Commercial sex workers (CSWs) have been documented as disseminating the HIV virus and other sexually transmitted infections (STIs). This study measured the HIV-related knowledge and behaviors of CSWs in three diverse population centers: Santo Domingo (Dominican Republic), Tijuana (Mexico), and Moscow (Russian Federation). Data were collected from CSWs (n=78) using a semi-structured interview format. Although respondents were aware of the HIV virus, self-reports revealed risk-taking practices. CSWs had limited skill at negotiating for reducing personal and partner risk, especially when economics was a factor. Outreach workers may be beneficial in developing a supportive role in this population to reduce risk practices and disease spread.
Key Words: HIV, sex workers, behavior
Introduction |
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| Abstract | Introduction | Methods | Results | Discussion | References |
The prevalence of human immunodeficiency virus (HIV) within the commercial sex industry contributes significantly to the spread of this disease worldwide (Mann, Tarantola & Netter, 1992). Sex with multiple partners, other high-risk sex practices, drug use, and inconsistent use of condoms among commercial sex workers (CSWs) have been cited as leading causes of the spread of HIV (Coates & Makadon, 1996; de Graaf, Vanwesenbeeck, van Zessen, Straver & Visser, 1993; Guenther-Grey, Schnell & Fishbein, 1995; Mertens & Carael, 1997; Richters, Donovan, Gerofi & Watson, 1988).
Research documents that low social economic status also is a factor in the spread of the virus within the industry (Carswell, Lloyd & Howells, 1989; Coates & Makadon, 1996; Jochelson, Mothibeli & Leger, 1991; Karim, Karim, Soldan & Zondi, 1995; Simonsen, Plummer, Ngugi, Black, Kreiss, Gakinya, Waiyaki, D'Costa, Ndinya-Achola, Piot & Ronald, 1990). For instance, the poor are more vulnerable to acts of violence, forced sex and street crime, less likely to request or receive police protection, and less likely to trust public health authorities (Cohen & Coyle, 1990). This vulnerability is especially true among street workers, those not associated with a brothel or escort service, and those who do not have their own residence or dwelling (Alexander, 1992).
The National Task Force on Prostitution reports that about 1% of American women have exchanged sex for money (Alexander, 1987). The exact risk of becoming infected with HIV as a result of coming into contact with a CSW has been difficult to determine in the United States due to variations in local prevalence of disease, the extent of high-risk practices, especially injection drug use, the extent of condom use, and the array of sexual practices employed (Cohen, 1994). A Canadian report cited by Bastow (1995) indicates that prostitutes are no more likely than any other women to be infected with HIV or other sexually transmitted infections unless they are also intravenous drug users. For different groups of prostitutes in the United States and European countries, the rate of HIV infection varies from 0 to as much as 47.5% (Cohen, 1994). The female prostitute to male client transmission rate of HIV is not well studied, but female-to-male transmission rates are believed to be lower than male-to-female or male-to-male rates (Cohen, 1994). In a New York study, a transmission rate of 1.4% (female prostitute to male client) was estimated by one clinic (Chaisson, Stoneburner, Lifson, et al., 1990). Bastow (1995) cites
The primary purpose of this study was to measure the HIV-related knowledge and behaviors of CSWs in three diverse population centers where the commercial sex trade is known widely to exist: Santo Domingo (Dominican Republic), Tijuana (Mexico), and Moscow (Russian Federation). |
evidence that CSWs use condoms more consistently than other populations similar in age, race, and gender. Thus, transmission rates by this mode could plausibly, be low. It is even harder to estimate the HIV seroprevalence rate among male prostitutes. Bastow (1995) cites figures for the United States that range from 50% in one study to as low as 11%.
Internationally, outreach health workers have focused on promoting condom education, usage and availability in combating the virus among CSWs (Montague & Catino, 1996; Nzila, Laga, Thiam, Mayimona, Edidi, Van Dyck, Behets, Hassig, Nelson, Mokwa, Ashley, Piot & Ryder, 1991; Population Services International, 1996). In Thailand, an increase from 15,000 to 50,000 condoms used in the Samut Sakhon Province showed a decrease in incidence of sexually transmitted infections from 13% to 0.5% (World Health Organization, 1992). In New York City, the decline in the rate of HIV infection over a five-year period in one project was attributed to its condom distribution policy (Whitmore, Wallace & Weiner, 1996). Training, educating, and disseminating HIV information also has been a successful tool in building a defense against the virus. Peer educators in Zimbabwe (Lamptey, 1991), health care providers in Singapore (Wong, Chan, Koh & Wong, 1994-95), and outreach workers in California (Dorfman, Derish & Cohen, 1992) have shown that education reduces the spread of HIV. These studies show that condoms and education are important elements in HIV-risk reduction.
