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National Research Council (US) Committee on AIDS Research and the Behavioral, Social, and Statistical Sciences; Miller HG, Turner CF, Moses LE, editors. AIDS: The Second Decade. Washington (DC): National Academies Press (US); 1990.

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AIDS: The Second Decade.

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4Interventions for Female Prostitutes

In the beginning stages of the AIDS epidemic, many people feared that female prostitutes would become widely infected and spread the AIDS virus to their male clients.1 At present, this fear appears to be unfounded, at least in the United States. The evidence instead suggests that prostitutes' risk of transmission is more closely associated with drug use than with multiple sexual clients. The evidence also indicates that the risk of transmission through sexual contact is greater in the personal relationships of female prostitutes than in their paying ones.2 Data to support these inferences are sparse, however, because research on prostitution is limited. For this reason, and because the future dynamics of the epidemic are still unclear, there is a continuing need to monitor any future role that prostitution may play in transmitting HIV.

As is the case for other individuals believed to be at-risk for HIV infection, the design of effective intervention strategies should be informed by an understanding of the risk-associated behaviors of the prostitute and her partners, as well as the conditions under which the behaviors occur. Unfortunately, information about women who work as prostitutes is scant, and knowledge of their clients is sketchier still.3 The stigmatized and generally illegal nature of prostitution has meant that studies necessarily have had to rely on small nonprobability samples or on ethnographic research, neither of which yields results that can be generalized to the female sex worker population as a whole. Moreover, such studies cannot provide an accurate estimate of the number of women who work as prostitutes. Instead, estimates of the total population are constructed from informed “guesstimates” of knowledgeable observers or from arrest and imprisonment records that capture the subsets of female sex workers who are most likely to come into contact with the criminal justice system-that is, the poor, the inexperienced, minorities, drug users, and women who work the streets (Turner, Miller, and Moses, 1989). Little is known about the occupational histories of prostitutes, but anecdotal evidence suggests that this is a dynamic population. Thus, despite predictions of “once bad, always bad,” women tend to move into and out of prostitution; there are few data about these patterns, however, or about the relative amounts of time women spend as sex workers and about when and why former prostitutes return to this work (Goldstein, 1979; Delacoste and Alexander, 1987; Potterat et al., in press).

In the following section, the committee reviews the literature on prostitution as it relates to the AIDS epidemic in the United States. In presenting this overview, the committee wishes to emphasize that our understanding of this population is far from complete and our knowledge of the widely varied contexts in which its members work is limited. Caution must thus be exercised in deriving generalizations from the findings presented below. Although all prostitutes share the common characteristic of exchanging sexual acts for some kind of payment, there is in fact great diversity in all aspects of the social organization of prostitution and its relations to the larger society in which it is embedded.

THE EPIDEMIOLOGY OF AIDS AND HIV INFECTION AMONG PROSTITUTES

There are no accurate estimates of the prevalence of HIV infection among female prostitutes in the United States. Serologic surveys capture only those women who volunteer for testing, those who seek care in public clinics for sexually transmitted diseases (STDs), those involved in drug treatment programs, or those in contact with the criminal justice system. Nonetheless, these data shed some light on the distribution of the disease within the population. An important source of information about HIV infection rates among prostitutes is CDC's ongoing multicenter study of 1,396 women, which relies on nonprobability samples of participants from diverse populations around the country. Samples at eight sites were constructed from volunteers who had engaged in prostitution at least once since 1978. The women were recruited from brothels, detention centers, methadone clinics, STD clinics, and networks of “street walkers” and “call girls.” Data from this coordinated study (Table 4–1) indicate that the rates of HIV infection among female prostitutes vary greatly from site to site, ranging from zero to 47.5 percent (Darrow et al., in press.)4

TABLE 4–1. HIV Seroprevalence in 1986–1987 Among Women Who Reported Engaging in Prostitution (at least once) since January 1978.

TABLE 4–1

HIV Seroprevalence in 1986–1987 Among Women Who Reported Engaging in Prostitution (at least once) since January 1978.

Yet despite apparently high seroprevalence rates in some areas, HIV infection is not necessarily an occupational hazard for female prostitutes in the United States. Rather, two other factors are indicated: prostitutes are more likely to become infected as a result of unprotected intercourse in the context of a personal relationship than unprotected intercourse with paying clients, and prostitutes who are IV drug users are more likely to acquire HIV infection from contaminated drug injection equipment than from work-related sexual behavior. The risk prostitutes pose to their male clients appears to be minimal, although data regarding these men are extremely limited, in part owing to the criminalization of prostitution and the reluctance of clients to be identified. Nevertheless, the available data on all of these transmission risks argue for continued attention to the differential risk of infection for prostitutes related to IV drug use and differential risk associated with particular contexts of sexual activity.

Risks Related to Drug Use and Sexual Transmission

Data from the CDC multicenter study show that rates of HIV infection are much higher among female sex workers who report a history of IV drug use than among those for whom no evidence of drug use is found (19.9 percent versus 4.8 percent). As shown in Table 4–1, HIV seroprevalence rates vary by locale but are higher in most sites for IV drug users. In addition, in a separate analysis of respondents in this study who did not report IV drug use and had no physical signs of injection, HIV infection was associated with large numbers of personal (i.e., nonpaying) sexual partners (Darrow et al., 1988). Variations in infection rates by locale may reflect different injection patterns or different seroprevalence rates in the heterosexual or IV drug-using populations, or they may be an artifact of the disparate sampling schemes used at the several sites. Follow-up studies are now being conducted in Atlanta, Colorado Springs, and San Francisco; these efforts will include prostitutes and their sexual and needle-sharing partners (Darrow et al., 1989).5

Although these studies show that the risk for female sex workers is primarily associated with injecting drugs, the proportion of sex workers who inject drugs is not known with any certainty. One estimate, based on a nonprobability sample of 75 arrested sex workers in New York, found that one-third had injected drugs in the past two years; half had injected drugs at least once in their lives (Des Jarlais et al., 1987). However, data collected from CDC's multicenter study indicate greater uncertainty in these estimates: between 27 and 73 percent of prostitutes recruited from settings as diverse as legal brothels and STD clinics were found to have injected drugs at some time (Darrow et al., 1989).

IV drug use may not be evenly distributed throughout the population of female sex workers. Indeed, ethnographic and survey data indicate that needle use is more common among prostitutes who work on the street and among minorities than it is among other sex workers (Goldstein, 1979; Khabbaz et al., 1990).6 Lower rates of IV drug use among women who work primarily for escort services or brothels would be consistent with the lower rates of HIV infection reported in this group (Fischl et al., 1987; Seidlin et al., 1988).7 In fact, the causal connection, if any, between prostitution and drug use (or vice versa) is unknown. Given the evidence, however, that HIV infection among female prostitutes has occurred mainly among those who use IV drugs and that prostitutes thus appear to be at increased risk for HIV infection primarily through drug use rather than through sexual practices, the committee recommends that the National Institute on Drug Abuse and the Centers for Disease Control continue to support and strengthen current efforts to understand and intervene in the relationship between drug use and prostitution.8 In its first report, the committee recommended that steps be taken to close the vast gaps in knowledge regarding the relationship between sexual behavior and drug use (Turner, Miller, and Moses, 1989). In the case of drug use and prostitution, the committee found that such steps should include better understanding of the following: variations in drug use across different subpopulations of prostitutes, the effect of drug use on risk-associated behaviors, the relationship between drug use and prostitution and the conditions and antecedents surrounding their initiation, and interventions that might protect prostitutes from the threat of HIV infection and other dangers associated with drug use.

