The Use of Female Sex Workers Among Men in Nepal: Prevalence, STIs/HIV-Related Risk Behaviors, and Gender Ideology

Heterosexual sex involving female sex workers (FSWs) is widely documented for its role in facilitating the spread of sexually transmitted infections (STIs)/HIV. Critical to such studies, and increasingly considered essential to HIV prevention efforts, is the gender constructs and power dynamics within relationships. However, little efforts have been made, which focus on male clients of FSWs, particularly on the relationship between gender ideologies and men’s sexual contact with FSWs, within the Nepali context. 

The present study aims to fill this critical gap by assessing the prevalence of use of FSWs and its association with STIs/HIV-related risk behaviors and gender ideologies among Nepali men. We used data from the nationally representative Nepal Demographic Health Survey (NDHS) 2011. For the purpose of analyses, we included a sample of 4,121 men, aged 15–49 years. During data analyses, we used multivariate logistic regression models, adjusted for the following variables: age, region, residence, religion, educational level, wealth index, employment status, and cigarette smoking status. 

Of the total sample, approximately 5% reported the use of FSWs in their lifetime. In regression models, men who had sex with FSWs were more likely to report a history of STIs, not using condom all the time, more than one sexual partner, and have had early sexual debut. Respondents reporting the endorsement of violence against wives and male sexual entitlement were significantly more likely to report sexual contact with FSWs. 

Our findings highlight the need to develop and implement specifically tailored interventions toward male clients of FSWs, with a particular emphasis on promoting equitable gender roles and beliefs.

Full article at:    http://goo.gl/e97o7T

By: Roman Shrestha,^1,2 Pramila Karki,^2,3 and Michael Copenhaver^2,3

¹Department of Community Medicine and Health Care, University of Connecticut Health Center, Farmington, CT, USA

²Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, CT, USA

³Department of Allied Health Sciences, University of Connecticut, Storrs, CT, USA

Prim Prev Insights. Author manuscript; available in PMC 2016 Jun 27.

Published in final edited form as:

Prim Prev Insights. 2016; 6: 11–17.

Published online 2016 Jun 9. doi:  10.4137/PPRI.S39664

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The relationship between violence and engagement in drug dealing and sex work among street-involved youth

OBJECTIVES:

Street-involved youth are highly vulnerable to violence. While involvement in income-generating activities within illicit drug scenes is recognized as shaping youths' vulnerability to violence, the relative contributions of different income-generating activities remain understudied. We sought to examine the independent effects of drug dealing and sex work on experiencing violence among street-involved youth.

METHODS:

Data were derived from a prospective cohort of street-involved youth aged 14-26 who used drugs in Vancouver, British Columbia, between September 2005 and May 2014. Multivariable generalized estimating equations were used to examine the impact of involvement in drug dealing and sex work on experiencing violence.

RESULTS:

Among 1,152 participants, including 364 (31.6%) women, 740 (64.2%) reported having experienced violence at some point during the study period. In multivariable analysis, involvement in drug dealing but not sex work remained independently associated with experiencing violence among females (adjusted odds ratio [AOR]: 1.43; 95% confidence interval [CI]: 1.08-1.90) and males (AOR: 1.50; 95% CI: 1.25-1.80), while involvement in sex work only was not associated with violence among females (AOR: 1.15; 95% CI: 0.76-1.74) or males (AOR: 1.42; 95% CI: 0.81-2.48).

CONCLUSION:

Findings indicate that involvement in drug dealing is a major factor associated with experiencing violence among our sample. In addition to conventional interventions, such as addiction treatment, novel approaches are needed to reduce the risk of violence for drug-using youth who are actively engaged in drug dealing. The potential for low-threshold employment and decriminalization of drug use to mitigate violence warrants further study.

Purchase full article at:   http://goo.gl/emWqd9

By: Hayashi K1, Daly-Grafstein B, Dong H, Wood E, Kerr T, DeBeck K.

• 1Department of Medicine, University of British Columbia; British Columbia Centre for Excellence in HIV/AIDS. khayashi@cfenet.ubc.ca.
• Can J Public Health. 2016 Jun 27;107(1):e88-93. doi: 10.17269/cjph.107.5219. 

