title: High burden of STI and HIV in male sex workers working as internet escorts for men in an observational study: a hidden key population compared with female sex workers and other men who have sex with men.
abstract: BACKGROUND
  Male sex work in the western countries has changed, including now a subculture of male sex workers who have paid sex with men arranged for via the internet. The men involved in this subculture do not easily identify themselves as sex workers nor as homosexual, and are therefore missed by regular health care and public health interventions. These male sex workers may form a hidden key population for sexually transmitted infections (STIs) and HIV, bridging towards other persons outside this context.
  
  
  METHODS
  This clinic-based observational study included consultations by male sex workers (n = 212), female sex workers (n = 801) and in men having sex with men who did not report being paid for sexual contacts (MSM, n = 2703) who received STI and HIV testing and counselling at our clinic during the study period. In this study we compare the consultations in male sex workers to those in in female sex workers and MSM. Demographic characteristics and sexual behaviour of the male sex workers, female sex workers and MSM were compared using chi-square tests and non-parametric tests. Using univariate and multivariate regression analyses, determinants for STI positivity in male sex workers were evaluated.
  
  
  RESULTS
  Male sex workers tested positive for STI (including HIV) in 40 % of the consultations; female sex workers and MSM respectively in 9 and 14 % of the consultations. A new HIV infection was found in 8 % of the consultations of male sex workers. Male sex workers were a young population of migrant sex workers from Eastern Europe. They reported more often to also have sex contacts with women and other sex workers. Male sex workers are at a higher risk for one or more new STI than female sex workers and other MSM, even after correction for age, ethnicity, known HIV positivity and behavioural variables.
  
  
  CONCLUSIONS
  Male sex workers form a hidden key population that impacts the transmission of STI and HIV within the MSM population and, possibly, to the heterosexual population. They require specific targeted interventions. Although targeting male sex workers is labour intensive it is feasible and important to reduce STI transmission.
authors.affiliation: Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, 6160, HA, Geleen, The Netherlands. amanja.verhaegh@ggdzl.nl.
authors.forename: Amanja
authors.initials: A
authors.lastname: Verhaegh-Haasnoot
authors.affiliation: Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, 6160, HA, Geleen, The Netherlands. nicole.dukers@ggdzl.nl.|Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center (MUMC+), 6202, AZ, Maastricht, The Netherlands. nicole.dukers@ggdzl.nl.
authors.forename: Nicole H T M
authors.initials: NH
authors.lastname: Dukers-Muijrers
authors.affiliation: Department of Sexual Health, Infectious Diseases and Environmental Health, South Limburg Public Health Service, 6160, HA, Geleen, The Netherlands. christian.hoebe@ggdzl.nl.|Department of Medical Microbiology, School of Public Health and Primary Care (CAPHRI), Maastricht University Medical Center (MUMC+), 6202, AZ, Maastricht, The Netherlands. christian.hoebe@ggdzl.nl.
authors.forename: Christian J P A
authors.initials: CJ
authors.lastname: Hoebe
mesh_terms: D000293:Adolescent; D000328:Adult; D000554:Ambulatory Care Facilities; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000453:epidemiology; D020010:Heterosexuality; D018451:Homosexuality, Male; D006801:Humans; D020407:Internet; D008297:Male; D011634:Public Health; D012309:Risk-Taking; D060386:Sex Workers; D012725:Sexual Behavior; D012749:Sexually Transmitted Diseases / Q000175:diagnosis* / Q000453:epidemiology; D055815:Young Adult