Rhodes et al., (1994) evaluated the HIV prevalence in female
drug injectors and found a 12.9% HIV prevalence among female drug
injectors involved in prostitution and 14.4% HIV prevalence among drug
injectors not involved in prostitution.  They found that women not
involved in prostitution were less likely to be in contact with a drug
treatment or helping agency and were less likely to have had an HIV
test. Respondents in contact with a treatment agency and respondents
involved in prostitution were more likely to be aware of their HIV
status, and 72% of non-prostitute women confirmed HIV+ were unaware of
their positive status.  The authors concluded, "These findings of no
higher HIV prevalence among female drug injectors also involved in
prostitution lend some support to emerging evidence which associates
HIV transmission among women prostitutes with an involvement in
injecting drug use rather than with an involvement in prostitution per
se."

	While these results are encouraging, drug use among
prostitutes appears to be high.  Of 85 prostitutes in Glasgow, 81%
were i.v. drug users, their most commonly used drugs being heroin and
temazepam. While 98% indicated that they always used condoms during
vaginal intercourse, this only applied to commercial sex; only 17%
always used condoms with their regular sexual partners, who were
frequently drug abusers (Green et al., 1993).

CLIENTS OF SEX WORKERS ARE AT GREATER RISK OF CONTRACTING HIV

	Ruiz et al. (1993) evaluated a population of 40 men and women
who allegedly acquired HIV through heterosexual contacts.  All men had
occasional sexual contacts with prostitutes.  The women had no clear
behavioral pattern associated with HIV infection, but they are
believed to have contracted it through heterosexual contact with HIV+
men.

	Figueroa et al (1994) reported that between November 1990 and
January 1991 HIV infection in Kingston, Jamaica was 3.1% (31 of
1,006), a tenfold rise in seroprevalence in 4.5 years. Nineteen of 517
(3.7%) heterosexual men, 3 of 5 (60%) homosexual/bisexual men, and 9
of 484 (1.9%) women were infected with HIV. In heterosexual men,
factors associated with HIV infection after age adjustment included
present complaint of genital ulcer (odds ratio = 7.3), past history of
genital ulcer (odds ratio= 4.3), positive syphilis serology (odds
ratio =3.4), sex with a prostitute in the past month (odds ratio =
3.8), three or more sex partners in the month prior to complaint (odds
ratio= 3.6), and bruising during sex (odds ratio=4.0).

	However, this story is complicated by the other behaviors of
this population; i.e., men who use prostitutes often engage in other
high-risk behaviors.  For example, of 112 men in London who used
female prostitutes, 5% were HIV+; however, 36% reported having sex
with other men, 2% reported using injected drugs, 8% had a history of
blood transfusion, 13% reported a past history of gonorrhea, and 9%
said that they had also been paid for sex (Day et al., 1993).  In
another strange correlation, a study of 150 men in Thailand showed
that risk of HIV infection was increased (odds ratio=3.6) in men who
visited a prostitute at least once a month; however, this risk was the
same (odds ratio=3.5) in men who smoked cigarettes, suggesting that a
general unhealthy lifestyle is a risk factor for HIV infection
(Siraprapasiri et al., 1996).

	Past history of sexually transmitted diseases (STDs) clearly
increases risk of acquiring HIV.  Cameron et al. (1989) studied a
group of 422 men who (a) had a STD (other than HIV) and (b) who used
prostitutes.  In this group, 12% were HIV+ and an additional 3.2%
seroconverted to HIV+ during the study.  Every man who seroconverted
had a genital ulcer of some kind related to his previous STD.  The
authors concluded that men with other STDs have a very high risk of
acquiring HIV from a prostitute.

	Transmission of HIV from male to female in unprotected sex
appears to be high.  A study in Thailand identified 405 HIV+ men who
were unaware of their HIV status until they donated blood.  Of these
men, 98% had sex with a prostitute.  In addition, 46% of the wives/sex
partners of these men were also HIV+.  Risk factors for transmission
from male to female were genital herpes, gonorrhea, or chlamydia
infection.  In contrast, regular use of a condom decreased
transmission to one tenth that of the main group (odds ratio=0.1;
Nagachinta et al., 1997).

CONCLUSIONS

	The results of these studies are fairly consistent and
indicate the following: Outside of East Africa, the prevalence of HIV
in sex workers is generally only a few percent, and not significantly
different than the HIV incidence in the population as a whole.  While
prostitution per se is not a significant risk factor for acquiring HIV
infection, i.v. drug use is, and a significant proportion of sex
workers are also i.v. drug users.  Men who use prostitutes do have a
higher risk of acquiring HIV, but only if they have other STDs, or
engage in other high risk behaviors (e.g., anal sex without a condom).
If you have no STDs, use a condom, and avoid sex workers with needle
marks in the arms, your risk is probably no greater than your risk of
getting AIDS from your girlfriend or mistress.  If you have a history
of STDs, don't use a condom, and use sex workers who are known
i.v. drug users...good luck!