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Exchange Sex and HIV Infection among Men Who Have Sex with Men: 20 US Cities, 2011

This study assessed the prevalence of exchanging sex for money or drugs among men who have sex with men (MSM) in the 2011 US National HIV Behavioral Surveillance system. Prevalence of HIV, being HIV-positive but unaware (HIV-positive-unaware), risk behaviors and use of services were compared between MSM who did and did not receive money or drugs from one or more casual male partners in exchange for oral or anal sex in the past 12 months. 

Among 8411 MSM, 7.0 % exchanged sex. MSM who exchanged sex were more likely to be non-Hispanic black, live in poverty, have injected drugs, have multiple condomless anal sex partners, be HIV-positive and be HIV-positive-unaware. 

In multivariable analysis, exchange sex was associated with being HIV-positive-unaware (aPR 1.34, 95 % CI 1.05-1.69) after adjusting for race/ethnicity, age, education, poverty, and injecting drugs. 

MSM who exchange sex represent an important group to reach with HIV prevention, testing, and care services as they were more likely to report behavioral risk factors that put them at risk of HIV.

Purchase full article at:  http://goo.gl/ptrrEk

By: M Nerlander L^1,2, Hess KL³, Sionean C³, E Rose C³, Thorson A⁴, Broz D³, Paz-Bailey G³.

¹Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, MS-E46, Atlanta, GA, 30329, USA. vif7@cdc.gov.

²Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. vif7@cdc.gov.

³Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, MS-E46, Atlanta, GA, 30329, USA.

⁴Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.

AIDS Behav. 2016 Jun 15. [Epub ahead of print]

  

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High prevalence of unhealthy alcohol use and comparison of self-reported alcohol consumption to phosphatidylethanol among women engaged in sex work and their male clients in Cambodia

BACKGROUND:

In Cambodia, most of the female sex workers (FSW) work in venues where unhealthy alcohol use is ubiquitous and potentially contributing to the HIV epidemic. However, no accurate data exists. We compare self-reported unhealthy alcohol consumption to a biomarker of alcohol intake in Cambodian FSW and male clients, and determine factors associated with unhealthy alcohol use.

METHODS:

A cross-sectional study was conducted among FSW (n=100) and male clients (n=100) in entertainment and sex work venues in Cambodia. Self-reported unhealthy alcohol use (AUDIT-C) was compared to phosphatidylethanol (PEth) positive (≥50ng/ml), a biomarker of alcohol intake. Sociodemographics data was collected. Correlates of self-reported unhealthy alcohol use and PEth positive were determined.

RESULTS:

The prevalence of PEth positive in FSW was 60.0%. Self-reported unhealthy alcohol consumption was reported by 85.0% of the women. Almost all women (95.0%) testing PEth positive also reported unhealthy alcohol use. Prevalence of unhealthy alcohol consumption (self-report and PEth positive) was higher in FSW working in entertainment establishments compared to other sex work venues (p<0.01). Among male clients, 47.0% reported unhealthy alcohol consumption and 42.0% had a PEth positive. However, only 57.1% of male clients with PEth positive reported unhealthy alcohol use.

CONCLUSIONS:

Unhealthy alcohol consumption is prevalent in Cambodian sex work settings. Self-reported unhealthy alcohol use is well reported by FSW, but less by male clients. These findings highlight the urgency of using accurate measures of unhealthy alcohol consumption and integrating this health issue into HIV prevention interventions.

Purchase full article at:  http://goo.gl/OVW2hK

By:  Couture MC¹, Page K², Sansothy N³, Stein E⁴, Vun MC⁵, Hahn JA⁶.

¹Department of Population Health Sciences, School of Nursing and Health Professions, University of San Francisco, 2130 Fulton St., San Francisco, CA 94117, United States. Electronic address: mcouture@usfca.edu.

²University of New Mexico Health Sciences Center, Dept. of Internal Medicine MSC 10 5550, 1 University of New Mexico, Albuquerque, NM 87131, United States.