In addition to HIV transmission associated with injection practices, risks related to the evolving drug scene—in particular, the threat now presented by noninjected drugs, such as crack—have increased. As discussed in Chapter 1, the use of crack may foster increased demand for sexual services, which can be supplied by women exchanging sex for the drug itself or for money to buy it. Some of the risk associated with prostitutes' nonpaying sexual partners may be related to the use of crack or other drugs. For example, crack use in New York has been associated with sexual transmission of HIV (Chiasson et al., 1989).9 In addition, Shedlin (1987) reports that female prostitutes recruited primarily through drug treatment programs in New York City and Bridgeport, Connecticut, identified “crack addiction” as one of the primary reasons for engaging in unprotected intercourse, particularly among younger women who worked on the streets. Friedman and coworkers' (1988) ethnographic research on “crack houses” (buildings in which crack is sold and used) also confirmed the link between crack use and unprotected intercourse and, occasionally, street prostitution. Many of the acts of unprotected intercourse reported by Friedman and colleagues occurred between male IV drug users and female crack users,10 thus increasing the risk of spread of the virus.

Clearly, the risks associated with crack are related to unprotected intercourse rather than to a specific characteristic of the drug or the route of administration. The context of the sexual encounter is thus an important factor in differential rates of HIV transmission. Also of importance to the level of HIV transmission risk shared by female prostitutes and their clients is the specific set of sexual activities the client purchases. These factors are discussed in the sections that follow.

Context-Related Risks

The context of the sex-for-money exchange involves a variety of elements, from setting and time limitations to cultural preferences and the nature of the relationship between the partners. Most sexual encounters with female prostitutes are brief. For street prostitutes, the time from striking the bargain—which activities for what price—to their return to the street may be only a dozen minutes or so. More extended periods of time and a wider variety of sexual techniques are generally more expensive and primarily characteristic of outcall or other off-street practitioners. Within time-limited contexts, oral sex is frequently preferred by both clients and prostitutes (see, e.g., Shedlin, 1987). Neither partner need remove his or her clothing, and the act is usually over quickly, thus reducing vulnerability for both. It may also reduce transmission risks among female prostitutes and their male clients.

On the other hand, clients' sexual technique preferences vary substantially by class and culture. Although street prostitutes in New York report that oral sex is the activity of preference (Des Jarlais et al., 1987), women who work as prostitutes among newly immigrant Latino populations report that vaginal intercourse is preferred by their clients (Magana and Carrier, in press). In these cases, transmission risks may be higher, particularly if there is a history of STDs or current infection. In addition, some men may choose anal intercourse, which carries an even greater risk of viral transmission, particularly if condoms are not used. The frequency of anal sex in this population is not known.11 Not all female prostitutes offer this service; others may charge premium rates for anal sex, which may reduce demand. It is clear, however, that the distribution of sexual techniques offered by women and desired by clients in any community could affect rates of viral transmission. The need for safer sex practices and the ability to modify dangerous practices are affected by the degree to which these practices are ingrained in the local culture, as well as by the strength of an individual client's desires.

The use of condoms for protection against HIV and other STDs appears to vary with the nature of the relationship between the sexual partners. Several studies of condom use among female prostitutes report that unprotected intercourse is more likely to occur in the context of a personal relationship than in a paid transaction. In an earlier (1987) report of the ongoing CDC multicenter study, more than 80 percent of the women surveyed reported at least occasional use of condoms, but that use was much more likely to occur with clients (78 percent) than with husbands or boyfriends (16 percent). In a sample of approximately 500 prostitutes living in the San Francisco area (who were recruited by other prostitutes hired to do outreach and through sex-related media), J.B. Cohen and coworkers (1989) found that 90 percent reported at least one instance of condom use with paying customers. In fact, 38 percent said they always used condoms with clients, compared with only 14 percent who sometimes used condoms with husbands or boyfriends. Studies of prostitutes in Europe have also found less reported use of condoms in the context of personal relationships than in professional ones (Day, Ward, and Harris, 1988; Hooykaas et al., 1989).12 In fact, it is among sex workers with large numbers of nonpaying sexual partners that the risk of sexual transmission of HIV infection has been found to be highest (Darrow et al., 1988).

The lower frequency of condom use in personal relationships may have something to do with the distinction both female prostitutes and their husbands or boyfriends make between intimate sexual acts and paid sex (J.B.Cohen, 1989). Shedlin (1987), for example, noted that the prostitutes in her study differentiated between what they did with clients and intimate acts reserved for their personal partners, such as kissing. In another study (Darrow et al., in press), female prostitutes reported that their personal sexual partners saw themselves as having a low risk of infection because they believed the women consistently used condoms with clients. As a result, many prostitutes reported difficulties in persuading their private partners to use condoms.

Client-Related Risks

The extent of the risk of HIV infection for paying customers of prostitutes is not known with certainty, but the number of cases ascribed to contact with female sex workers has not been large, and the few existing studies of prostitutes' clients have found relatively low rates of HIV infection. However, data on clients come from a limited group of studies that have relied on small, nonprobability samples, and their results must be interpreted with caution. Wallace, Mann, and Beatrice (1988) recruited paying customers of prostitutes through advertisements in a New York City weekly newspaper, television and radio news stories about the study, ads placed at union headquarters, and hotline referrals. Interviews and blood specimens were obtained from 340 men with a history of sexual contact with female prostitutes and no other risk factors for infection. Six of the men were found to be infected. Upon reinterview, however, three later admitted other risk behavior, leaving three (0.9 percent) seropositive men whose only alleged risk factor was unprotected sexual contact with a prostitute. These three infected men reported a mean of 575 lifetime contacts with prostitutes (compared to an overall average of 94 contacts for study participants). As noted earlier, although the risk of infection for female sex workers is not clearly related to the number of clients, this study provides some evidence, albeit limited, that for clients a large number of prostitute contacts may be associated with a greater risk of acquiring HIV.

In another study, Chiasson and colleagues (1988) recruited 671 men from a New York City STD clinic and found that 138 men reported no risk factors for AIDS except vaginal intercourse with prostitutes. Of the 138 men, 2 (1.4 percent) were found to be infected. Among 222 respondents who reported no risk factors at all, 3 men (1.4 percent) were found to be seropositive. The following year, the same investigators (Chiasson et al., 1989) collected data from 955 men recruited from another New York STD clinic situated in an area in which the cumulative HIV incidence rate was high and drug use, including the use of crack, was common. Of the 571 men with no identifiable risk factors, 262 reported contacts with prostitutes, and 15 (5.7 percent) of the 262 men were antibody positive. (In addition, five seropositive men reported sexual contact with known crack users.) Neither study reported the average number of prostitute contacts for the infected men. Nevertheless, the higher infection rate in the second study suggests the need for continued monitoring of the population of men who report sexual contact with prostitutes.

Finally, in a CDC follow-up study of 1,138 AIDS cases originally diagnosed in adult males with no reported risk factors, investigators were able to identify a risk factor in all but 281 of the cases. Of these 281 remaining cases with no identifiable risk factor, 178 were reinterviewed. Ninety-six of these men responded to the question on prostitute contact, and 33 reported contact with female sex workers. These 33 men account for only 0.08 percent of the 41,770 adult cases of AIDS diagnosed at the time of the study (Castro et al., 1989), thus suggesting a limited transmission threat posed by female prostitutes.

Although these data affirm the possibility that female prostitutes can transmit infection, questions regarding the accuracy of risk reporting may cast doubt on any conclusion regarding the extent of such transmission. A problem relevant to reporting prostitute contact is response bias attributable to deliberate misreports of behavior to project an image of “social desirability.” Castro and colleagues (1989), for example, suggest that men who engage in risk-associated behaviors other than contact with female sex workers may nevertheless report prostitute contact to prevent further investigation of other risk factors the respondent may consider more sensitive or stigmatizing (e.g., same-gender sexual contacts). (Chapter 6 provides a more detailed discussion of the difficulties in validating self-reported data on sexual practices.) Although the number of men who have become infected through contact with female prostitutes is not known, it appears to be small when compared with the number of men who report other risk behaviors.