Most research on the relationship between CSWs and HIV has focused on the role of the worker as a vector of the disease, with HIV risk reduction efforts often targeting the sex worker for behavior modification. According to Coates and Makadon (1996), decreasing the rate of infection among CSWs may be more effective if less blame is placed on the worker and more research is performed about the context in which the sex work is transacted. Negotiating safer sex, while being economically dependent on the client, is difficult, especially if the client is physically overpowering or the economic status of the sex worker is low.
Purpose
The primary purpose of this study was to measure the HIV-related knowledge and behaviors of CSWs in three diverse population centers where the commercial sex trade is known widely to exist: Santo Domingo (Dominican Republic), Tijuana (Mexico), and Moscow (Russian Federation). These three cities were selected because they also happened to be at or near sites where the investigators were carrying out other health education-related research activities. A secondary purpose of this study was to identify the relationship of knowledge and behavior on the negotiation between CSWs and their clients.
Methods |
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| Abstract | Introduction | Methods | Results | Discussion | References |
Under the supervision of members of the research team, an 18-item forced-response interview schedule was administered by trained commercial sex workers indigenous to the respective data collection locales. Items included: (1) knowledge and beliefs about HIV/AIDS, and (2) specific behaviors occurring between the workers and their clients. The survey was used as a framework for the semi-structured interviews. Additional queries were made for clarification where necessary. For example, some of the CSWs who were HIV-positive wanted to discuss their frustrations and future options, whereas others wanted additional information on birth control methods. To establish content validity, the interview schedule was expert-generated in English based on epidemiologically significant risk behaviors and common myths related to susceptibility and transmission. Subsequently, the interview schedule was translated to written Spanish by a native Spanish-speaker of the Dominican Republic, and pilot-tested for clarity with native Spanish-speakers with national origins in Puerto Rico, Mexico, the Dominican Republic, and Colombia. For the Muscovite sample, a simultaneous oral translation, rather than a written translation, was made by a peer-interviewer who was a native Russian speaker. The nature of the survey content, as well as the nature of those being surveyed (limited sampling pool) made the establishment of reliability (e.g., test/retest) and extensive pilot-testing impractical. However, reliability for survey items of a similar nature have been reported for audiences in the Dominican Republic (Westhoff, Holcomb & McDermott, 1996-97; Westhoff, McDermott & Holcomb, 1996), Moscow (Westhoff, Klein, McDermott, Schmidt & Holcomb, 1996), and the United States (McDermott, Hawkins, Moore & Cittadino, 1987; McDermott, Liller & Rosevelt, 1990; McDermott, Sarvela & Bajracharya, 1988).
Because of the different cultures represented by each setting, the means and logistics for data collection varied. Data in Santo Domingo were collected from street workers who solicited their clients on one of the city's major thoroughfares. The avenue is a busy commercial district during the day. At dusk the street changes its ambience as stores close with burglar-proof shields covering the windows and doors. At full darkness the street becomes active again with CSWs gathering in doorways or leaning against store fronts. Few men can be seen on a normal night, with a ratio of 10 to 20 women for every male walking down the street. Interviews were conducted on two occasions on this main artery in Santo Domingo. After an initial contact had been made with a CSW (peer-interviewer) willing to assist in data collection, interviews were conducted from inside a parked automobile. In exchange for the interview, each CSW received ten condoms, twenty pesos ($1.50 U.S.), and HIV educational material prepared for Spanish-speaking audiences.
Data collection occurring in Tijuana was similar to that in Santo Domingo. A peer-interviewer was again used to interview each CSW. The location was off of the main thoroughfare of the city. Unlike the venue in Santo Domingo, the area had many inexpensive hotels and establishments that served alcohol. The ratio of CSWs to clients was more difficult to estimate because of the mix of other people walking the street. The interviews were conducted on the street rather than in a car, which allowed for semi-privacy against a store window or in an adjacent alley. Condoms, money, and HIV educational material prepared for Spanish-speaking audiences comparable to that described above were again given in exchange for the information.