³National Center for HIV, AIDS, Dermatology and STDs, #245H, Street 6A, Phum Kean Khlang, Sangkat Prekleap Russey Keo, Phnom Penh, Cambodia; University of Health Sciences-Cambodia, #73 Monivong Boulevard, Srah Chak, Phnom Penh, Cambodia.

⁴Global Health Sciences/Prevention and Public Health Group, University of California San Francisco, Mission Hall, 550 16th St., Third Fl., Box 1224, San Francisco, CA 94158, United States.

⁵National Center for HIV, AIDS, Dermatology and STDs, #245H, Street 6A, Phum Kean Khlang, Sangkat Prekleap Russey Keo, Phnom Penh, Cambodia.

⁶Department of Medicine, University of California San Francisco, Mission Hall, 550 16th St., Third Fl., Box 1224, San Francisco, CA 94158, United States.

Drug Alcohol Depend. 2016 May 21. pii: S0376-8716(16)30117-X. doi: 10.1016/j.drugalcdep.2016.05.011. [Epub ahead of print]

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The use of structural equation modelling and behavioural theory to target priority interventions to increase condom use among the intimate partners of sex workers in French Guiana

French Guiana is the French overseas territory that is most affected by HIV. Sex work seems to be an important driver of the epidemic. Although female sex workers are informed by local NGOs, they still have risky behaviours, including not using condoms with their intimate partner despite knowing HIV is highly prevalent. 

The objective of this study was to find intervention targets on this specific behaviour. For this, a structural equation model (SEM) was built using assumptions from behavioural theories. Behaviour theories attempt to connect research and practice. Within the health belief model framework, perceived threats, perceived benefits, and self-perceived efficacy were tested. Vulnerability was added because of the particular context of French Guiana. 

The results highlight that female sex workers’ perceived self-efficacy was central in condom use with the intimate partner (with a significant correlation coefficient of 0.52 in the SEM). The perceived self-efficacy was strongly influenced by sociodemographic factors, particularly by nationality. Female sex workers from Brazil seemed to be more comfortable about asking their intimate partner to use condoms (OR: 7.81; CI: 1.87–32.63) than sex workers of other nationalities. 

These results emphasize that prevention interventions for female sex workers should emphasize their empowerment.

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By:  Marie-Claire Parriault^a*, Astrid Van Melle^a, Célia Basurko^a, Leila Adriouch^b, Stéphanie Rogier^a, Pierre Couppié^c & Mathieu Nacher^ab

^a INSERM CIC 1424, Cayenne General Hospital, Cayenne, French Guiana

^b COREVIH Guyane, Cayenne General Hospital, Cayenne, French Guiana

^c Department of Dermatology, Cayenne General Hospital, Cayenne, French Guiana

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What role does transactional sex play in the HIV/STI and reproductive health risk behaviour among high-tier entertainment centre workers in China?

China's rapid economic growth over the last three decades has led to increased population wealth and the proliferation of entertainment centres where people can conduct business, relax and meet new people. Little is known about the sexual risk behaviours of employees at high-tier entertainment centres. 

This paper addresses this gap in knowledge by comparing HIV risk perception and sexual and reproductive health behaviours among female and male employees at three high-tier entertainment centres in two cities in China, comparing those who report a history of transactional sex to those who do not. 

In both cities, participants who reported a history of transactional sex were more likely than those without a history of transactional sex to report multiple sexual partnerships, more lifetime sexual partners, a history of sexually transmitted infections (STIs), having anal sex and/or recent abortions, and were more likely to perceive themselves to be at risk for STIs/HIV. However, risk behaviour was also high among those with no history of transactional sex. 

These findings highlight the need for targeted sexual and reproductive health initiatives for employees in these work settings.

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By:  Mantell JE¹, LeVasseur MT, Sun X, Zhou J, Mao J, Peng Y, Zhou F, DiCarlo AL, Kelvin EA.

¹ HIV Center for Clinical and Behavioral Studies , New York State Psychiatric Institute and Columbia University , New York , NY , USA.

Glob Public Health. 2015;10(8):947-67. doi: 10.1080/17441692.2015.1045918.