In its first report, the committee recognized both the need for and the difficulties involved in collecting high-quality data on the clients of female prostitutes. At that time, a number of possible approaches were suggested: studies using household samples in which men are asked about contact with prostitutes; specialized samples of men who might not be reached through household samples but who nonetheless are or have been associated with prostitutes; special studies of men who are particularly likely to use the services of prostitutes; and studies of men from cultures in which the patronage of prostitutes is considered part of the normative repertoire of sexual behavior. The committee reaffirms its support for these suggestions. In addition, because so little is known about the role of prostitutes' clients in the spread of HIV infection, the committee recommends that the Public Health Service undertake a series of feasibility studies to determine the best ways to gather appropriate information about prostitutes' clients and their role in the spread of HIV to the larger population.

The segment of the female prostitute population that does not inject drugs appears to pose only a limited threat to clients at this time, and sexual contact with clients appears to be less of a threat to prostitutes than either drug use or personal sexual relationships. However, as other populations have demonstrated, the problem of HIV infection is not static. The risks may, indeed, be limited, but changes seen over the course of the first decade of the epidemic argue for continued vigilance. Given the factors that are known to distinguish the risk profile of many prostitutes (unprotected sexual contacts and IV drug use), the committee recommends that the Centers for Disease Control continue to monitor the effects of the AIDS epidemic in this population. Activities should include a continuing, systematic effort to track the incidence and prevalence of both HIV infection and sexually transmitted diseases in this group. To reach both prostitutes and their clients, knowledge of the varying patterns of prostitution and prostitute patronage is critical. The available data on such patterns are presented in the following section.

PATTERNS OF PROSTITUTION

Stereotypical depictions of prostitution tend to present two ends of a spectrum: the pathos associated with streetwalkers and the sophisticated elegance of call girls. The reality is that women who engage in prostitution have a wide range of lifestyles, work in many different milieus, and have varying feelings about their work, ranging from degradation and despair to pride (James, 1977; B.Cohen, 1980; Carmen and Moody, 1985; Perkins and Bennett, 1985; Delacoste and Alexander, 1987; Shedlin, 1987). These differing patterns have important implications for intervention efforts. The place of work, services offered, number of clients served, local prevalence of infection, and availability and use of protective measures are all factors that affect the risk of HIV infection for female prostitutes, and they should be taken into account in the design and delivery of AIDS prevention programs for this population. Several different lifestyles of female prostitutes and their implications for outreach and intervention strategies are described below.

Street Prostitution

The most familiar form of prostitution, and the one that draws the most attention, is street prostitution (James, 1977; Alexander, 1987). Carmen and Moody (1985) report that in this country the preponderance of recreational sex involves random, unplanned activity. Thus, it makes sense that prostitutes congregate around locations where travel may be delayed, tourists are at loose ends, or men find themselves free of work-related obligations, affording them time to spend with sex workers. In the urban setting, street prostitution often occurs in “stroll districts” in which potential clients can be found: streets near hotels (whether downtown or near airports), fast-food restaurants, train stations, and bus stations frequented by tourists and other transients (James, 1977; B.Cohen, 1980; Carmen and Moody, 1985). Rural variations include truck-stop prostitution; female sex workers solicit clients in the parking lots of restaurants where long-haul truckers congregate or make contact with them through CB radios (Luxenberg and Klein, 1984). Other women, traveling in groups of two or three, may work a circuit that might include conventions, migrant labor camps, lumber camps, job training camps, or work camps (James, 1977). Perhaps less obvious to the general public is prostitution that occurs in bars, a pattern in which women solicit clients and leave to have sex in another location, perhaps a hotel room. Women who work the streets are more likely than other groups of prostitutes to have pimps, although an unknown proportion of street prostitutes work independently (James, 1977; Alexander, 1987).13

Patterns of street prostitution may be similar across cities of the same size and culture, but they may be dissimilar across regions of the country and across cities of unequal size. The visibility of street prostitution is particularly affected by aggressive law enforcement efforts, which generally focus on women who are openly soliciting business (James, 1977).14 Indeed, highly proactive police work and long sentences can drive street prostitutes (and massage parlors) out of a specific city or neighborhood, at least temporarily. Few jurisdictions of any size, however, will expend the level of effort necessary to reduce prostitution substantially. More often, police will engage in management efforts to “keep it within bounds” through periodic sweeps and crusades that increase the work-related expenses of female sex workers (e.g., time off the job, bail and other legal fees) and sometimes inconvenience clients but rarely change the form or prevalence of the activity.

The perception that intermittent police intervention (e.g., harassment, searches, arrests, detention) decreases the prevalence of prostitution is in part a function of removing women from the street to jails. But this is merely a temporary absence, part of what James (1977) calls the “revolving door” of street/jail/street. For women who are not detained, police intervention may result in migration to other areas. The migratory pattern of street work is well recognized by researchers who have studied prostitutes and is referred to as “horizontal mobility” or the “scatter syndrome” (Carmen and Moody, 1985:194). In fact, Carmen and Moody (1985) suggest that short-term police crackdowns have more impact on migratory patterns of female prostitutes than on the practice of prostitution per se. For women who are detained, Alexander (1987) postulates that the usual activities of the police may reinforce reliance on pimps who can arrange for bail or attend to child care needs while the women are in custody, but that such activities are unlikely to be effective in reducing the prevalence of prostitution.

One consequence of migration is the problem it poses for AIDS outreach workers who wish to contact these women or, once reached, to maintain contact with them. There are also other repercussions associated with scatter and mobility. Without repeated contact with the targeted group, intervention staff may find it difficult to develop the credibility and trust needed to convey information and provide services, especially to a population that is suspicious of authority figures. Moreover, women who have migrated to new areas may find themselves more vulnerable and therefore more amenable to enticements offered by pimps. Not only may mobility impair efforts to find and retain street prostitutes in prevention programs but the interpolation of pimps as mediators with the outside world may also undermine the ability of street outreach workers to identify and establish contact with prostitutes.

IV drug use is thought to be more common among street prostitutes than among other sex workers, and streetwalkers are also more likely to be poor and minority women (James, 1977; Goldstein, 1979). Some prostitutes report resorting to drug use as a result of their work; others report starting a career in prostitution to support a drug habit (Goldstein, 1979).15 (The role of crack in fostering prostitution is addressed later in this chapter.) As noted earlier, the relationship between prostitution and drug use is unclear, but the potential for HIV transmission has been established in situations in which both factors are present. Therefore, directing AIDS intervention efforts toward prostitutes who inject drugs makes eminent good sense.

Bar prostitution coexists with street prostitution but is less likely to result in arrest because police generally have to spend more resources to identify and entrap prostitutes who work in bars (so-called B girls). An observant bartender familiar with local vice squad personnel can either assist or foil police efforts (James, 1977). Some women who work in bars are afforded protection or at least a warning of ongoing police activity by the bartender, but these women must pay for this service by “pushing” drinks. (Whether bar prostitutes are independent or controlled by pimps, they often give large tips to the bartender or owner of the establishment.) At the same time, bar prostitutes are not entirely safe from police intervention. Because bartenders or owners are accountable to the police and other agencies that regulate alcohol sales, they sometimes find it useful to turn prostitutes over to the police intermittently. The usually clandestine activity of bar prostitutes hampers outreach efforts to prevent AIDS in this population.

Brothels

Prostitutes who work in brothels constitute another subgroup of the female sex worker population, and this subset of women can be further subdivided into workers at legal or illegal houses of prostitution. In the United States, brothels are legal places of business only in certain parts of Nevada and are separated from the rest of the town, often with fences (James, 1977; Carmen and Moody, 1985). The movements of women who work in Nevada's legal brothels are severely restricted (Carmen and Moody, 1985; Alexander, 1987). Because prostitutes are required to register with the sheriff (a process that includes fingerprinting), these restrictions are generally enforceable (James, 1977; Alexander, 1987). Registered prostitutes are not allowed to enter or solicit customers in a gambling casino or bar (although other women may be “working” there), be in the company of a man on the street or in a restaurant, or reside in the same community in which they work. They are required to live in the brothel during a three-week work shift; after their shift, they are off duty for a week or more during which time they are expected to leave town.