REFERENCES

Anonymous (1993) HIV infection in European female sex workers:
epidemiological link with use of petroleum-based lubricants. European
Working Group on HIV Infection in Female Prostitutes. AIDS.  7(3):
401-8

Barnes PF; Silva C; Otaya M (1996) Testing for human immunodeficiency
virus infection in patients with tuberculosis.  Am J Respir Crit Care
Med 153(4 Pt 1):1448-50

Calderon-EJ; Gomez-Lucia-E; Aguado-I; Pineda-JA; Essex-M; Leal-M
(1991) Absence of HTLV-I and HTLV-II infection in prostitutes in the
area of Seville, Spain. Eur-J-Clin-Microbiol-Infect-Dis. 10(9): 773-5

Cameron-DW; Simonsen-JN; D'Costa-LJ; Ronald-AR; Maitha-GM; Gakinya-MN;
Cheang-M; Ndinya-Achola-JO; Piot-P; Brunham-RC (1989) Female to male
transmission of human immunodeficiency virus type 1: risk factors for
seroconversion in men comments Lancet. 2(8660): 403-7

Day-S; Ward-H; Perrotta-L (1993) Prostitution and risk of HIV: male 
partners of female prostitutes. BMJ. 307(6900): 359-61

Figueroa-JP; Brathwaite-A; Morris-J; Ward-E; Peruga-A; Blattner-W;
Vermund-SH; Hayes-R (1994) Rising HIV-1 <B>prevalence</B> among
sexually transmitted disease clinic attenders in Jamaica: traumatic
sex and genital ulcers as risk factors J-Acquir-Immune-Defic-Syndr.
7(3): 310-6

Fox-E; Abbatte-EA; Wassef-HH; Woody-JN; Said-Salah; Sidrak-W;
Constantine-NT (1989) Low <B>prevalence</B> of HIV infection in
Djibouti--has the AIDS epidemic come to a stop at the Horn of Africa?
Trans-R-Soc-Trop-Med-Hyg. 83(1): 103-6

Fukushima Y; Takahashi H; Hall WW; Nakasone T; Nakata S; Song P; Dinh
Duc D; Hien B; Nguyen XQ; Ngoc Trinh T; et al (1995) Extraordinary
high rate of HTLV type II seropositivity in intravenous drug abusers
in South Vietnam.  AIDS Res Hum Retroviruses 11(5):637-45.

Gil VE; Wang MS; Anderson AF; Lin GM; Wu ZO (1996) Prostitutes,
prostitution and STD/HIV transmission in mainland China.  Soc Sci Med
42(1):141-52

Gras MJ; van der Helm T; Schenk R; van Doornum GJ; Coutinho RA; van
den Hoek JA (1997) HIV infection and risk behaviour among prostitutes
in the Amsterdam streetwalkers' district; indications of raised
prevalence of HIV among transvestites / transsexuals.  Ned Tijdschr
Geneeskd 141(25):1238-41.

Green-ST; Goldberg-DJ; Christie-PR; Frischer-M; Thomson-A; Carr-SV; 
Taylor-A (1993) Female streetworker--prostitutes in Glasgow: a 
descriptive study of their lifestyle. AIDS-Care.  5(3): 321-35

Hayes-CG; Manaloto-CR; Basaca-Sevilla-V; Padre-LP; Laughlin-LW; 
O'Rourke-TF; Espinosa-GE; Andrada-AB; Mejia-P; Cano-D (1990) 
Epidemiology of HIV infection among prostitutes in the Philippines. 
J-Acquir-Immune-Defic-Syndr.  3(9): 913-20

Hudson-CP; Hennis-AJ; Kataaha-P; Lloyd-G; Moore-AT; Sutehall-GM;
Whetstone-R; Wreghitt-T; Karpas-A (1988) Risk factors for the spread
of AIDS in rural Africa: evidence from a comparative
seroepidemiological survey of AIDS, hepatitis B and syphilis in
southwestern Uganda. AIDS. 2(4): 255-60

Hyams-KC; Phillips-IA; Tejada-A; Wignall-FS; Roberts-CR; Escamilla-J 
(1993) Three-year incidence study of retroviral and viral hepatitis 
transmission in a Peruvian prostitute population. 
J-Acquir-Immune-Defic-Syndr.  6(12): 1353-7

Kaptue-L; Zekeng-L; Djoumessi-S; Monny-Lobe-M; Nichols-D; Debuysscher-R 
(1991) HIV and chlamydia infections among prostitutes in Yaounde, 
Cameroon. Genitourin-Med. 67(2): 143-5

Kihara-M; Imai-M; Kondoh-M; Watanabe-S; Kihara-M; Soda-K (1993)
Prevalence of hepatitis C virus and human immunodeficiency virus
infection among Japanese female prostitutes
Nippon-Koshu-Eisei-Zasshi. 40(5): 387-91

Kopp-W; Dangl-Erlach-E (1986) HTLV-III monitoring in prostitutes in
Vienna Wien-Klin-Wochenschr. 98(20): 695-8

Mauclere-P; Mahieux-R; Garcia-Calleja-JM; Salla-R; Tekaia-F; Millan-J;
De-The-G; Gessain-A (1995) A new HTLV type II subtype A isolate in an
HIV type 1-infected prostitute from Cameroon, Central
Africa. AIDS-Res-Hum-Retroviruses. 11(8): 989-93