  

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Early sex work initiation and condom use among alcohol-using female sex workers in Mombasa, Kenya: A cross-sectional analysis

OBJECTIVES:

Early initiation of sex work is prevalent among female sex workers (FSWs) worldwide. The objectives of this study were to investigate if early initiation of sex work was associated with: (1) consistent condom use, (2) condom negotiation self-efficacy or (3) condom use norms among alcohol-using FSWs in Mombasa, Kenya.

METHODS:

In-person interviews were conducted with 816 FSWs in Mombasa, Kenya. Sample participants were: recruited from HIV prevention drop-in centres, 18 years or older and moderate risk drinkers. Early initiation was defined as first engaging in sex work at 17 years or younger. Logistic regression modelled outcomes as a function of early initiation, adjusting for drop-in centre, years in sex work, supporting others and HIV status.

RESULTS:

FSWs who initiated sex work early were significantly less likely to report consistent condom use with paying sex partners compared with those who initiated sex work in adulthood. There was no significant difference between groups in consistent condom use with non-paying sex partners. FSWs who initiated sex work early endorsed less condom negotiation self-efficacy with paying sex partners compared with FSWs who did not initiate sex work early.

CONCLUSIONS:

Findings highlight a need for early intervention for at-risk youth and adolescent FSWs, particularly in relation to HIV sexual risk behaviours. Evidence-based interventions for adolescent FSWs or adult FSWs who began sex work in adolescence should be developed, implemented and evaluated.

Purchase full article at:  http://goo.gl/Vi0r9e

By:  Parcesepe AM¹, L'Engle KL², Martin SL³, Green S³, Suchindran C⁴, Mwarogo P⁵.

¹Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA HIV Center for Clinical and Behavioral Studies, Columbia University and New York State Psychiatric Institute, New York, New York, USA.

²FHI 360, Durham, North Carolina, USA Population Health Sciences, School of Nursing and Health Professions, University of San Francisco, San Francisco, California, USA.

³Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA.

⁴Department of Biostatistics, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA.

⁵FHI 360, Nairobi, Kenya.

Sex Transm Infect. 2016 May 23. pii: sextrans-2016-052549. doi: 10.1136/sextrans-2016-052549. [Epub ahead of print]

  

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Gender-based violence against female sex workers in Cameroon: Prevalence and associations with sexual HIV risk and access to health services and justice

Abstract

BACKGROUND/OBJECTIVES:

Female sex workers (FSWs) are at risk for HIV and physical and sexual gender-based violence (GBV). We describe the prevalence of lifetime GBV and its associations with HIV risk behaviour, access to health services and barriers in accessing justice among FSWs in Cameroon.

METHODS:

FSWs (n=1817) were recruited for a cross-sectional study through snowball sampling in seven cities in Cameroon. We examined associations of lifetime GBV with key outcomes via adjusted logistic regression models.

RESULTS:

Overall, 60% (1098/1817) had experienced physical or sexual violence in their lifetime. GBV was associated with inconsistent condom use with clients (adjusted OR (AOR) 1.49, 95% CI 1.18 to 1.87), being offered more money for condomless sex (AOR 2.09, 95% CI 1.56 to 2.79), having had a condom slip or break (AOR 1.53, 95% CI 1.25 to 1.87) and difficulty suggesting condoms with non-paying partners (AOR 1.47, 95% CI 1.16 to 1.87). Violence was also associated with fear of health services (AOR 2.25, 95% CI 1.61 to 3.16) and mistreatment in a health centre (AOR 1.66, 95% CI 1.01 to 2.73). Access to justice was constrained for FSWs with a GBV history, specifically feeling that police did not protect them (AOR 1.41, 95% CI 1.12 to 1.78).

DISCUSSION:

Among FSWs in Cameroon, violence is prevalent and undermines HIV prevention and access to healthcare and justice. Violence is highly relevant to FSWs' ability to successfully negotiate condom use and engage in healthcare. In this setting of criminalised sex work, an integrated, multisectoral GBV-HIV strategy that attends to structural risk is needed to enhance safety, HIV prevention and access to care and justice.