Prostitutes in Nevada's legal brothels undergo mandatory weekly testing for gonorrhea and monthly testing for syphilis and HIV infection (Alexander, 1987; Rowe and Ryan, 1987), and each woman is required to pay for her own tests, which cost approximately $150 per month. There is little evidence of HIV infection among prostitutes working in legalized brothels (CDC, 1987; Rowe and Ryan, 1987). Moreover, the percentage of legal brothel workers and applicants reporting a history of IV drug use (27 percent) was lower than among any other group of sex workers who participated in the CDC multicenter study (Darrow et al., in press).

Life in illegal brothels may be quite different. Rules of behavior, residence, and personal care are generally more flexible and are set by the local establishment. Typically, a brothel is managed by a “madam,” but it may be run by an owner of either sex (James, 1977; Alexander, 1987). Female prostitutes who work in such brothels (on eight-hour shifts) generally live elsewhere (James, 1977). The extent of IV drug use in these establishments is unclear, although it has been reported that sex workers with a reputation for heavy drug use are excluded from employment in some brothels because of the problems associated with drug dependence (Goldstein, 1979).

Compared with drives against street prostitution, the suppression of off-street sex work, such as brothel employment, requires even greater efforts on the part of the law enforcement system, and few jurisdictions are willing to commit the resources necessary to eliminate this type of prostitution. For one thing, brothels are not always easy to identify, although they usually come to the notice of the police if they are of any size. The visibility of illegal brothels and their accessibility to the general public often depend on levels of local tolerance. Historically, “red-light districts” in the United States have housed many illegal yet tolerated brothels. At present, brothels appear to be less open to the general public, but they continue to be known to many individuals (cabdrivers, bartenders, others who may refer business to them). Nevertheless, for the purposes of AIDS prevention, most such organizations are difficult to identify and contact.

Massage Parlors

Other prostitutes work in massage parlors, spas, encounter studios, and other businesses with euphemistic names for essentially the same services. These businesses are generally identifiable from the street (Alexander, 1987). Not all massage parlors offer sexual services, but in those that do, it is customary for the masseuses to make arrangements with the customer regarding the services to be delivered and for the owner to feign ignorance of this illicit activity (James, 1977). The owners and managers of these businesses, who legally are considered pimps and panderers, may be resistant to onsite AIDS prevention programs for workers or clients, in part out of fear that such activities may be a prelude to or a “setup” for arrest.

In several U.S. cities, including San Francisco, massage parlors and their employees are required to obtain work licenses from the police department (Alexander, 1987), establishing a de facto form of legalized prostitution in this one setting. Paradoxically, however, women with a history of arrests for prostitution are denied licenses, and licenses are revoked after an arrest for prostitution.

Outcall Prostitution

Another segment of the prostitute population works on an “outcall” basis. The traditional call girl works independently, with a “book” of steady clients who are contacted by phone. Instead of recruiting clients from the street or meeting them in brothels or other centralized locations, the call girl sets up her own referral system (James, 1977; Alexander, 1987). A call girl may develop a list of phone numbers of potential clients in a variety of ways, including the purchase of names from other call girls (James, 1977). When business is slow, income can often be generated by telephoning known customers and extending invitations. Usually, call girls are more affluent and have better working conditions than most prostitutes (Gagnon and Simon, 1973; James, 1977; B.Cohen, 1980; Shedlin, 1987). Prices for services may vary, but the generally higher socioeconomic status of their clients provides call girls with a higher price per transaction than is received by most prostitutes. In addition, because of their lower public visibility, call girls generally have fewer problems with the police than do streetwalkers.

Over the last two decades, “escort services,” originally an outcall feature of massage parlors, have begun to develop as businesses in their own right. The owner of an escort service that employs female sex workers meets the legal definition of a pimp. Unlike pimps who may have sexual or personal relationships with street prostitutes, however, the relationship between the owner of an escort service and a call girl is usually restricted to business. In general, there is little or no personal contact between sex workers and agents.

There are certain legal benefits to this new system of services. Managers of escort agencies can deny knowledge of sexual transactions between clients and employees, claiming that the only service advertised and offered is companionship. Moreover, because the fee is understood to include sexual services, the outcall worker does not have to discuss price, which makes it difficult for law enforcement personnel to collect evidence of solicitation (Perkins and Bennett, 1985). Many cities license escort services through the police department, again barring anyone with a history of prostitution-related arrests from obtaining a license.

The implications for AIDS prevention of this pattern of prostitution are still unclear. For example, the extent of drug use in these establishments is not known, but at least one ethnographic study has reported that many of the “better” agencies forbid drug use (Shedlin, 1987). What is clear is that prostitutes who work on an outcall basis (either through an escort service or on their own) are among the least visible and most independent of all prostitute subgroups.16 This independence may exacerbate existing problems in gaining access to this subgroup to provide AIDS education.

Crack and Prostitution

In the past, women often engaged in sex with men for a “taste” of heroin or cocaine, or they might work as prostitutes to make money to purchase their own supply. In a number of urban settings a new form of sexual barter has arisen in connection with the widespread use of crack. Crack-related prostitution displays some similarities with past practices involving drug-sex interaction, but certain features of crack suggest that the use of this drug may evoke a qualitatively different situation. For example, crack provides only short-term effects (addicts often require 10 to 20 “hits” per day); there is evidence of increased sexual arousal among men who smoke crack (unlike heroin, which tends to dampen sexual excitement); and because the drug is so inexpensive (a vial may cost less than $5, a “toke” as little as 50 cents), very young people— including girls in their early teens—can afford it. Some of these young women engage in sex with men either directly for the drug or for money with which to purchase it. Men who wish to have sex with these young women (either when they themselves have taken crack or when they have not) can purchase these sexual services quite inexpensively. Some of the women become so-called “crack whores,” spending a great deal of time in crack houses and engaging in sex with customers. Because money may not change hands or is immediately used for drugs rather than subsistence, the women exchanging sex for drugs may not consider themselves to be prostitutes and, indeed, may not view their actions as work.

Researchers in this area report ethnographic evidence that crack has begun to change street prostitution. Outreach workers in Harlem, for example, have found that very young teenage girls engage in sexual intercourse with IV drug users to receive crack (Friedman et al., 1988). In a study of 82 teenage female crack users from the San Francisco area, 24 (29 percent) reported exchanging sexual favors for drugs or money (Fullilove et al., 1990). In some areas, older, more experienced women are leaving the streets because of their fear of AIDS and the violence associated with crack; younger women addicted to this drug are taking their place (Shedlin, 1987).17

In the case of crack, the risk of HIV infection is related to the exchange of sex for drugs and the disinhibition associated with crack use that fosters frequent unprotected sex (Friedman et al., 1988; Abramowitz et al., 1989; Worth et al., 1989). Because crack is highly addictive and provides only a short-term “high,” supporting a crack habit may require a large number of sexual partners or sexual acts, thus amplifying the risk for HIV infection (Weissman, 1988). Because a woman may have multiple partners during the course of one time period at a crack house, one would predict a significant level of HIV risk associated with the activity if there is infection among local crack users or their sexual partners. The committee has already commented in Chapter 1 on research relating crack use to HIV and other STDs (Chiasson et al., 1989; J.B. Cohen et al., 1989; Fullilove et al., 1989). It reiterates here its counsel on the need to monitor the spread of infection among crack users.

INTERVENTION PROGRAMS

The picture of prostitution that emerges from these limited data is not an integrated one. Rather, it is a composite of very different women, some working independently, others with procurers; soliciting on the streets or working in organized sites; earning subsistence wages or lucrative incomes; living with drug dependence or living drug free. Some women, such as those who exchange sex for crack, do not view their activities as work at all and do not see themselves as part of the sex industry. Many, perhaps most, have other identities in addition to their sex work roles. This diversity needs to be considered in designing intervention strategies for reducing HIV risk because it has important consequences for selecting access routes to the various subpopulations and for tailoring the content of interventions. In addition, at least two essential themes have been noted by those who have worked with female prostitutes: for a message to be heard, the source must be trustworthy and nonjudgmental, and the content must reflect sex workers' interests.

