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4 Interventions for Female Prostitutes In the beginning stages of the AIDS epidemic, many people feared that femade prostitutes would become widely infected and spread the AIDS virus to them male clients.) At present, this fear appears to be unfounded, at least in the United States. The evidence instead suggests that prostitutes' risk of transmission is more closely associated with Mug use than with multiple sexual clients. The evidence also indicates that the risk of transmission through sexual contact is greater ire the personal relationships of female prostitutes than in their paying ones.2 Data to support these inferences are sparse, however, because research on prostitution is limited. For this reason, and because the future dynamics of the epidemic are still unclear, there is a continuing need to monitor any fixture role that prostitution may play in transmitting HIV. ~ The term prostitute is used to denote the diverse group of women who exchange sexual acts for money, goods, or services as a means (or partial means) of their livelihood or survival. Other terms—such as sex workers, sex industry workers, and commercial sex workers—have also been used to describe this population in an effort to avoid the judgments that are often associated with the term prostitute. The committee appreciates this distinction but has chosen to use the terms interchangeably. None of the terms are intended to convey any judgment about individuals who work in this area. Because so little is known about male prostitutes, the committee has restricted its focus to females. although male prostitutes are also at risk of acquiring and spreading HIV infection. One study of 152 male prostitutes recruited from the streets of Atlanta, Georgia, found that 27 percent were infected. Compared with seronegative respondents, male prostitutes who were HIV positive had spent more years as prostitutes, were more likely to self-identify as homosexual, and had had more encounters involving receptive anal intercourse in the month prior to the interview (Elifson et al., 1989). 2The rate of HIV infection appears to be highest among prostitutes who report IV drug use (CDC, 1987). A recent study of the prevalence of related viruses (HTLV-I/II) among female prostitutes also found rates to be highest among women who had injected drugs (Khabbaz et al., 1990). In addition, a recent study of prostitutes who did not use drugs found a significant relationship between infection and the number of personal (i.e., nonpaying) heterosexual pawners (Darrow et al., 1988). 253

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254 ~ AIDS: THE SECOND DECADE As is the case for other individuals believed to be at-risk for HIV in- fection, the desi:,n of effective intervention strategies should be informed by an understanding of the risk-associated behaviors of Me prostitute and her partners, as well as the conditions under which the behaviors occur. Unfortunately, information about women who work as prostitutes is scant, and knowledge of their clients is sketchier still.3 The stigma- tized and generally illegal nature of prostitution has meant that studies necessarily have had to rely on small nonprobability samples or on ethno- graphic research, neither of which yields results that can be generalized to the female sex worker population as a whole. Moreover, such studies cannot provide an accurate estimate of the number of women who work as prostitutes. Instead, estimates of the total population are constructed from informed "guesstimates" of knowledgeable observers or from arrest and imprisonment records that capture the subsets of female sex work- ers who are most likely to come into contact with the criminal justice system-that is, the poor, the inexperienced, minorities, drug users, and women who work the streets (Turner, Miller, and Moses, 19891. Little is known about the occupational histories of prostitutes, but anecdotal evidence suggests that this is a dynamic population. Thus, despite pre- dictions of '`once bad, always bad," women tend to move into and out of prostitution; there are few data about these patterns, however, or about the relative amounts of time women spend as sex workers and about when and why former prostitutes return to this work (Goldstein, 1979; Delacoste and Alexander, 1987; Potterat et al., In press). In the following section, the committee reviews the literature on prostitution as it relates to the AIDS epidemic in the United States. On presenting this overview, the committee wishes to emphasize that our understanding of this population is far from complete and our knowledge of the widely varied contexts in which its members work is limited. Caution must thus be exercised in deriving generalizations from the findings presented below. Although all prostitutes share the common characteristic of exchanging sexual acts for some kind of payment, there is in fact great diversity in all aspects of the social organization of prostitution and its relations to the larger society in which it is embedded. THE EPIDEMIOLOGY OF AIDS AND HIV INFECTION AMONG PROSTITUTES There are no accurate estimates of the prevalence of HIV infection among female prostitutes in the United States. Serologic surveys capture only 3For examples of research that reflect the perspective of prostitutes, see Jaget (1980), Perkins and Bennett (1985), and Delacoste and Alexander (1987).