Purchase full article at:  http://goo.gl/YZY1Uk

By:  Decker MR¹, Lyons C², Billong SC³, Njindam IM², Grosso A², Nunez GT², Tumasang F⁴, LeBreton M⁵, Tamoufe U⁶, Baral S².

¹Department of Population, Family & Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA Center for Public Health & Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

²Center for Public Health & Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

³Comité national de lutte contre le sida (CNLS), Ministère de la Sante Publique (MINSANTE), Yaoundé, Cameroon.

⁴PEPFAR DSF Ministère de la Sante Publique (MINSANTE), Yaoundé, Cameroon.

⁵Global Viral, Yaoundé, Cameroon Mosaic, Yaoundé, Cameroon.

⁶Global Viral, Yaoundé, Cameroon.

Sex Transm Infect. 2016 Jun 8. pii: sextrans-2015-052463. doi: 10.1136/sextrans-2015-052463. [Epub ahead of print]

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Is Involvement in Sex Work Associated with Engagement in HIV-Related Medical Care in Latin American Men Who Have Sex with Men? Results of a Large, Multinational Internet Survey

Men who have sex with men (MSM) who engage in transactional sex are at increased HIV risk, and face complex barriers to care seeking. Among 2,035 men recruited through an MSM social/sexual networking website in Latin America and who reported being HIV-infected, 186 (9.1%) reported being paid for sex with another man in the past year. Engagement in transactional sex was associated with decreased odds of receiving medical care for HIV (AOR=0.57, 95% CI=0.37–0.85). No significant differences were seen in being on antiretroviral therapy (ART) or ART adherence once in care. Interventions in this population should focus on reducing barriers to engagement in care.

...Results of this analysis suggest that there are disparities in receipt of HIV medical care associated with recent engagement in transactional sex among HIV-infected MSM in Latin America. The ability to access HIV-related medical care is related not only to availability of care facilities, but also barriers and facilitators to engagement and retention in care, and these factors may be compounded for MSM who engage in transactional sex. For example, stigma and discrimination may limit care seeking to a greater extent among men who engage in transactional sex, given multiple sources of stigma. Previous research suggests that MSM may face sexual stigma from multiple dimensions. Stigma from healthcare providers may limit disclosure of sexual orientation or sexual behaviors among MSM, if they anticipate discrimination following disclosure.¹⁶Among people living with HIV, HIV and healthcare stigma has been associated with decreased care-seeking behavior.^9,12 MSM who engage in transactional sex may experience additional stigma due to being involved in sex work, which is illegal and/or socially unacceptable across most of Latin America, and which has been described as a barrier to care seeking among female sex workers.^17,18 Although experienced and/or perceived stigma could act as a mechanism through which MSM who engage in transactional sex in Latin America have decreased engagement in HIV care, we were unable to quantify experiences of stigma in this study. Future work should consider the role of experienced and/or perceived stigma specifically as a barrier to engaging in care in this population.

...Interestingly, although participants who engaged in transactional sex were less likely to be engaged in HIV-related medical care, prior research by this team¹⁵ and by others in other regions²¹ indicates that MSM who engage in transactional sex are more likely to have a history of HIV testing and of HIV diagnosis.^22,23 This may indicate that men who engage in transactional sex are aware of their increased risk and thus are more likely to test for HIV, but that there are structural, interpersonal, and individual factors—including differential power dynamics due to social or economic position, physical or sexual violence, substance use, and/or psychological distress⁷—which are major barriers to linkage and continued engagement in care if diagnosed...

  

Full article at:  http://goo.gl/5RWUOC

By: Katie B. Biello, PhD, MPH, ^1,,2 Catherine E. Oldenburg, MPH,¹ Joshua Rosenberger, PhD,³ Kenneth H. Mayer, MD,^2,,4,,5 David Novak, MSW,⁶ and Matthew J. Mimiaga, ScD, MPH^1,,2,,7,,8

¹Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts.

²The Fenway Institute, Fenway Health, Boston, Massachusetts.

³Department of Global and Community Health, George Mason University, Fairfax, Virginia.