Access

At first glance, it might seem sensible to launch AIDS intervention activities from existing institutional bases (such as law enforcement agencies, STD clinics, or other public health programs) because these locations are typical points of contact with some sex workers. However, prostitutes' experiences with these institutions in many instances have not led to relationships of trust. As a result, intervention efforts made by or through these agencies may be severely handicapped in terms of earning participant trust and gaining acceptance of the AIDS prevention messages being delivered (Stephens et al., 1989).

The theory of adoption and diffusion of innovation predicts that trusted and respected leaders in any community are important resources to be mobilized in the design and implementation stages of activities to introduce a new product or procedure (Rogers, 1962; Becker, 1970; Rogers and Adhikarya, 1980). For this reason, involving prostitutes and ex-prostitutes directly in the design and implementation of AIDS prevention programs may instill trust and facilitate access to the population and the recruitment of participants; it may also help to ensure that the implemented programs reflect the needs of prostitutes and the diversity of contexts in which they work. Peer-led programs involve the target audience as part of the solution to the problem rather than as merely the object of their efforts. Several existing AIDS programs for female prostitutes in this country and abroad have used women from the sex industry as part of their outreach and educational efforts (Locking, 1988; Sanchez, 1988; J.B.Cohen et al., 1989; Kinnell and Griffiths, 1989; Monny-Lobe et al., 1989b; Nichols et al., 1989; Rosario et al., 1989; Stephens et al., 1989). The knowledge that these women bring to a project regarding the local population has often been important in encouraging recruitment, maintaining participation, and ensuring follow-up.

Understanding how the business of prostitution is organized is important for designing methods to gain access to the different groups of female sex workers. Prostitutes who work independently (e.g., call girls) are often difficult to contact because they are less visible and accessible than other sex workers. In addition, they may be the most isolated of all sex workers and the least integrated into information networks. Researchers have located independent sex workers through ads in daily newspapers, classified telephone directories, sex-related newspapers, and other media.18 Ethnographic research may also be used to identify and utilize existing networks of independent sex workers to reach this subpopulation. For example, Shedlin's (1987) model for delivering AIDS prevention education to prostitutes grew out of her work with a group of female street prostitutes who had initially been recruited to receive other social services. (For descriptions of additional programs, see also B.Cohen [1980] and Carmen and Moody [1985].) Finally, current and former street prostitutes may be able to deliver health messages effectively by contacting women who are currently in the industry.

Workers in organized sites, such as brothels, massage parlors, escort services, and the like, are less visible than street workers but may be more accessible for prevention efforts (especially those delivered by former sex workers), even though the illegal nature of prostitution may make managers reluctant to allow educators access to workers. Individuals who have established intervention programs for prostitutes at organized sites offer the following advice for the design and execution of AIDS prevention projects. First, problems can arise if project staff become overly identified with the owners of organized prostitution sites. The prevention efforts offered by these projects should be presented as a resource for sex workers, acting, for example, as an advocacy group to support prostitutes' rights to safe working conditions. Second, in areas where prostitution is illegal, management personnel of organized sites must be convinced of the trustworthiness of AIDS outreach workers and the benefits to be gained from safer sex practices. (Without the cooperation of the management, it will be extremely difficult to identify and contact women working in these establishments.)19 Finally, managers of organized sites may discourage prostitutes from using condoms because they fear losing business and consequently income. The implementation of AIDS prevention efforts may be particularly difficult if some sites in a community promote the use of condoms and others do not. Because some clients are not willing to use condoms, such a two-tiered system may draw business away from prostitutes who insist on protected sex and contribute to conditions under which HIV and other STDs can spread. Alternatively, with the appropriate introduction, condom use may provide a positive selling point for such businesses, as both prostitutes and clients become more aware of AIDS. The Australian experiment discussed in the next section has tried to implement a universal condom policy in a manner that enhances the attractiveness of a brothel.

Types of Interventions

Ideally, any intervention program for female prostitutes should serve its targeted population in a nonjudgmental fashion, forming partnerships that will help each individual understand her level of risk, make appropriate behavioral changes, and facilitate the development of required skills to sustain those changes over time. In the case of sex workers, it may be particularly important to state the spirit and goals of the program in clear, unambiguous language. Because prostitutes have often been stigmatized by society and labeled as deviant by some research activities, AIDS education and research programs targeting this population need to stress that their goal is to help prostitutes protect themselves from HIV infection. Conversely, if female sex workers perceive the primary purpose of interventions to be the protection of clients, it may be difficult to gain their trust and cooperation.

Because the major risk factor associated with infection among prostitutes appears to be IV drug use, AIDS prevention should highlight drug treatment and safer injection projects, as well as the prevention of IV drug use. As noted earlier, such efforts would surely benefit from a better understanding of the connection between IV drug use and prostitution. It is also vital to provide instructions regarding safer needle use for women who continue to inject drugs. Both referral to treatment and education about safer injection practices can be delivered through street outreach projects. For example, outreach programs to distribute bleach to drug users in New York and San Francisco have incorporated street counseling and drug treatment referral (Des Jarlais, 1987). These program components are being delivered in outreach projects directed toward prostitutes, using mechanisms as innovative as a prostitute collective, which was organized by the New York City ADAPT (Association for Drug Abuse Prevention and Treatment) project for participation in a series of weekly meetings to discuss drug and sex risk reduction techniques (Friedman et al., 1989).

The second increased risk factor for female sex workers is multiple unprotected sex acts. Many of the safer sex education programs designed for the broader population of women at risk may also be appropriate for women who work in the sex industry. In their personal lives, prostitutes enact the same intimate roles (e.g., spouses, lovers) as women in the larger female population. In addition, however, they face unique problems in changing high-risk sexual practices because sex occurs not only in a personal context but also with clients. Intervention programs for prostitutes must take into account the number and diversity of risk behaviors in which sex workers engage and the contexts in which these behaviors are enacted.

Many existing street outreach programs are designed to protect street prostitutes from HIV infection by providing them with information about safer sex and IV drug use practices. An example of such a program is the ongoing California Prostitutes Education Project (CAL-PEP). This program employs former female street prostitutes who walk through stroll districts, introducing themselves and the program as they encounter sex workers. The outreach workers provide information about how AIDS is transmitted and how to prevent infection (both injection based and sexually transmitted). They distribute small bottles of bleach and instructions on how to clean injection equipment, as well as safer-sex kits (small plastic bags containing five different kinds of condoms and safer-sex guidelines) (Alexander, 1988). CAL-PEP also holds monthly workshops for street workers. Training sessions include a number of components: a discussion of how HIV is transmitted and how to prevent infection; a demonstration of how to clean injection equipment; a demonstration of how to use condoms (including instructions on using condoms for oral sex as well as for vaginal and anal intercourse, avoiding breakage, and using a lubricating spermicide for additional protection); and a practice session for newly learned skills and roles, with special emphasis on encouraging the cooperation of both paying clients and nonpaying partners in the use of safer-sex practices. The project has also established support groups to provide a comfortable opportunity for prostitutes to continue to discuss their concerns about AIDS, obstacles to behavioral change, and strategies for facilitating change. Support group sessions have been held in a van, in hotel rooms, and in places where prostitutes congregate.

Similar peer-led intervention workshops have also been conducted for organized workers in brothels, massage parlors, sex clubs, erotic dancing theaters, and other locations that employ sex workers.20 As noted earlier, many of these projects use current and former prostitutes familiar with a particular work location to win over management and gain access to sex workers.21 For example, in a program developed by the Australian Prostitutes Collective, outreach teams contacted the managers of brothels to make arrangements for bringing safer-sex and IV drug use training sessions onto the premises (Overs and Hunter, 1989). This program also developed a Safe House Endorsement policy: houses that enacted and enforced mandatory condom policies and maintained good working conditions received a certificate of endorsement from the project. Project planners hoped to encourage the patronage of only those houses that had received endorsements.