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FEMALE PROSTITUTES | 255 those women who volunteer for testing, those who seek care in public clinics for sexually transmitted diseases (STDs), those involved in drug treatment programs, or those in contact with the criminal justice system. Nonetheless, these data shed some light on the distribution of the disease within the population. An important source of information about HIV infection rates among prostitutes is CDC's ongoing multicenter study of 1,396 women, which relies on nonprobability samples of participants from diverse populations around the country. Samples at eight sites were constructed from volunteers who had engaged in prostitution at least once since 1978. The women were recruited from brothels, detention centers, methadone clinics, STD clinics, and networks of "street walkers" and "call girls." Data from this coordinated study (Table 4-1) indicate that the rates of HIV infection among female prostitutes vary greatly from site to site, ranging from zero to 47.5 percent (Darrow et al., in press.14 Yet despite apparently high seroprevalence rates in some areas, HIV infection is not necessarily an occupational hazard for female prostitutes in the United States. Rather, two other factors are indicated: prostitutes are more likely to become infected as a result of unprotected intercourse in the context of a personal relationship than unprotected intercourse with paying clients, and prostitutes who are TV drug users are more likely to acquire HIV infection from contaminated drug injection equipment than from work-related sexual behavior. The risk prostitutes pose to their male clients appears to be minimal, although data regarding these men are extremely limited, in part owing to the criminaTization of prostitution arid the reluctance of clients to be identified. Nevertheless, the available data on all of these transmission risks argue for continued attention to the differential risk of infection for prostitutes related to IV drug use and differential risk associated with particular contexts of sexual activity. Risks Related to Drug Use and Sexual Transmission Data from the CDC multicenter study show that rates of HIV infection are much higher among female sex workers who report a history of IV drug use than among those for whom no evidence of drug use is found (19.9 percent versus 4.S percent). As shown in Table 4-1, HIV seroprevalence rates vary by locale but are higher in most sites for IV drug users. In addition, in a separate analysis of respondents in this study who did not report IV drug use and had no physical signs of injection, HIV infection was associated with large numbers of personal (i.e., nonpaying) sexual partners (reavow et al., 19881. Variations in infection rates by locale may 4These data correct Table 2.8 of Tumer, Miller, and Moses ( 1989:143), which includes the results of 60 serologic retests that were originally reported to the editors as individual respondents.

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256 no A_ Ct C) ._ CO _` C> o - C~ Cal an - , lo: o ._ - 3 - U, o ._ 00 ._ en C) o an Pt o at: 3 - ~s C, U2 C) Ed o -o ~ ~ Z no Cal - oo - .= C) C) C) U. ~ - m o ._ - C-> C) - o Ct _ ~ ~ O C_ o Cal ~ :: 3 ~ no ._ ~ o _ . ~ U' Ce , . ~ C.) ~ . ~ Cal ~ . _ ·_ o CC ~ ~ ~ ~ C) _,= o.O C) ,, _ ,= — Ct: ~ ~ l~ } :: C) ~— — ..O ..o ~ s Cal U: Ct ~ — ,° o .° o ~ o O ~ 0 a ~ ' ~ ' ~ ~ ¢, 0 00. O. 0, ~ O. ~ ~ C~] £ o o ~ ~ ~ U~ <~ ~ _ ~o o ~ o oo _ ~ _ ~ ~ o ~ ~ U~ <: o — ~ _ _ ~ ~ ~ _ r~ _ ~ - o ~ oo ~ ~ _ o o o ~ o ~ o ao {_ ~ o V~ Ct~ '~} (Sx (~) ~ = ~ o, _ ~ ~ ~ ~ ~ x _ ~i ~ O ~ ~ ~ _ — d' — oo ._ V, ~ 01) ~ ~ CC ~ I, o & ~ C) a :; ~ .= ~ z z _` C'3 & . - - - C) 3 ~i CI!4' o C~