Data collection in Moscow was performed by a CSW approximately 40 years old, a native Muscovite who was fluent in both Russian and English. This peer-interviewer had a college degree, had worked as a professional journalist, and had traveled abroad extensively to English-speaking and other countries. In contrast to the experiences in Santo Domingo and Tijuana, the interviewer was paid for her services ($200 U.S.), but no money or other items were given to the interviewees. Another difference between the Muscovite workers and the ones in Santo Domingo and Tijuana was the work setting where interviews were carried out. Rather than conducting business on a main avenue, most of these Muscovite CSWs were either at the street entrance or in the lobby or bar of a large hotel used exclusively by foreigners. Again, the number of CSWs exceeded the number of males present by approximately 4 to 1. In addition to the CSWs themselves, other hotel staff, including doormen, bartenders, security personnel, and women who were stationed at desks outside the elevators of every hotel floor each played some role in facilitating contact with potential clients. Anecdotal reports by hotel staff indicated that approximately 500 CSWs, known as international girls or interdevochka (Marsh, 1996), "worked" the hotel, with approximately 150 present at any one time, somewhat more apparent during the evening hours. Interviews at the hotel were conducted in peripheral areas of the hotel lobby, or in booths within one of the cocktail lounges.
For all three sites, data collection always was in the presence of at least one of the principal investigators, who maintained a discreet distance to permit confidentiality. Sometimes, peer-interviewers consulted with one of the investigators to seek clarity about a question or a response. CSWs at each site knew the interviewer as another worker, appeared to feel relaxed about answering the questions, and completed the interview without protest. The interviewer documented the data by checking off the responses on the interview schedule as each question was asked. Notes also were written by the interviewer which were shared subsequently with the investigators after the completion of each interview. All interviews were conducted in the CSWs' native language (Spanish in Santo Domingo and Tijuana; Russian in Moscow). Time constraints, safety issues, and other intervening factors prohibited some interview questions from being asked in Tijuana and Moscow.
Data were analyzed using SPSS for Windows 8.0 (SPSS, 1997). Frequency distributions are reported. Where special or unique findings occurred, crosstabulations are reported by city. Pertinent anecdotal data are also presented.
Results |
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| Abstract | Introduction | Methods | Results | Discussion | References |
The refusal rate to be interviewed among CSWs was between 10% and 15% and was fairly constant across the three cities. Once initiated, no interviews were halted due to the content of the questions. In all, 78 commercial sex workers were interviewed: 10 in Tijuana, 50 in Santo Domingo, and 18 in Moscow. Their age ranged from 16 to 50 years of age, with a mean age of 27 years. The respondents were all females (94.9%), except for four males in Santo Domingo who were dressed in women's clothing and makeup. Results are reported in Table 1.
Examination of the findings
indicate that specific HIV knowledge varies and that some myths about modes of
transmission still abound. Concerning selected knowledge and beliefs about HIV/AIDS, the
following data were generated:
27 16 - 50 In addition, among
respondents, 80.8% had been HIV-tested at least once. Seven of the CSWs (9.0%) indicated
that test results revealed them to be HIV-positive. When asked about other sexually
transmitted infections (STIs), 21.8% responded that they had been treated for an STI.
Crosstabulation showed that 100% of the women in the Tijuana sample reported being treated
for an STI at least once. Although most of the CSWs
were knowledgeable about HIV and were aware of its life-threatening consequences,
economics rather than safe sex considerations became the main bargaining tool in
negotiations with potential clients. Although 94.1% reported knowing that a condom can
help prevent HIV transmission, and 96.2% reported that they ask their clients to wear a
condom, 20.5% of the CSWs were willing to have male clients not wear a condom in exchange
for accepting more money in return. The actual percentage of HIV-positive CSWs may be
underreported considering the stigma and potential impact that revealing such information
could have on client recruitment. The prevalence of HIV-positive CSWs poses a risk to
persons purchasing services from them, and willingness of some CSWs to perform services
unprotected in exchange for more money places them at risk as well, especially as the
number of sexual exchanges increases. These results offer a
limited look at the HIV-related risks of commercial sex workers in three diverse settings.
Considering the numerous CSWs worldwide, this study presents only a snapshot of the risk
activity of 78 workers. The findings should be interpreted cautiously, considering the
sensitivity of surveys concerning sex for hire. Like any other sexuality study using a
self-reported method, there is uncertainty regarding the accuracy of the information
reported. Other limitations include the modest effort to establish psychometric properties
for the interview schedule across language and culture. Moreover, peer interviewers were
trained quickly even though one of the investigators rehearsed several times with each
interviewer. Additionally, interviewer bias could not be ruled out. The effect of setting
could make the quality of information obtained suspect. At least one study has
compared the risk of CSWs on the street with CSWs who are employed in a brothel or have
their own residence (Deren, Sanchez, Shedlin, Davis, Beardsley, Jarlais & Miller
(1996). These risks, as noted earlier, are external factors surrounding life on the street
and are shared commonly with drug abusers, homeless people, street children and others who
spend much of their time on the street (Westhoff, Coulter, McDermott & Holcomb, 1995).