Another type of intervention—voluntary anonymous counseling and HIV antibody testing of prostitutes in the context of a supportive environment —has been advocated and implemented in several communities. However, the lack of solid evaluation data on the vast majority of programs precludes drawing firm conclusions about the effectiveness of these efforts in changing behavior.22 Where mandatory HIV antibody testing has also been implemented (e.g., for convictions of prostitution or as a prerequisite to drug treatment), prostitutes have expressed resentment (Shedlin, 1987). Jurisdictions that encourage voluntary testing while mandating HIV tests for women convicted of prostitution may compromise the usefulness of voluntary testing. At the least, such a policy sends out mixed messages to sex workers, raising serious doubts about the benefits these women may gain from testing and how information on test results is to be used (Decker, 1987; J.B.Cohen, Alexander, and Wofsy, 1988; Rosenberg and Weiner, 1988).

Some intervention programs advocate eliminating prostitution but neglect important economic realities. Prostitution provides better economic incentives and more flexible work schedules than many other jobs available to women who are likely to have few alternative employment opportunities. If intervention programs do not include vocational training components, they may well be unsuccessful because they do not address the limited occupational skills and survival needs of this population (Decker, 1987). Making the transition to lower-paying legitimate jobs can be difficult for many female sex workers, but the process may be eased with the help of former prostitutes who can provide role models as well as support and counseling (Alexander, 1987; J.B.Cohen, Alexander, and Wofsy, 1988).

Finally, AIDS prevention programs related to prostitution must look at both the supply of and demand for these services. Client demand for unprotected sex can make it difficult for prostitutes to adopt safer-sex technologies (Rosenberg and Weiner, 1988). Thus, safer-sex intervention efforts that focus exclusively on sex workers and fail to include their clients neglect an important aspect of AIDS prevention and may prove unsuccessful. Although the current risk of HIV infection associated with unprotected sex with a female sex worker is small, it will remain so only if both clients and prostitutes adopt safer sexual practices on a wider scale and more consistent basis. Given that there is both a supply of and demand for prostitution and little likelihood that the AIDS epidemic will eliminate either, messages designed to protect the health of all participants should tell men to use condoms if they have sex with prostitutes.

IMPEDIMENTS TO MORE EFFECTIVE INTERVENTIONS

The barriers that have impeded AIDS prevention efforts among prostitutes fall into several categories. In some cases the obstacles to prevention within this population are similar to those hindering interventions among other groups. For example, because the major HIV risk factor in the sex worker population is IV drug use, providing treatment for drug use and information about safer injection practices is of paramount importance. A major barrier to such interventions is the inability of current treatment programs to respond to demand (IOM/NAS, 1988; Turner, Miller, and Moses, 1989). Long waiting lists for admission are common, program retention rates are low, and support services, such as job training, are deficient. The lack of drug-use treatment facilities is of particular concern because the risk of transmission among IV drug users is clear and efforts to prevent this type of transmission have lagged far behind what is needed. Prostitutes who are drug users may have a difficult time securing needed services because there are fewer drug treatment openings for women than for men, especially for women with children.

The illegality and marginality of prostitution constitute another series of barriers to deploying interventions and adopting new behaviors (Decker, 1987; J.B.Cohen, Alexander, and Wofsy, 1988). In particular, the illegal nature of prostitution often forces female sex workers and their agents (pimps, madams, massage parlor and outcall service operators) to conceal their practices, thereby limiting educators' access to these groups and restricting support group and outreach activities. Laws against prostitution have other ramifications for intervention as well, which are discussed in the sections below.

Laws Against Prostitution

It is a crime to solicit or engage in an act of prostitution in all 50 states and the District of Columbia; the only legal exception is brothel prostitution, which is a local option in rural Nevada counties with populations of fewer than 250,000 inhabitants (Decker, 1987; Rowe and Ryan, 1987). Prostitution is defined as a lewd act in exchange for money or other consideration. Violation of these laws is generally a misdemeanor, except in states that have passed AIDS-related legislation increasing the charge to a felony for an individual arrested after testing positive for HIV infection (see, for example, Shaw, 1988). In addition, all states have laws against living off the earnings of a prostitute (pimping), encouraging anyone to work as a prostitute (pandering or procuring), or running a house of prostitution. Various statutes also deal with the abuse of minors in prostitution.

Federal law is applied when a person crosses state lines to work as a prostitute or sends money earned by prostitution in one state to another state. In addition, U.S. immigration laws bar anyone who has ever worked as a prostitute, either legally or illegally, from entering the country. Such laws can also be used to deport aliens who work as prostitutes after entering the United States, even if the work is legal (Alexander, 1987).

Enforcement rates of laws against prostitution appear to vary by state and region as well as over time.23 A recent AIDS-related concern that has arisen in connection with law enforcement is the use of condoms as probative or indirect evidence of a crime. There is anecdotal evidence that law enforcement officials in some locales seize condoms as evidence of intent to commit or solicit prostitution. In some jurisdictions the practice has been abolished; as the San Francisco Police Department has stated, “[t]he police value of these materials as indirect evidence of prostitution …is exceeded by their AIDS prevention value” (Department Special Order 87–13).24 Where it continues, the practice of using condoms as evidence of a crime dampens AIDS interventions that seek to persuade prostitutes and others in the sex industry to make condoms available to clients.

Although many prostitution laws were originally enacted to protect women from exploitation, such laws can also have the effect of cultivating secrecy among prostitutes and a wariness of outsiders that impedes outreach efforts to promote health education and risk reduction. Research has shown that in jurisdictions in which prostitution is illegal and the law is enforced, it does not go out of existence but instead goes underground in a way that increases the difficulties of outreach to female sex workers for public health purposes (B.Cohen, 1980; Carmen and Moody, 1985; Alexander, 1987). If police confiscate condoms as evidence of intent to solicit prostitution or if possession of condoms is listed on an arrest record, prostitutes receive a message that is inconsistent with what is being asked of them by public health authorities. Prostitutes may thus be discouraged from carrying condoms on their person, making it even more likely that they will engage in unprotected sex.

AIDS-Related Legislation

In an attempt to control the spread of HIV, some states have proposed or passed special AIDS legislation that targets persons working as prostitutes (Rowe and Ryan, 1987). One type of statute restricts the activities of infected individuals, and another calls for mandatory HIV testing of prostitutes. Not much is currently known about the enforcement of these laws, but both types of legislation have consequences for the implementation of AIDS prevention programs.

Restriction of Infected Individuals

In some locales, local health officers can “restrict” (either through quarantine or isolation) individuals who have a communicable disease that is thought to endanger the public health. In Colorado, for example, the statute is rather stringent and singles out HIV as an isolable condition. If a person is reasonably believed to be infected with HIV, a representative of Colorado's public health office can issue a cease-and-desist order for specified dangerous conduct (in this case, prostitution); violation can result in a criminal penalty (Gostin and Ziegler, 1987).

The impact of such laws on HIV transmission and on the ability to provide intervention and other services is not known. However, legal provisions for isolation are unlikely to address fundamental problems of HIV transmission, according to a report by the Institute of Medicine (IOM/NAS, 1988). Indeed, the threat of such restrictive action may cause at-risk individuals, including prostitutes, to avoid HIV testing and other help-seeking measures in order to escape identification by the authorities.

Mandatory HIV Testing

A few states have passed legislation or have bills pending that would require anyone convicted or arrested for prostitution to be tested for HIV infection (Gostin and Ziegler, 1987; Rowe and Ryan, 1987). For example, Florida requires women convicted of prostitution to undergo screening for a variety of STDs, including HIV; women who are found to be infected must submit to treatment and counseling as a condition for release (Gostin and Ziegler, 1987). In addition, some states have imposed penalties on HIV-infected persons who are convicted of exposing other individuals to the virus. Prostitutes obviously will be affected by these laws, even when they are not specific targets of the legislation (Gostin and Ziegler, 1987).