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FEMALE PROSTITUTES | 257 reflect different injection patterns or different seroprevalence rates in the heterosexual or IV drug-using populations, or they may be an artifact of the disparate sampling schemes used at the several sites. Follow- up studies are now being conducted in Atlanta, Colorado Springs, and San Francisco; these efforts will include prostitutes and their sexual and needle-sharing partners (Darrow et al., 1989~.5 Although these studies show that the risk for female sex workers is primarily associated with injecting drugs, the proportion of sex workers who inject drugs is not known with any certainty. One estimate, based on a nonprobability sample of 75 arrested sex workers in New York, found that one-third had injected drugs in the past two years; half had injected drugs at least once in their lives (Des Jariais et al., 1987~. However, data collected from CDC's multicenter study indicate greater uncertainty in these estimates: between 27 and 73 percent of prostitutes recruited from settings as diverse as legal brothels and STD clinics were found to have injected drugs at some time (Darrow et al., 1989~. TV drug use may not be evenly distributed throughout the population of female sex workers. Indeed, ethnographic and survey data indicate that needle use is more common among prostitutes who work on the street and among minorities than it is among other sex workers (Goldstein, 1979; Khabbaz et al., 19901.6 Lower rates of IV drug use among women who work pnmar~ly for escort services or brothels would be consistent with the lower rates of HIV infection reported in this group (Fischl et SThat the source of infection was contaminated injection equipment rather than multiple professional customers is given further credence by the results of Wolfe and colleagues (1989). Their study of 220 female intravenous drug users recruited from methadone maintenance programs and detoxification treatment facilities in San Prancisco found that seropositivity was not in fact associated with "paid sex." Moreover, Khabbaz and colleagues' (1990) analyses of data on the prevalence of HTLV-I/II infection from the CDC multicenter study of female prostitutes found statistically significant positive associations between seropositivity for these viruses and the use of shooting galleries, needle-sharing, duration of injecting career, and frequency of drug use. Infection was not associated with number of sexual partners. 6In a survey of 1,305 female prostitutes from the CDC multicenter study, 600 reported that they had injected illicit drugs at some time in their lives or had physical signs (needle marks) of IV drug use (Khabbaz et al., 1990). Slightly more than half (318, or 53 percent) were nonwhite (217 blacks, 73 white Hispanics, 13 black Hispanics, 10 American Indians, and 5 Asians). Other analyses of these data find that 84 percent of IV drug-using women reported street prostitution compared with a significantly smaller proportion (74.3 percent) of women with no history or signs of injection (W. W. Darrow, chief of the Social and Behavioral Studies Section, Center for Infectious Diseases, CDC, personal commu- nication, October 6, 1989). In another study of 60 women who reported drug use, Goldstein (1979) found that 43 also reported prostitution. The vast majority (96 percent) of the 25 streetwalkers inter- viewed in this study reported regular heroin use. In contrast. none of the 18 prostitutes who worked in massage parlors, as call girls, or as madams reported regular use of heroin, although 22 percent had used the drug at least once. Of the 25 streetwalkers interviewed, 64 percent were black, and 20 percent were Hispanic.

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258 ~ AIDS: THE SECOND DECADE al., 1987; Seidlin et al., 1988~.7 In fact, the causal connection, if any, between prostitution and drug use (or vice versa) is unknown. Given the evidence, however, that HIV infection among female prostitutes has occurred mainly among those who use IV drugs and that prostitutes thus appear to be at increased risk for HIV infection pnmarily through drug use rather than through sexual practices, the committee recommends that the National Institute on Drug Abuse and the Centers for Dis- ease Control continue to support and strengthen current efforts to understand and intervene in the relationship between drug use and prostitutions In its first report, the committee recommended that steps be taken to close the vast gaps in knowledge regarding the relationship between sexual behavior and drug use (Turner, Miller, and Moses, 19891. In the case of Mug use and prostitution, the committee found that such steps should include better understanding of the following: variations in Mug use across different subpopulations of prostitutes, the effect of drug use on nsk-associated behaviors, the relationship between drug use and prostitution and the conditions and antecedents surrounding their ~nitia- tion, and interventions that might protect prostitutes from the threat of HIV infection and other dangers associated with drug use. In addition to HIV transmission associated with injection practices, risks related to the evolving drug scene in particular, the Great now presented by noninjected drugs, such as crack have increased. As discussed in Chapter I, the use of crack may foster increased demand for sexual services, which can be supplied by women exchanging sex for the Hug itself or for money to buy it. Some of the risk associated with prostitutes' nonpaying sexual parmers may be related to He use of crack or other drugs. For example, crack use in New York has been associated with sexual transmission of HIV (Chiasson et al., 1989~.9 In addition, 7A serologic survey of 90 streetwalking female prostitutes recruited from a depressed inner-city area of south Florida and 25 women who worked for an escort service in a middle-class urban area of that state found that 41 percent of the streetwalkers were infected but none of the women from the escort service were seropositive (Fischl et al., 1987). These results are consistent with findings from the CDC multicenter study, in which brothel workers and applicants constituted the group with the lowest rates of IV drug use and the lowest rates of HIV infection (Darrow et al., in press). ~CDC supports ongoing studies of female prostitutes in several cities (see Table 4-1) that are investi- gating the sexual and social networks of prostitutes as well as strategies for outreach, treatment, and social mobilization of female sex workers. NIDA funds outreach and education programs for a diverse population of women, including prostitutes. 9In a study of HIV infection among patients seeking treatment at an STD clinic, Chiasson and cowork- ers (1989) found that, among twelve infected men who reported no same-gender sexual contact, no IV drug use, and no sexual contact with a person known to be infected with HIV, three had a history of sexual contact with known crack users, one was a crack user himself, and eight reported contacts with prostitutes. Furthennore, of the six seroposiiive women identified in this study who also reported no