McKeganey-N; Barnard-M; Leyland-A; Coote-I; Follet-E (1992) Female
streetworking prostitution and HIV infection in
Glasgow. BMJ. 305(6857): 801-4

Nagachinta T; Duerr A; Suriyanon V; Nantachit N; Rugpao S; Wanapirak
C; Srisomboon J; Kamtorn N; Tovanabutra S; Mundee Y; Yutrabutr Y;
Kaewvichit R; Rungruengthanakit K; de Boer M; Tansuhaj A; Flowers L;
Khamboonruang C; Celentano DD; Nelson KE (1997) Risk factors for HIV-1
transmission from HIV-seropositive male blood donors to their regular
female partners in northern Thailand.  AIDS 11(14):1765-72.

Ngugi-EN; Plummer-FA; Simonsen-JN; Cameron-DW; Bosire-M; Waiyaki-P;
Ronald-AR; Ndinya-Achola-JO (1988) Prevention of transmission of human
immunodeficiency virus in Africa: effectiveness of condom promotion
and health education among prostitutes. Lancet. 2(8616): 887-90

Rhodes-T; Donoghoe-M; Hunter-G; Stimson-GV (1994) HIV prevalence no
higher among female drug injectors also involved in prostitution
AIDS-Care. 6(3): 269-76

Rodier-GR; Couzineau-B; Gray-GC; Omar-CS; Fox-E; Bouloumie-J; Watts-D
(1993) Trends of human immunodeficiency virus type-1 infection in
female prostitutes and males diagnosed with a sexually transmitted
disease in Djibouti, east Africa. Am-J-Trop-Med-Hyg. 48(5): 682-6

Ruiz-A; Falguera-M; Puig-T; Gazquez-I; Perez-J; Rubio-M (1993)
Epidemiologic and clinical characteristics and clinical course of the
HIV positive patient infected by heterosexual transmission
Rev-Clin-Esp. 193(4): 159-63

Siraprapasiri T; Foy HM; Kreiss JK; Pruithitada N; Thongtub W (1996)
Frequency and risk of HIV infection among men attending a clinic for
STD in Chiang Mai, Thailand. Southeast Asian J Trop Med Public Health
27(1):96-101.

Taylor-A; Frischer-M; McKeganey-N; Goldberg-D; Green-S; Platt-S (1993)
HIV risk behaviours among female prostitute drug injectors in
Glasgow. Addiction. 88(11): 1561-4

Tchoudomirova K; Domeika M; M;ardh PA (1997) Demographic data on
prostitutes from Bulgaria--a recruitment country for international
(migratory) prostitutes.  Int J STD AIDS 8(3):187-91.

van-Haastrecht-HJ; Fennema-JS; Coutinho-RA; van-der-Helm-TC; Kint-JA;
van-den-Hoek-JA (1993) HIV <B>prevalence</B> and risk behaviour among
prostitutes and clients in Amsterdam: migrants at increased risk for
HIV infection. Genitourin-Med. 69(4): 251-6


===========================================================================
Subject:      Re: HIV risks
From:         jayhawk <jayhawk@anon.nymserver.com>
Date:         1998/06/24

>So, if you really want to minimize your risks, only shower once a
>month, wearing a helmet; do your work on the floor, not a desk; drink
>only beer; only have sex with people who come to your door (ie, don't
>drive anywhere because the risk of death in an auto accident is much
>higher than all these other risky behaviors) and then use three
>condoms, just in case the first two both break - that is a risk often
>overlooked by the extremely cautious among us.

This is very nicely put and hits the nail on the head.  Everything you do in
life has risks.  Not eating vegetables has risks (increased risk of cancer)
whereas eating vegetables has risks (many are loaded with carcinogens
themselves).  You would be safer in the shower with a helmet, but then you
couldn't wash your hair, which would increase your risk of a scalp infection.
The truly important aspect is to understand the risks, decide what you can
tolerate, then make decisions accordingly.  Some people choose to mountain
climb or hang glide because it is fun, even though there is a good chance of
getting killed.  We choose a different hobby, even though it does have some
risks.  Sex workers choose their profession (considering what their other
options are) for money or because they love their work, but there are risks
that come with the job.

A couple of caveats though:

1.  Consider not just your risk but the risk to the woman.  You may be at very
low risk of contracting something via a BBBJ, but the woman may have 50 times
the risk of getting something from you.  Act like a responsible human being.

2.  Everyone discusses HIV as the one serious thing you can get.  It's hard to
get HIV.  It's easy to get hepatitis B or C, or syphilis, or chlamydia, etc.,
etc.  You are way more likely to die from hepB or C than HIV, which is why you
should get vaccinated for both if you are in this hobby.

3.  Look at the big picture.  The way I view it, I am not very likely to die
from getting HIV from a sex worker if I don't use a condom, but I am *much*
more likely to die because I get chlamydia, pass it to my wife, and have her
get a gun and shoot my nuts off!

JayHawk

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