It is unclear whether mandatory testing laws are effective in reducing the rate of transmission of HIV infection. Certainly, other attempts to legislate the control of STDs have not met with great success.25 Without safeguards in place to protect individuals who are found to be infected, female prostitutes may view compulsory HIV testing as harmful, which in turn may nullify any anticipated benefits. Moreover, such laws may divert resources from educational efforts that could be more effective in reducing the epidemic's spread.

Even in locales in which prostitution is legal, the benefits of mandatory HIV testing are not entirely clear. Policies that enforce regular medical examinations of prostitutes may also foster risk taking by engendering a false sense of security (i.e., that one is not at risk) that in reality cannot be ensured by weekly or monthly checkups to detect syphilis, gonorrhea, HIV infection, or other STDs (J.B.Cohen, Alexander, and Wofsy, 1988). For example, once mandatory HIV testing was instituted in Bavaria, West Germany, clients began to refuse to use condoms because they felt that testing had eliminated the risk of AIDS (Pheterson, 1989). Of course, this perception of eliminated risk does not take into account the possibility that the client could infect the prostitute. Very few countries have begun intervention efforts to educate customers about their responsibility for condom use.

Other Effects of Marginality

Groups such as prostitutes and drug users who live and work on the margins of society often experience subtle consequences of this marginality that may affect any attempts to facilitate behavioral change. The nature of sex work as a marginal profession, for example, creates barriers for some prostitutes that may impede their implementation of safer-sex behaviors. In legitimate workplaces, employees are protected by law from many hazardous conditions; they are able to organize to promote occupational safety and guaranteed fair wages. These patterns and practices are not necessarily available to prostitutes, even though safeguards, such as the technology currently advocated to reduce sexually transmitted HIV infection (latex condoms and spermicides with nonoxinol-9) have been available for decades to prevent other STDs.

At the same time, female prostitutes report problems persuading their partners, both paying and nonpaying, to use condoms (J.B.Cohen, 1987; Shedlin, 1987; Day, Ward, and Harris, 1988; Rosenberg and Weiner, 1988; Monny-Lobe et al., 1989c; Wilson et al., 1989; Darrow et al., in press). A prostitute's precarious financial position may make her vulnerable to customers who offer a higher price for sex without a condom. Moreover, prostitutes are at least as vulnerable as other women in their personal relationships. In contrast to professional relationships, the way in which personal sexual relationships are defined by sex workers and their partners often precludes condom use or other protective measures (J.B.Cohen, 1989).

Finally, the marginality of their profession and prostitutes' need to earn a living may engender a quite practical apprehension about AIDS education. It has been reported that streetwalkers are sometimes reluctant to accept materials labeled as “AIDS” information because the materials might be seen by others who might infer that any prostitute reading such material has already been infected. It thus becomes a wise business decision to refuse risk reduction literature (Shedlin, 1987).

Although female prostitutes do not appear to play an important role in transmitting HIV, a significant proportion of sex workers in some locales are infected with the virus, mainly from IV drug use practices and, to a lesser extent, from sexual contact with infected husbands and boyfriends. For this reason, it is important to extend to sex workers the services and education they need to prevent acquisition of the disease. Options for future HIV prevention efforts are presented below.

FUTURE NEEDS AND OPTIONS FOR HIV PREVENTION

Female prostitutes as drug users mandate a specific set of HIV prevention strategies, the most prominent of which include access to drug treatment centers and, for women who continue injecting, instructions on cleaning injection equipment. These interventions were discussed at length in Chapter 3 of the committee's first report (Turner, Miller, and Moses, 1989). In addition, prostitutes in their capacity as prostitutes have unique needs. The illegality and marginality of the sex industry raise a number of stubborn issues that resist resolution, but some of these issues can be affected by changes that would further the implementation of HIV interventions.

First, nationwide agreement is needed among enforcement and criminal justice personnel that the possession of condoms will not be used as evidence of intent to commit or solicit prostitution or, in the case of brothel owners and managers, as evidence of intent to commit the more serious offenses of pimping, pandering, or procuring. Such an agreement is consistent with recommended public health practices and has already been adopted by a handful of U.S. cities. Moreover, the policy of mandatory HIV testing for arrested or convicted prostitutes is not warranted at this time. Prostitutes' risk of HIV transmission is more closely associated with drug use than with sexual activity and appears to be greater in personal relationships than in paying ones. Mandatory testing programs that focus on female prostitutes as professional sex workers are thus mistargeted and reflect an injudicious use of resources, given that most serologic studies of prostitutes who do not inject drugs find few who are infected. In addition, one-sided testing policies that do not include the clients of prostitutes are not sound public health practice. The committee finds, therefore, that mandatory testing of prostitutes is unlikely to address the real sources of increased risk, which are tied to private, intimate relationships and clandestine use of illicit substances. Recently, the Institute of Medicine's Committee for the Oversight of AIDS Activities rejected the policy of mandatory testing and warned that tying antibody status to criminal activity might also discourage voluntary testing, counseling, and medical referral (IOM/NAS, 1988). The committee concurs with that position and urges the rejection of such policies.

Second, the connection between HIV infection and prostitution needs to be better understood. The known facts about this diverse population are few. There is currently some sense of the prevalence of HIV infection among female prostitutes, although studies to date have relied on small, geographically discrete groups that may or may not be representative of the larger population. Although some information is available on how and why women enter prostitution, little is known about how and why they leave this work (see, for example, Potterat and colleagues [1985]). Most existing studies are based on discrete groups of prostitutes and are outdated. In addition, support is needed for studies of men who are clients of prostitutes. For the purposes of understanding both HIV transmission and the design and implementation of intervention programs, data are needed on the work contexts of prostitutes, their personal social networks, their occupational histories, and their clients.

The committee believes such research efforts will benefit from input by women who have actually worked as prostitutes. Especially important are investigations of individuals who report behaviors recently found to be associated with HIV transmission, such as the young women who are exchanging sex for drugs but do not define themselves as being “in the business” —and so do not protect themselves against any STDs, including HIV infection. The relationship between crack use and sexual transmission of HIV is just beginning to be understood; a fuller understanding requires careful study of the subpopulation of women and men who exchange sex for crack to shed light on emerging patterns and risks. It is likely, however, that IV drug use will continue to be the major route of infection for prostitutes in the industrialized countries.

Finally, there is little information about the effectiveness of recently begun intervention efforts for this population, and the committee urges that this situation be corrected. Longitudinal studies of planned variations accompanied by rigorous evaluation are just as necessary and desirable for this population as for others at risk for HIV infection. Strategies for evaluating the risk reduction projects of community-based organizations have been laid out in Coyle, Boruch, and Turner (1990) and could prove to be useful in this arena as well. Without some evaluation of the effects of a project, be they positive or negative, planners lose the opportunity to understand what best facilitates change and where resources are best expended.

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Footnotes

1

The term prostitute is used to denote the diverse group of women who exchange sexual acts for money, goods, or services as a means (or partial means) of their livelihood or survival. Other terms—such as sex workers, sex industry workers, and commercial sex workers—have also been used to describe this population in an effort to avoid the judgments that are often associated with the term prostitute. The committee appreciates this distinction but has chosen to use the terms interchangeably. None of the terms are intended to convey any judgment about individuals who work in this area.

Because so little is known about male prostitutes, the committee has restricted its focus to females, although male prostitutes are also at risk of acquiring and spreading HIV infection. One study of 152 male prostitutes recruited from the streets of Atlanta, Georgia, found that 27 percent were infected. Compared with seronegative respondents, male prostitutes who were HIV positive had spent more years as prostitutes, were more likely to self-identify as homosexual, and had had more encounters involving receptive anal intercourse in the month prior to the interview (Elifson et al., 1989).

2

The rate of HIV infection appears to be highest among prostitutes who report IV drug use (CDC, 1987). A recent study of the prevalence of related viruses (HTLV-I/II) among female prostitutes also found rates to be highest among women who had injected drugs (Khabbaz et al., 1990). In addition, a recent study of prostitutes who did not use drugs found a significant relationship between infection and the number of personal (i.e., nonpaying) heterosexual partners (Darrow et al., 1988).