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FEMALE PROSTITUTES ~ 259 Shedlin (1987) reports that female prostitutes recruited pr~manly through drug treatment programs in New York City and Bridgeport, Connecticut, identified "crack addiction" as one of the primary reasons for engaging in unprotected intercourse, particularly among younger women who worked on the streets. Friedman and coworkers' (1988) ethnographic research on "crack houses" (buildings in which crack is sold and used) also confirmed the link between crack use and unprotected intercourse and, occasionally, street prostitution. Many of the acts of unprotected intercourse reported by Friedman and colleagues occurred between male IV drug users and female crack users,~° thus increasing the risk of spread of the virus. Clearly, the risks associated with crack are related to unprotected in- tercourse rather than to a specific characteristic of the drug or the route of administration. The context of the sexual encounter is thus an important factor in differential rates of HIV transmission. Also of importance to the level of HIV transmission risk shared by female prostitutes and their clients is the specific set of sexual activities the client purchases. These factors are discussed in the sections that follow. Context-Relatet1 Risks The context of the sex-for-money exchange involves a variety of ele- ments, from setting and time limitations to cultural preferences and the nature of the relationship between the partners. Most sexual encounters with female prostitutes are brief. For street prostitutes, the time from spiking the bargain—which activities for what price—to their return to the street may be only a dozen minutes or so. More extended penods of time and a wider variety of sexual techniques are generally more expensive and pr~manly characteristic of outcall or other off-street prac- titioners. Within time-limited contexts, oral sex is frequently preferred by both clients and prostitutes (see, e.g., Shedlin, 19871. Neither partner need remove his or her clothing, and the act is usually over quickly, thus reducing vulnerability for both. It may also reduce transmission risks among female prostitutes and their mate clients. On the other hand, clients' sexual technique preferences vary sub- stantially by class and culture. Although street prostitutes in New York report that oral sex is the activity of preference (Des parlays et al., 1987), history of IV drug use or sexual contact with an infected individual, four were prostitutes who used crack. 10In this study, ex-addict street outreach workers were used to identify informants among residents of buildings that served as crack houses. They reported that male addicts found female crack users to be an inexpensive and readily available source of sexual gratification.

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260 ~ AIDS: THE SECOND DECADE women who work as prostitutes among newly immigrant Latino popula- tions report that vaginal intercourse is preferred by their clients (Magana and CalTier, in press). In these cases, transmission risks may be higher, particularly if there is a history of STDs or current infection. In addition, some men may choose anal intercourse, which carries an even greater risk of viral transmission, particularly if condoms are not used. The frequency of anal sex in this population is not known. Not all female prostitutes offer this service; others may charge premium rates for anal sex, which may reduce demand. It is clear, however, that the distribution of sexual techniques offered by women and desired by clients in any community could affect rates of viral transmission. The need for safer sex practices and the ability to modify dangerous practices are affected by the degree to which these practices are ingrained in the local culture, as well as by the strength of an individual cTient's desires. The use of condoms for protection against HTV and other STDs appears to vary with the nature of the relationship between the sexual partners. Several studies of condom use among female prostitutes report that unprotected intercourse is more likely to occur in the context of a personal relationship than in a paid transaction. In an earlier (1987) report of the ongoing CDC multicenter study, more than 80 percent of the women surveyed reported at least occasional use of condoms, but that use was much more likely to occur with clients (78 percent) than with husbands or boyfriends (16 percent) In a sample of approximately 500 prostitutes living in the San Francisco area (who were recruited by other prostitutes hired to do outreach and through sex-related media), J. B. Cohen and coworkers (1989) found that 90 percent reported at least one instance of condom use with paying customers. In fact, 38 percent said they always used condoms with clients, compared with only 14 percent who sometimes used condoms with husbands or boyfriends. Studies of prostitutes in Europe have also found less reported use of condoms in the context of personal relationships than in professional ones (Day, Ward, and Hams, 1988; Hooykaas et al., 19891.~2 In fact, it is among sex 11 There are, however, some preliminary data on this practice from the CDC multicenter study. More than one-third (36.3 percent) of the women in the study reported at least one episode of anal intercourse (W. W. Darrow, chief of the Social and Behavioral Studies Section, Center for Infectious Diseases, CDC, personal communication, October 6, 1989). 12In a study of 91 prostitutes recruited from an STD clinic in London, Day, Ward, and Harris (1988) reported that more than half (59 percent) of the women reported consistent condom use with pay- ing customers. Of the 71 women who reported vaginal intercourse with their boyfriends, 6 percent said they used condoms consistently with these partners. The differential pattern of condom use did not change over the course of the 17-month study; however, the percentage indicating condom use increased for both groups.