⁴Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

⁵Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts.

⁶OLB Research Institute, Online Buddies, Inc., Cambridge, Massachusetts.

⁷Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.

⁸Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.

¹Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts.

²The Fenway Institute, Fenway Health, Boston, Massachusetts.

³Department of Global and Community Health, George Mason University, Fairfax, Virginia.

⁴Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

⁵Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts.

⁶OLB Research Institute, Online Buddies, Inc., Cambridge, Massachusetts.

⁷Department of Psychiatry, Harvard Medical School, Boston, Massachusetts.

⁸Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.

LGBT Health. 2016 Jun 1; 3(3): 233–237. doi:  10.1089/lgbt.2015.0006

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Sexual Coercion, Trauma, and Sex Work in Justice-Involved Women with Substance Use Disorders

Sexual victimization is strongly associated with mental health problems, traumatic responses, earlier onset of substance use and criminal justice involvement. It is well known that multiple forms of sexual victimization and aggression have been experienced by most incarcerated women. 

Two hundred women with a substance use disorder and involvement with the criminal justice system within the previous two years (parole, probation, arrest, or incarceration) were recruited from multiple sites in metropolitan Chicago. 

We examined whether empowerment moderates the relationship between trauma symptoms, trading sex and the experience of being forced or coerced to have sex. There was a significant three-way interaction between sexual coercion, trading, and empowerment scores on trauma symptoms. 

For individuals who have not traded sex, lower levels of empowerment were associated with a larger difference in trauma symptomatology between individuals who have been coerced and those who have not been coerced. For individuals who had been coerced to engage in sexual activity, lower levels of empowerment were associated with a larger difference in trauma symptomatology between those who have traded and those who have not traded. 

The promotion of empowerment beliefs and attitudes in women disproportionately impacted by violence and sexual trauma may reduce the harm that results from being victimized. Furthermore, providing specific interventions that educate women regarding gender roles and cultural values may help women avoid situations that result in exploitation and coercion.

Purchase full article at:   http://goo.gl/iuczfl

By: Salina DD1, Ram D2, Jason LA2.

• 1Northwestern University.
• 2DePaul University.
• J Aggress Maltreat Trauma. 2016;25(3):254-268. Epub 2016 Apr 6.

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"We Might Get Some Free Beers": Experience and Motivation for Transactional Sex among Behaviorally Bisexual Men in Vientiane, Laos

People engaging in transactional sex are considered a key population for HIV prevention. Prior quantitative surveys demonstrated that behaviorally bisexual men in Vientiane, Laos commonly transact sex. 

In 2013, we conducted a qualitative study to explore behaviorally bisexual men's experience, motivations, and perceptions related to transactional sex in Vientiane. Behaviorally bisexual men were recruited from bars, nightclubs, and dormitories for five focus group discussions (FGDs) and 11 in-depth interviews (n = 31). Additionally, young women were recruited from a university, garment factory, and nightclub for four FGDs (n = 22). Transcripts were translated and thematically coded. 

Bisexual male participants most commonly described being paid for sex by male-to-female transgender people and buying sex from women. Both male and female participants reported that older, single women pay younger men for sex. Negotiation and direction of sexual transactions are influenced by age, attraction, and wealth. Common motivations for selling sex included the need for money to support family or fund school fees, material gain, or physical pleasure. Transactional sex was often opportunistic. Some behaviorally bisexual men reported selling sex in order to pay another more desirable sex partner or to buy gifts for their regular sex partner. Participants perceived high risk associated with intercourse with female sex workers but not with other transactional sex partners. 

Health interventions are needed to improve knowledge, risk perception, and health behaviors, but must recognize the diversity of transactional sex in Vientiane. Both physical and virtual settings may be appropriate for reaching behaviorally bisexual men and their partners.

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By:  Bowring AL1,2, Pasomsouk N3, Hughes C4, van Gemert C5,6, Higgs P5,7, Sychareun V8, Hellard M5,6, Power R6,4,9.

