title: Street workers and internet escorts: contextual and psychosocial factors surrounding HIV risk behavior among men who engage in sex work with other men.
abstract: Sex work has been associated with elevated risk for HIV infection among men who have sex with men (MSM) in many settings. This mixed methods study examined sexual risk among MSM sex workers in Massachusetts, collecting formative data on HIV risk behavior by sex worker type in order to gain a better understanding of how to tailor prevention interventions to this unique and high-risk subgroup of MSM. Two groups of MSM sex workers were recruited between January and March 2008: street workers (n=19) and internet escorts (n=13). Participants completed a semistructured qualitative interview and quantitative psychosocial assessment battery; interviews were conducted until redundancy in responses was achieved. Almost one third (31%) were HIV-infected. The majority of participants (69%) reported at least one episode of unprotected serodiscordant anal sex (either insertive or receptive) with a mean of 10.7 (SD=42.2) male sex partners of an unknown or different HIV serostatus in the past 12 months. Salient findings included: (a) internet sex workers reported being paid substantially more for sex than street sex workers; (b) inconsistent condom use, high rates of unprotected sex, and low rates of HIV status disclosure with sex work partners for both internet and street workers; general perceptions of a lack of trust on the part of sex work partners (i.e., telling them what they want to hear), offers of more money for unprotected sex; (c) contextual differences in risk taking: internet sex workers reported that they are more likely to engage in sexual risk-taking with noncommercial sex partners than sex partners who pay; (d) HIV status and STI history: two street workers became infected in the context of sex work, and 25% of the entire sample had never been tested for sexually transmitted infections (STI); and (e) motivations and reasons for doing sex work, such as the "lucrativeness" of sex work, as a means to obtain drugs, excitement, power, "why not?" attitude, and because social norms modeled this behavior. Study findings can be used to generate hypotheses for designing and providing tailored primary and secondary prevention interventions for this at-risk subgroup of MSM.
authors.affiliation: The Fenway Institute, Fenway Community Health, Prudential Tower, 4th Floor, 800 Boylston Street, Boston, MA 02119, USA. mmimiaga@fenwayhealth.org
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Mimiaga
authors.forename: Sari L
authors.initials: SL
authors.lastname: Reisner
authors.forename: Jake P
authors.initials: JP
authors.lastname: Tinsley
authors.forename: Kenneth H
authors.initials: KH
authors.lastname: Mayer
authors.forename: Steven A
authors.initials: SA
authors.lastname: Safren
mesh_terms: D017280:Condoms / Q000706:statistics & numerical data; D015658:HIV Infections / Q000453:epidemiology / Q000523:psychology*; D006306:Health Surveys; D018451:Homosexuality, Male / Q000523:psychology*; D006801:Humans; D020407:Internet; D008297:Male; D008603:Mental Health; D012309:Risk-Taking; D011477:Sex Work / Q000523:psychology*; D012725:Sexual Behavior / Q000523:psychology; D012749:Sexually Transmitted Diseases / Q000453:epidemiology / Q000523:psychology; D012959:Socioeconomic Factors; D019966:Substance-Related Disorders / Q000150:complications
references.citation: Am J Public Health. 2003 Jun;93(6):926-32
references.pmid: 12773357
references.citation: Am J Public Health. 2001 Jun;91(6):892-4
references.pmid: 11392929
references.citation: Sex Transm Dis. 2006 Apr;33(4):228-34
references.pmid: 16565643
references.citation: J Gen Intern Med. 1997 Apr;12(4):250-3
references.pmid: 9127231
references.citation: Int J Epidemiol. 2001 Dec;30(6):1449-54; discussion 1455-6
references.pmid: 11821362
references.citation: MMWR Surveill Summ. 2006 Jul 7;55(6):1-16
references.pmid: 16826162
references.citation: Future Child. 1994 Summer-Fall;4(2):31-53
references.pmid: 7804768
references.citation: J Homosex. 2007;53(1-2):7-35
references.pmid: 18019068
references.citation: Am J Public Health. 2003 Jun;93(6):933-8
references.pmid: 12773358
references.citation: J Health Care Poor Underserved. 1992 Summer;3(1):222-34; discussion 235-9
references.pmid: 1327239
references.citation: AIDS Care. 2004 Nov;16(8):1021-35
references.pmid: 15511734
references.citation: Annu Rev Sex Res. 2001;12:242-89
references.pmid: 12666742
references.citation: Child Abuse Negl. 1992 Nov-Dec;16(6):855-64
references.pmid: 1486514
references.citation: JAMA. 1984 Oct 12;252(14):1905-7
references.pmid: 6471323
references.citation: Sex Transm Dis. 1998 Aug;25(7):353-60
references.pmid: 9713915
references.citation: Sex Transm Infect. 2000 Aug;76(4):294-8
references.pmid: 11026887
references.citation: AIDS Care. 1997 Jun;9(3):273-84
references.pmid: 9290833
references.citation: Am J Public Health. 2004 Jul;94(7):1207-17
references.pmid: 15226145
references.citation: Child Abuse Negl. 2001 Apr;25(4):557-84
references.pmid: 11370726
references.citation: Am J Public Health. 2004 Nov;94(11):1998-2003
references.pmid: 15514243
references.citation: J Biosoc Sci. 2006 Jan;38(1):117-31
references.pmid: 16321168
references.citation: Am J Psychiatry. 1974 Oct;131(10):1121-3
references.pmid: 4416585
references.citation: J Stud Alcohol. 1994 Nov;55(6):692-4
references.pmid: 7861797
references.citation: Arch Sex Behav. 2008 Oct;37(5):845-53
references.pmid: 18288599
references.citation: Sex Transm Dis. 2007 Feb;34(2):113-9
references.pmid: 16810121
references.citation: Soc Sci Med. 1991;32(5):535-9
references.pmid: 2017720
references.citation: J Homosex. 2007;53(1-2):219-40
references.pmid: 18019076