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FEMALE PROSTITUTES ~ 261 workers with large numbers of nonpaying sexual partners that the risk of sexual transmission of HIV infection has been found to be highest (Darrow et al., 19881. The lower frequency of condom use in personal relationships may have something to do with the distinction both female prostitutes and their husbands or boyfriends make between intimate sexual acts and paid sex (J. B. Cohen, 19891. Shedlin (1987), for example, noted that the prostitutes in her study differentiated between what they did with clients and intimate acts reserved for their personal partners, such as kissing. In another study (Darrow et al., in press), female prostitutes reported that their personal sexual partners saw themselves as having a Tow risk of infection because they believed the women consistently used condoms with clients. As a result, many prostitutes reported difficulties in persuading their private partners to use condoms. Client-Related Risks The extent of the risk of HIV infection for paying customers of prostitutes is not known with certainty, but the number of cases ascribed to contact with female sex workers has not been large, and the few existing studies of prostitutes' clients have found relatively low rates of HIV infection. However, data on clients come from a limited group of studies that have relied on small, nonprobability samples, and their results must be interpreted with caution. Wallace, Mann, and Beatrice (1988) recruited paying customers of prostitutes through advertisements in a New York City weekly newspaper, television and radio news stories about the study, ads placed at union headquarters, and hotline referrals. Interviews and blood specimens were obtained from 340 men with a history of sexual contact with female prostitutes and no other risk factors for infection. Six of the men were found to be infected. Upon reinterview, however, three later admitted other risk behavior, leaving three (0.9 percent) seropositive men whose only alleged risk factor was unprotected sexual contact with a prostitute. These three infected men reported a mean of 575 lifetime contacts with prostitutes (compared to an overall average of 94 contacts for study participants). As noted earlier, although the risk of infection for female sex workers is not clearly related to the number of clients, this study provides some evidence, albeit limited, that for clients a large number of prostitute contacts may be associated with a greater risk of acquiring HIV. In another study, Chiasson and colleagues (1988) recruited 671 men from a New York City STD clinic and found that 138 men reported no risk factors for AIDS except vaginal intercourse with prostitutes. Of the 138

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262 ~ AIDS: THE SECOND DECADE men, 2 (1.4 percent) were found to be infected. Among 222 respondents who reported no risk factors at all, 3 men (~.4 percent) were found to be seropositive. The following year, the same investigators (Chiasson et al., 1989) collected data from 955 men recruited from another New York STD clinic situated in an area in which the cumulative HIV incidence rate was high and drug use, including the use of crack, was common. Of the 571 men with no identifiable risk factors, 262 reported contacts with prostitutes, and 15 (5.7 percent) of the 262 men were antibody positive. (In addition, five seropositive men reported sexual contact with known crack users.) Neither study reported the average number of prostitute contacts for the infected men. Nevertheless, the higher infection rate in the second study suggests the need for continued monitoring of the population of men who report sexual contact with prostitutes. Finally, in a CDC follow-up study of 1,138 AIDS cases originally diagnosed in adult males with no reported risk factors, investigators were able to identify a risk factor in all but 281 of the cases. Of these 281 remaining cases with no identifiable risk factor, 178 were reinterviewed. Ninety-six of these men responded to the question on prostitute contact, and 33 reported contact with female sex workers. These 33 men account for only 0.08 percent of the 41,770 adult cases of AIDS diagnosed at the time of the study (Castro et al., 1989), thus suggesting a limited transmission threat posed by female prostitutes. Although these data affirm the possibility that female prostitutes can transmit infection, questions regarding the accuracy of risk reporting may cast doubt on any conclusion regarding the extent of such transmission. A problem relevant to reporting prostitute contact is response bias at- tributable to deliberate misreports of behavior to project an image of "social desirability." Castro and colleagues (1989), for example, sug- gest that men who engage in nsk-associated behaviors other than contact with female sex workers may nevertheless report prostitute contact to prevent further investigation of other risk factors the respondent may consider more sensitive or stigmatizing (e.g., same-gender sexual con- tacts). (Chapter 6 provides a more detailed discussion of the difficulties in validating self-reported data on sexual practices.) Although the number of men who have become infected through contact with female prostitutes is not known, it appears to be small when compared with the number of men who report other risk behaviors. In its first report, the committee recognized both the need for and the difficulties involved in collecting high-quality data on the clients of female prostitutes. At that time, a number of possible approaches were suggested: studies using household samples in which men are asked