• 1Centre for Population Health, Burnet Institute, 85 Commercial Rd., Melbourne, VIC, 3004, Australia. annab@burnet.edu.au.
• 2Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia. annab@burnet.edu.au.
• 3Burnet Institute, Vientiane, Lao PDR.
• 4Centre for International Health, Burnet Institute, Melbourne, Australia.
• 5Centre for Population Health, Burnet Institute, 85 Commercial Rd., Melbourne, VIC, 3004, Australia.
• 6Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
• 7Faculty of Health Sciences, National Drug Research Institute, Curtin University, Fitzroy, Melbourne, Australia.
• 8Faculty of Postgraduate Studies, University of Health Sciences, Vientiane, Lao PDR.
• 9Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.
• Arch Sex Behav. 2016 Mar 23.  

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Older Male Clients of Female Sex Workers in the United States

Recent research has provided increased information about the clients of sex workers; however, little is known about the population of older male customers who contract for heterosexual services online. 

Clients (N = 208) between 60 and 84 years of age were obtained through sex work review sites and online discussion forums. Participants completed a 129-item questionnaire focusing on physical health, sexual and non-sexual behaviors with sex providers, and the qualities sought in the same. 

More than half reported having visited sex providers between 13 and 24 times or more during the past 12 months. Participants' advancing age was positively associated with frequency of paid sex. Most frequent sexual activities with providers were fellatio without a condom, followed by penile-vaginal sex with a condom. Analyses also examine the relationship between aging and buying sex. 

Those with higher incomes and without spouses or partners were more likely to report non-sexual activities with providers, and many participants sought a "GFE" or girlfriend experience, in which paid sexual exchanges are part of a relationship that mirrors conventional non-remunerative relationships.

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By:  Milrod C1, Monto M2.

• 1, 519 N. La Cienega Blvd, #209, Los Angeles, CA, 90048, USA. christinemilrod@gmail.com.
• 2Department of Sociology and Social Work, University of Portland, Portland, OR, USA. 
• Arch Sex Behav. 2016 Apr 5.

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Risk Factors Associated with HIV among Men Who Have Sex With Men (MSM) in Ecuador

The Joint United Nations Program on HIV/AIDS estimates that between 0.3% and 0.7% of adults aged 15 to 49 years were living with HIV in Ecuador in 2013. However, very little is known about the HIV prevalence rate among men who have sex with men (MSM) in that country. 

A cross-sectional survey was conducted to investigate the knowledge, attitudes, and practices regarding HIV/AIDS as well as to estimate the prevalence of HIV among MSM in one of the cities with high HIV prevalence rates in Ecuador. In this study, questionnaires were administered to 307 adult MSM. 

An HIV prevalence of 10% was observed. Knowledge about HIV was high; 91% of participants could identify how HIV is transmitted. Although consistent condom use for anal sex was relatively high (89%) among participants who reported having pay-for-service clients, only 64% reported using a condom during oral sex with a client. Participants who had multiple male sexual partners (i.e., their stable male partners plus other partner[s]) had 3.7 times higher odds of testing positive for HIV compared with those who did not. They also had reduced odds of condom use. Participants who were forced to have anal receptive sex had 3 times higher odds of testing positive for HIV. 

Despite the finding that participants exhibited high knowledge about HIV/AIDS, a high prevalence rate of HIV was observed, which warrants targeted behavioral interventions. These data are consistent with MSM being one of the highest at-risk population groups for HIV in this region of Ecuador.

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By:  Hernandez I1, Reina-Ortiz M2, Johnson A3, Rosas C4, Sharma V3, Teran S4, Naik E3, Salihu HM5, Teran E6, Izurieta R3.

• 1Pontificia Universidad Católica del Ecuador, Quito, Ecuador.
• 2University of South Florida, Tampa, FL, USA Fundación Raíces, Esmeraldas, Ecuador.
• 3University of South Florida, Tampa, FL, USA.
• 4Universidad San Francisco de Quito, Quito, Ecuador.
• 5Baylor College of Medicine, Houston, TX, USA.
• 6Universidad San Francisco de Quito, Quito, Ecuador eteran@usfq.edu.ec.
• Am J Mens Health. 2016 May 8. pii: 1557988316646757 

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