The greatest risk for CSWs found in this study, and was typical at all three sites, was
the negotiating power the client appears to have over the worker. Furthermore, with
clients who refuse to pay or who threaten violence, insisting on use of a condom might
only exacerbate the risk. Being on the margin of society, the ability of CSWs to negotiate
safer working conditions is limited. Moreover, a CSW's financial position can make her
vulnerable to customers willing to pay more money for unprotected sex and other high-risk
practices (Day, 1988). It has been shown here and
in similar studies (e.g., Karim, et al., 1995) that sex with a condom does bring a reduced
price during the negotiations. As Karim, et al. (1995) point out, sustaining sufficient
earnings while using a condom requires CSWs to take on more clients. More clients means
increasing the competition among the workers, as well as risk. Older women, such as a
50-year-old Muscovite CSW who was interviewed for this study, already have more difficulty
attracting clients than their younger co-workers, and are less apt to insist on condom
use. The limited knowledge of the client may be a further impediment for the woman who is
trying to reduce her sexual risk. It is unknown how much information a client has about
HIV, although it could be assumed that anyone seeking a CSW, and then willing to pay
additionally for a "condomless act" may himself have a knowledge deficiency
about HIV/AIDS. This lack of knowledge places an even greater burden on the negotiations.
The skewness in negotiating prowess between a CSW and a client is not uncommon (Deren, et
al., 1996; Ford, Wirawan & Fajans, 1998; Karim, et al., 1995). The roots of prostitution
in some of the cities studied in this paper have direct links to prevailing economic
conditions. In the former Soviet Union, it is estimated that one out of every eight school
girls aspires to be a "hard currency" call girl when she grows up (Goscilo,
1996). A 1990 survey showed that the then Soviet women ranked prostitution 8th in a list
of what they felt to be the top 20 occupations in the USSR. Around the same time,
one-third of high school girls reported that they would exchange sex for hard currency
(Goscilo, 1996). According to one report, some prostitutes engaged in sexual activities
for as little as $0.40 in U.S. currency (Kon, 1995). There seems to be a strong positive
link between prostitution in Russia and the rise in cases of HIV/AIDS and other sexually
transmitted infections, such as syphilis, where the Russian rate is estimated to be 100
times higher than the average rate in the countries that comprise the European Union
(McAdams, 1997; St. Petersburg Press, 1997). Kon (1995) reports the
following demographic profile of prostitutes working in Moscow: 87% under the age of 25
years (with 50% under the age of 18 years); 9.1% entered the CSW trade before age 14; and
12% began their CSW career after being raped. In the same study, 9.1% reported having a
university education. Moreover, two-thirds of Muscovite prostitutes have no income outside
of the CSW trade, one-fourth were married, one-fifth had children, and one in seven had
one or more sexually transmitted infections (Kon, 1995). Prostitution is an economic
endeavor for Russian women with limited economic choices. Between 1992 and 1993, 70% of
Russians laid off from jobs were women (Marsh, 1996). This statistic alone makes the
estimate of the existence of over 10,000 prostitutes in Moscow alone an easy one to
understand. For some women, prostitution is the only alternative to a male enforced
unemployment situation (McVicker, 1999). This situation has, perhaps, led to what Marsh
(1996) labels as the "Madonna/whore complex," where the prostitute is
divergently viewed as the "hooker with a heart of gold" and as a brash woman
trying to claim superiority over men (McVicker, 1999). A possible contribution to
the status of both prostitution and sexually transmitted infection (including HIV/AIDS)
rates in Russia today is the absence of state sanctioned sex education in schools during
the days of Communist Party rule. At the same time, condoms were known to be in short
supply, and many women never knew they were pregnant until they were in their fifth month
following conception (Goscilo, 1996). Furthermore, Russia was not prepared for the
onslaught of HIV/AIDS, and previous government-sponsored programs may have led citizens to
believe that only homosexuals and drug users contracted the disease (Kon, 1995; McVicker,
1999). The Russian experience may
not be typical of prostitutes everywhere, but it graphically describes the plight of women
in economic strife who have a narrow range of options to sustain a living wage. In
Tijuana, women reportedly came to work in industrial plants but could not support
themselves on the $30 per month minimum wage (World Sex Guide Document, 1999).