3

For examples of research that reflect the perspective of prostitutes, see Jaget (1980), Perkins and Bennett (1985), and Delacoste and Alexander (1987).

4

These data correct Table 2.8 of Turner, Miller, and Moses (1989:143), which includes the results of 60 serologic retests that were originally reported to the editors as individual respondents.

5

That the source of infection was contaminated injection equipment rather than multiple professional customers is given further credence by the results of Wolfe and colleagues (1989). Their study of 220 female intravenous drug users recruited from methadone maintenance programs and detoxification treatment facilities in San Francisco found that seropositivity was not in fact associated with “paid sex.” Moreover, Khabbaz and colleagues' (1990) analyses of data on the prevalence of HTLV-I/II infection from the CDC multicenter study of female prostitutes found statistically significant positive associations between seropositivity for these viruses and the use of shooting galleries, needle-sharing, duration of injecting career, and frequency of drug use. Infection was not associated with number of sexual partners.

6

In a survey of 1,305 female prostitutes from the CDC multicenter study, 600 reported that they had injected illicit drugs at some time in their lives or had physical signs (needle marks) of IV drug use (Khabbaz et al., 1990). Slightly more than half (318, or 53 percent) were nonwhite (217 blacks, 73 white Hispanics, 13 black Hispanics, 10 American Indians, and 5 Asians). Other analyses of these data find that 84 percent of IV drug-using women reported street prostitution compared with a significantly smaller proportion (74.3 percent) of women with no history or signs of injection (W.W.Darrow, chief of the Social and Behavioral Studies Section, Center for Infectious Diseases, CDC, personal communication, October 6, 1989). In another study of 60 women who reported drug use, Goldstein (1979) found that 43 also reported prostitution. The vast majority (96 percent) of the 25 streetwalkers interviewed in this study reported regular heroin use. In contrast, none of the 18 prostitutes who worked in massage parlors, as call girls, or as madams reported regular use of heroin, although 22 percent had used the drug at least once. Of the 25 streetwalkers interviewed, 64 percent were black, and 20 percent were Hispanic.

7

A serologic survey of 90 streetwalking female prostitutes recruited from a depressed inner-city area of south Florida and 25 women who worked for an escort service in a middle-class urban area of that state found that 41 percent of the streetwalkers were infected but none of the women from the escort service were seropositive (Fischl et al., 1987). These results are consistent with findings from the CDC multicenter study, in which brothel workers and applicants constituted the group with the lowest rates of IV drug use and the lowest rates of HIV infection (Darrow et al., in press).

8

CDC supports ongoing studies of female prostitutes in several cities (see Table 4–1) that are investigating the sexual and social networks of prostitutes as well as strategies for outreach, treatment, and social mobilization of female sex workers. NIDA funds outreach and education programs for a diverse population of women, including prostitutes.

9

In a study of HIV infection among patients seeking treatment at an STD clinic, Chiasson and coworkers (1989) found that, among twelve infected men who reported no same-gender sexual contact, no IV drug use, and no sexual contact with a person known to be infected with HIV, three had a history of sexual contact with known crack users, one was a crack user himself, and eight reported contacts with prostitutes. Furthermore, of the six seropositive women identified in this study who also reported no history of IV drug use or sexual contact with an infected individual, four were prostitutes who used crack.

10

In this study, ex-addict street outreach workers were used to identify informants among residents of buildings that served as crack houses. They reported that male addicts found female crack users to be an inexpensive and readily available source of sexual gratification.

11

There are, however, some preliminary data on this practice from the CDC multicenter study. More than one-third (36.3 percent) of the women in the study reported at least one episode of anal intercourse (W.W.Darrow, chief of the Social and Behavioral Studies Section, Center for Infectious Diseases, CDC, personal communication, October 6, 1989).

12

In a study of 91 prostitutes recruited from an STD clinic in London, Day, Ward, and Harris (1988) reported that more than half (59 percent) of the women reported consistent condom use with paying customers. Of the 71 women who reported vaginal intercourse with their boyfriends, 6 percent said they used condoms consistently with these partners. The differential pattern of condom use did not change over the course of the 17-month study; however, the percentage indicating condom use increased for both groups.

13

The female prostitute who works alone—either through circumstances beyond her control or more often by choice—is referred to as an “outlaw” (Carmen and Moody, 1985).

14

Such differential enforcement often results in an overrepresentation of street prostitutes in statistics generated by the criminal justice system.

15

In Goldstein's (1979) research, 58 percent of the streetwalkers participating in the study started using heroin once they became prostitutes; 24 percent had used heroin regularly before their entry into prostitution.

16

Most male escorts, also known as call boys, work independently, although there are some organized male escort services (Pittman, 1971; Gagnon and Simon, 1973; Perkins and Bennett, 1985).

17

Once on the street, these young women may also be at increased risk of initiating heroin use (Friedman et al., 1988).

18

In Holland (Paalman and deVries, 1988), outreach efforts for both female prostitutes and their clients also provide condom-promoting messages in pornographic magazines, on radio stations, and through posters. For additional information on methods of reaching the population of female prostitutes, see J.B.Cohen and colleagues (1988b).

19

In such cases it may be possible to design health education projects that involve currently employed women as agents of education and training. One such program in the Dominican Republic uses a train-the-trainers strategy wherein working prostitutes are elected by their peers as representatives of the local sex workers' community to participate in a Ministry of Public Health project, the National Struggle Against AIDS. These representatives are trained to provide safer sex information, education, and motivation to their fellow workers (Rosario et al., 1989).

20

In Holland, outreach programs for female prostitutes have distributed brochures on protective measures to prevent HIV and other STDs, towels bearing the slogan “Nice and Safe, Use a Condom,” and calling cards with this message in eight languages to facilitate communication with clients (Paalman and deVries, 1988). In addition, clients of prostitutes have been organized to serve as distributors of condoms to other prospective clients.

21

Peer-led programs from several other countries have reported promising results in behavioral change among prostitutes (Ngugi et al., 1988; Monny-Lobe et al., 1989a,b; Plummer et al., 1989). In some studies, self-reports of behavioral change have been supported by decreased rates of HIV seroconversion and of other STDs (Ngugi et al., 1988).

22

In a prospective study of 240 sexually active women from the San Francisco area, J.B.Cohen and coworkers (1988a) found substantial risk reduction at 6- to 12-month follow-ups after HIV antibody testing. However, 11 percent of the women tested continued to report IV drug use, 24 percent reported anal sex, and 32 percent reported more than 10 sexual partners. For additional information on designs for the evaluation of both counseling and testing projects and community-based outreach, see Coyle, Boruch, and Turner (1990).

23

In most cities, there appear to be periods of intense enforcement, followed by periods of relative inactivity (Alexander, 1987), as indicated by the fluctuating statistics on arrests related to prostitution. There are many possible explanations for such variability include shifts in the overall economic and political climate of the country and perhaps even the fear of AIDS. Alternatively, changes in criminal justice statistics may reflect differences in the way data are collected and tabulated.

24

In response to public health concerns, for example, the San Francisco Police Department issued an order on April 10, 1987, that reads in part “this [Police] Department and the District Attorney's Office have examined the current practice of routine confiscation of condoms and bleach containers for evidence during prostitution and drug-related arrests. Effective immediately,…[they] shall not be seized as evidence, unless…[as] evidence of a crime other than prostitution….” (Department Special Order 87–13).

25

In an effort to stem venereal disease, Congress passed the May Act in 1941, making “vice activities” near military installations a federal offense; during World War II, the May Act served as a prod to local communities to suppress prostitution. Yet despite the ensuing incarceration of several thousand prostitutes, military physicians found no decline in the “venereal problem” (Brandt, 1988).

Copyright ©1990 by the National Academy of Sciences.
Bookshelf ID: NBK235365

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