Male sex workers: practices, contexts, and vulnerabilities for HIV

acquisition and transmissionStefan D Baral, M Reuel Friedman, Scott Geibel, Kevin Rebe,

Borche Bozhinov, Daoude Diouf, Keith Sabin, Claire Holland, Roy Chan, Carlos Cáceres

Overview

Objectives Methods Male sex workers or men who sell sex? Epidemiology of HIV among male sex workers

Burden of HIV, HIV Acquisition and Transmission Risks HIV Surveillance Limitations

Advancing HIV Prevention, Treatment, and Care Moving Forward

Objectives

Synthesize available ethnographic and HIV epidemiologic and prevention science studies focused on male sex workers

Provide justification for dedicated advocacy, funding, definitional consistency for surveillance, and research initiatives for male sex workers

Methods

Systematic Reviews Peer reviewed/non-peer reviewed literature from 2000-2013

HIV Epidemiology (Burden/Risks) Male Sex Workers specifically or Male Sex Workers examined separately

within larger studies of MSM or FSW HIV Prevention Science Studies

Lower and Middle Income settings supported by regional consultations with sex workers, government, and academia

Latin America and the Caribbean Eastern Europe/Former Soviet Union Sub-Saharan Africa (West/Central, Eastern, and Southern Africa)

Asia (South/South East Asia) Review of UNGASS (2002-2012) and GARPR (2014) Data

Male Sex Workers or Men Who Sell Sex

Complex Identities Small proportion of men who sell sex identify as male sex workers Sexual orientation ranges from gay to straight

Male sex Workers are less visible than female sex workers Smaller population Male sex work generally less socially accepted than female sex work Far less documentation in the scientific literature and public domain

Evolving Modalities of Sex Work In some settings, male sex work has moved nearly exclusively to online

marketing approaches with decreased reliance on street or venue-based commercial sex

Burden of HIV Among Male Sex Workers

Data Availability Systematic Review of the Literature

2000-2013 81 different studies across 19 countries

UNAIDS Review 2009-2013 UN General Assembly Special Session on HIV/AIDS

Indicators/Global AIDS Response Progress Reporting 27/192 countries reporting HIV prevalence among male sex workers

44 countries with any HIV prevalence data among Male Sex Workers

Global HIV prevalence among male sex workers, 2000-2013

Source: Baral, Friedman, Geibel, Rebe, Bozhinov, Diouf, Sabin, Holland, Chan, Caceres. The Lancet, 2014

Limited Studies Focused on Male Sex Workers

Source: Baral, Friedman, Geibel, Rebe, Bozhinov, Diouf, Sabin, Holland, Chan, Caceres. The Lancet, 2014

HIV Surveillance Studies

Female Sex Workers

Male Sex Workers

Transgender Sex Workers

Men who Sex with Men

Male Sex Workers

People who Inject Drugs

Male Sex Workers often represent a small subsample of studies focused on MSM or Female Sex Workers

Male Sex Workers are often included in samples with transgender sex workers

Data Quality Limitations

Sample size and data quality vary greatly in UNGASS/GARPR Data Many countries report less than 10 participants in nationwide

surveys

Male Sex Work has not been clearly defined Multiple settings, including USA, do not identify male sex work

as a behavioral category necessitating HIV surveillance Inconsistency in the definition of male sex workers and recall

windows for sex work behaviors challenge interpretation

Source: Centers for Disease Control and Prevention (CDC). HIV surveillance: United States, 1981–2008. MMWR Morb Mortal Wkly Rep 2011; Global AIDS Response Progress Reporting 2014.

Vulnerabilities for HIV

HIV Risks

Individual

Behavioral

Biologic

Network

Size

Density

Structural

Stigma/Criminalization

Social Determinants of Health

Individual and Networks Level Risk

Individual Behavioral Risks

Higher numbers of sexual partners Significant variability in access to and use of appropriate condoms and condom

compatible lubricants among male sex workers Biological Risk

High efficiency of HIV transmission during anal intercourse with serodiscordant and viremic partners

High levels of untreated anal and penile sexually transmitted infections

Network Level Large sexual network

People living with HIV (including acutely infected), people who inject drugs Non-Dense Sexual Network

Limited awareness of HIV status of other members of sexual network

Criminalization and Stigma

Sex work

Same-sex practices

Non-disclosure of HIV status

Substance use

Layers of Criminalization

Intersecting male sex work

stigmas

Sexual Orientation

HIV-Related Stigma

Internalized Stigma

Substance-Use Related

Stigma

Socio-economic

status

Same-Sex Practices

Layers of Stigma

Behavioral HIV Intervention Studies

17 Specific HIV intervention studies since 1993

9 Formative Studies 8 Impact Studies

Key Themes

Drop-in centers w/ multiple services available

Strengths-based approaches Material and social resources

Brief interventions Harm reduction, RESPECT model

Key Themes

Locale, context, & stakeholders are essential considerations

Individual- and network-level Harm reduction, HIV/STI testing and

treatment Multiple services

Jobs, housing, legal, substance use Community-level

Stigma reduction specific to male sex workers

Advancing HIV Prevention and Treatment and Care

Engage male sex workers where they are working Characterize local dynamics of commercial sex

ranging from the streets to the web Integrate behavioral, biomedical, and structural

approaches With high force of HIV transmission, consider ART-

based approaches including Universal access to treatment for those living with HIV PrEP, PEP, and rectal microbicides when available

Engage country-level, regional, and global networks supporting sex workers

Address policy failures that potentiate risks and undermine HIV prevention, treatment, and care programs

Male sex workers are a diverse, complex and unique key population for HIV prevention, treatment, and care

Improved HIV surveillance and prevention science data informing rights-affirming, evidence-based services specifically for male sex workers are needed to improve health outcomes among these men and the people within their sexual networks

Moving Forward