HIV Risk Among Persons Who Exchange Sex for Money or Nonmonetary Items

The term “people who exchange sex for money or nonmonetary items” (hereinafter referred to as “people who exchange sex”) includes a broad range of persons who trade sex for income or other items including food, drugs, medicine, and shelter. Persons who exchange sex are at increased risk of getting or transmitting HIV and other sexually transmitted diseases (STDs) because they are more likely to engage in risky sexual behaviors (e.g., sex without a condom, sex with multiple partners) and substance use. Those who exchange sex more regularly as a source of ongoing income are at higher risk for HIV than those who do so infrequently. Persons who engage in such activities include escorts; people who work in massage parlors, brothels, and the adult film industry; exotic dancers; state-regulated prostitutes (in Nevada); and men, women, and transgender persons who participate in survival sex, i.e., trading sex to meet basic needs of daily life. For any of the above, sex can be consensual or nonconsensual.

It is important for people who exchange sex to get tested for HIV regularly and know their status. Knowing one’s status helps determine the best prevention or care options:

• Condoms are highly effective in preventing a person from getting or transmitting HIV infection if used the right way every time during sex.
• For persons who are HIV-negative, prevention options like pre-exposure prophylaxis (PrEP), taking HIV medicines daily to prevent getting HIV, may be beneficial.
• For people who are living with HIV, taking medicines to treat HIV (called antiretroviral therapy or ART) the right way every day can help keep them healthy and greatly reduce their chance of transmitting HIV to others.

Prevention Challenges

Lack of Data

There is a lack of population-based studies on persons who exchange sex, although some studies have been done in singular settings such as prisons and exotic dance clubs. However, the illegal—and often criminalized—nature of exchange sex makes it difficult to gather population-level data on HIV risk among this population. This lack of data creates significant barriers to developing targeted HIV prevention efforts.

Socioeconomic Factors

Many persons who exchange sex face stigma, poverty, and lack of access to health care and other social services—all of which pose challenges to HIV prevention efforts. Existing research shows that

• Many persons who exchange sex may have a history of homelessness, unemployment, incarceration, mental health issues, violence, emotional/physical/sexual abuse, and drug use.
• Some transgender persons may turn to exchange sex because of discrimination and lack of economic opportunities. They may exchange sex to generate income for rent, drugs, medicines, hormones, and gender-related surgeries.

Sexual Risk Factors

Persons who exchange sex may not use condoms consistently. Several factors may contribute to this behavior, including

• Economics: Persons who exchange sex may receive more money for sex without a condom.
• Partner type: Persons who exchange sex may use condoms less often with regular clients than with one-time clients and even less frequently with intimate partners.
• Power dynamics: Unequal power in a relationship with clients may make it difficult for persons who exchange sex to negotiate condom use.

Other risk factors for this population include

• Multiple high-risk sex partners, e.g., partners who do not know they are living with HIV or other STDs.
• More money for sex with partners known to be HIV positive.

Drug and Alcohol Use

There is a strong link between exchange sex and drug and alcohol use. Persons who exchange sex, if under the influence of drugs or alcohol, may have impaired judgment, engage in riskier forms of sex such as anal sex, and have difficulty negotiating safer sex (condom use, for example) with their customers. People who trade sex for drugs tend to have more clients, use condoms less often, and are more likely to share needles and other drug works.

Knowledge of HIV Status

Many persons who exchange sex may not know their HIV status because they

• Do not know where to access available services.
• Are uncomfortable sharing information about sexual and substance use histories as part of HIV testing protocol.

Some persons who know their HIV status may be reluctant to seek or stay in care because of

• Mistrust of the health care system.
• Concern that they may lose income if identified as being HIV-positive.
• Financial circumstances and other barriers (e.g., health insurance) that affect health care access.

What CDC Is Doing

CDC and its partners are pursuing a high-impact approach to advance the goals of the recently updated National HIV/AIDS Strategy and maximize the effectiveness of current HIV prevention methods among persons who exchange sex. Activities include

• Support and technical assistance to help community-based organizations implement interventions directed toward persons who exchange sex (e.g., condom distribution, community mobilization, HIV testing, and coordinated referral networks).
• Support for effective behavioral HIV interventions for sex workers, such as Community PROMISE, a community-level HIV/STD prevention program for a variety of populations, including persons who exchange sex, that uses role-model stories and peer advocates to distribute prevention materials within social networks.
• Act Against AIDS, a national initiative that focuses on raising awareness, fighting stigma, and reducing the risk of HIV infection among at-risk populations.
• Comprehensive HIV Prevention Programs for Health Departments, a 5-year HIV prevention initiative for health departments in states, territories, and select cities, including those serving clients at risk for HIV infection because of exchanging sex. Starting in 2012, CDC has awarded at least $330 million each year ($343.7 million in 2015) under this funding opportunity.
• Evaluating HIV prevalence, risk behaviors, and use of services among women who exchange sex in five cities as part of the heterosexual cycle of the 2016 National HIV Behavioral Surveillance (NHBS).

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