Prostitution is not explicitly forbidden in Mexico, but is selectively enforced by police
and other government agencies. The result of these vague and inconsistent guidelines has
been the establishment of "prostitution worker unions" that stage sit-ins and
marches to protest police corruption, combat police "shutdowns," and make
provisions for CSWs to obtain monthly medical examinations performed by doctors of their
own choosing or ones provided by the city. In the Dominican Republic,
a strategy known as "provocative theater," where skits about HIV/AIDS are put on
in bars and brothels by theater groups, has been used to reach CSWs (Castillo &
Moreno, 1997). Through this technique, actors facilitate audience participation in the
construction of solutions to problems encountered in the commercial sex industry. In
addition, CSW peer educators, serving as "health messenger leaders" focused on
gender issues and self-esteem empowerment, are credited for being responsible for
documented declines in syphilis, gonorrhea, and HIV seroprevalence in Santo Domingo
(Moreno, Ferreira, Rosario & Bella, 1997). These peer educators produce a newsletter
(called La Nueva
Historia) with a distribution greater than 5000 copies per month. As indicated earlier, some
CSWs in the Santo Domingo sample were cross-dressing men. Other reports document the
presence of cross-dressing men in the commercial sex industry, as well as their
receptivity to such risk activities as anal and oral sex, and rates of HIV seroprevalence
(Tabet, de Moya, Holmes, Krone, de Quinones, de Lister, Garris, Thorman, Castellanos,
Swenson, Dallabetta & Ryan, 1996). Conclusion Peer educators have been shown to be an effective tool
in some outreach programs It is recommended that
HIV-prevention outreach workers be knowledgeable of the risks associated with the CSW
population. Peer educators have been shown to be an effective tool in some outreach
programs (Karim, et al., 1995; Montague & Catino, 1996; Moreno, et al., 1997; Wong, et
al., 1994-95). With training, former CSWs are able to distribute HIV literature and
condoms, and, to some extent, modify behavior. A significant HIV-risk reduction among CSWs
will come about only when they are empowered by enhanced HIV knowledge and greater
self-efficacy. Outreach programs can assist by: (1) increasing the CSWs' negotiation and
communication skills, (2) informing and providing access to barrier methods that will give
the women greater control over negotiations, and (3) improving access to health care
services. According to McVicker (1999), in places such as Russia, "education and the
dispersion of condoms at the local level will help to alleviate some of the problems but
not the entire situation." According to Cohen (1994,
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when you have sex with prostitutes or others you don't know,' then men who continue to
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405-421. World
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Internet accessed November 30, 1999. [Reprint (PDF) Official Layout of this article] Copyright © 2000 by IEJHE.
Table 1. Responses to
Interview Questions Asked of Commercial Sex Workers in Three Cities
Tijuana
(n=10)Santo Domingo
(n=50)Moscow
(n=18)Total
(n=78)
n
%
n
%
n
%
n
%
Have
you ever heard of HIV (the AIDS virus)?
10
100
50
100
18
100
78
100
Do
you know of a place (clinic) that you can be tested for HIV/AIDS?
10
100
39
78.0
18
100
67
85.9
Have
you ever been tested for HIV?
9
90
36
72
18
100
63
80.8
Were
the results positive?
3
30
3
6
1
5.6
7
9
Have
you ever been treated for another sexually transmitted infection?
10
100
5
10
2
11.1
17
21.8
Is
there a cure for AIDS?
Not asked
5
10
8
44.4
13
19.1a
Can
a person get the AIDS virus from blood or semen?
9
90
48
96
18
100
67
96.2
Can
a person get the AIDS virus from sharing a needle?
10
100
46
92
18
100
74
94.9
Will
condom use help to prevent AIDS?
Not asked
46
92
18
100
54
94.1a
Do
you perform oral sex on clients?
6
60
25
50
14
77.8
45
57.7
Do
you have oral sex performed on you by clients?
Not asked
26
52
12
66.7
38
55.9
Do
you allow anal sex performed on you by clients?
4
40
6
12
3
16.7
13
16.7
Do
you normally ask the client to use a condom?
7
70
50
100
18
100
75
96.2
Would
you take more money to not use a condom?
9
90
4
8
3
16.7
16
20.5
Do
you work (have sex) when you have a sore or lesion?
Not asked
1
2
2
11.1
3
4.4a
Do
you allow a client to have sex with you if he has a sore or lesion?
Not asked
3
6
1
5.6
4
5.9a
Can
you get AIDS from a mosquito?
8
80
39
78
Not asked
47
78.3a
Are
you a female (or male)?
10
100
46
92
18
100
74
94.9
Mean
age of sample (years)
30
26
28
Age
range of sample (years)
23 - 48
16 - 49
19 - 50
a Percentage
based on combined sample for two cities in which item was asked
Discussion
Abstract
Introduction
Methods
Results
Discussion
References
References
Abstract
Introduction
Methods
Results
Discussion
References
