AIDS The Second Decade (1990) / Chapter Skim
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4 Interventions for Female Prostitutes
4 Interventions for Female Prostitutes
Pages 253-288
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From page 253... ...
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.
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From page 254... ...
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, 19891.
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From page 255... ...
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.S percent)
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From page 256... ...
256 no A_ Ct C)
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From page 257... ...
TV 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., 19901.6 Lower rates of IV drug use among women who work pnmar~ly for escort services or brothels would be consistent with the lower rates of HIV infection reported in this group (Fischl et SThat 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)
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From page 258... ...
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 pnmarily 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 prostitutions 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, 19891. In the case of Mug use and prostitution, the committee found that such steps should include better understanding of the following: variations in Mug use across different subpopulations of prostitutes, the effect of drug use on nsk-associated behaviors, the relationship between drug use and prostitution and the conditions and antecedents surrounding their ~nitiation, and interventions that might protect prostitutes from the threat of HIV infection and other dangers associated with drug use.
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From page 259... ...
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,~° thus increasing the risk of spread of the virus.
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From page 260... ...
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 Hams, 1988; Hooykaas et al., 19891.~2 In fact, it is among sex 11 There are, however, some preliminary data on this practice from the CDC multicenter study. More than one-third (36.3 percent)
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From page 261... ...
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.
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From page 262... ...
, for example, suggest that men who engage in nsk-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)
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From page 263... ...
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.
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From page 264... ...
Cohen, 1980; Carmen and Moody, 19851. 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~.
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From page 265... ...
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 (Iames, 1977; Goldstein, 19791. 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,
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From page 266... ...
The usually clandestine activity of bar prostitutes hamper 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.
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From page 267... ...
Moreover, the percentage of legal brothel workers and applicants reporting a history of IV drug use (27 percent) was Tower than among any other group of sex workers who participated in the CDC multicenter study (Darrow et al., In press)
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From page 268... ...
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.
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From page 269... ...
Moreover, because the fee is understood to include sexual services, the outcall worker does not have to discuss pnce, which makes it difficult for law enforcement personnel to collect evidence of solicitation (Perkins and Bennett, 19851. Many cities license escort services through the police department, again barring anyone with a history of prostitution-related arrests from obtaining a license.
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From page 270... ...
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, 19881. 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.
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From page 271... ...
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)
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From page 272... ...
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 downer sex workers)
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From page 273... ...
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 {V drug use, AIDS prevention should highlight drug treatment and safer injection projects, as well as the prevention of IV drug use.
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From page 274... ...
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 TV drug use practices.
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From page 275... ...
Junsdictions 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.
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From page 276... ...
Thus, safer-sex intervention efforts that focus exclusively on sex workers and fall 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.
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From page 277... ...
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.
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From page 278... ...
Although many prostitution laws were onginally 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.
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From page 279... ...
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.
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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.
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From page 281... ...
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.
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From page 282... ...
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.
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(1988a) Changes in risk behavior for HIV infection and transmission in a prospective study of 240 sexually active women in San Francisco.
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B (1988bJ Sexual behavior and HIV infection risk among 354 sex industry wome in a participant based research and prevention program.
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(1988) Crack use puts women at risk for heterosexual transmission of HIT from intravenous drug users.
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(1989) Impact of pilot interventions to reduce the spread of HIV infection among high risk women in Africa.
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(1989) The agglutinating approach to joint STD/AIDS prevention and control in female sex workers in the Dominican Republic.
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From page 288... ...
(1989) HIV infection in female intravenous drug users in San Francisco.
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