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FEMALE PROSTITUTES ~ 263 about contact with prostitutes; specialized samples of men who might not be reached through household samples but who nonetheless are or have been associated with prostitutes; special studies of men who are particularly likely to use the services of prostitutes; and studies of men from cultures in which the patronage of prostitutes is considered part of the normative repertoire of sexual behavior. The committee reaffimns its support for these suggestions. In addition, because so little is known about the role of prostitutes' clients in the spread of HIV infection, the committee recommends that the Public Health Service undertake a series of feasibility studies to determine the best ways to gather appropriate information about prostitutes' clients and their role in the spread of HIV to the larger population. The segment of the female prostitute population that does not inject drugs appears to pose only a limited threat to clients at this time, and sexual contact with clients appears to be less of a threat to prostitutes than either drug use or personal sexual relationships. However, as other populations have demonstrated, the problem of HTV infection is not static. The risks may, indeed, be limited, but changes seen over the course of the first decade of the epidemic argue for continued vigilance. Given the factors that are known to distinguish the risk profile of many prostitutes (unprotected sexual contacts and rv drug use), the committee recommends that the Centers for Disease Control continue to monitor the effects of the AIDS epidemic in this population. Activities should include a continuing, systematic effort to track the incidence and prevalence of both HIV infection and sexually transmitted diseases in this group. To reach both prostitutes and their clients, knowledge of the varying patterns of prostitution and prostitute patronage is critical. The available data on such patterns are presented in the following section. PATTERNS OF PROSTITUTION Stereotypical depictions of prostitution tend to present two ends of a spectrum: the pathos associated with streetwalkers and the sophisticated elegance of call girls. The reality is that women who engage in prostitu- tion have a wide range of lifestyles, work in many different milieus, and have varying feelings about their work, ranging from degradation and de- spair to pride (Iames, 1977; B. Cohen, 1980; Carmen and Moody, 1985; Perkins and Bennett' 1985; Delacoste and Alexander, 1987; Shedlin, 1987~. These differing patterns have important implications for inter- vention efforts. The place of work, services offered, number of clients served, local prevalence of infection, and availability and use of pro- tective measures are all factors that affect the risk of HIV infection for female prostitutes, and they should be taken into account in the design

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278 ~ Alas: THE SECOND DECADE has been abolished; as the San Francisco Police Department has stated, "the police value of these materials as indirect evidence of prostitution . . . is exceeded by their AIDS prevention value" (Department Special Order 87-131.24 Where it continues, the practice of using condoms as evidence of a crime dampens AIDS interventions that seek to persuade prostitutes and others in the sex industry to make condoms available to clients. Although many prostitution laws were onginally enacted to protect women from exploitation, such laws can also have the effect of cultivat- ing secrecy among prostitutes and a wariness of outsiders that impedes outreach efforts to promote health education and risk reduction. Research has shown that in jurisdictions in which prostitution is illegal and the law is enforced, it does not go out of existence but instead goes underground in a way that increases the difficulties of outreach to female sex workers for public health purposes (B. Cohen, 1980; Carmen and Moody, 1985; Alexander, 19871. If police confiscate condoms as evidence of intent to solicit prostitution or if possession of condoms is listed on an arrest record, prostitutes receive a message that is inconsistent with what is being asked of them by public health authorities. Prostitutes may thus be discouraged from carrying condoms on their person, making it even more likely that they will engage in unprotected sex. AIDS-Related Legislation In an attempt to control the spread of HIV, some states have proposed or passed special AIDS legislation that targets persons working as prostitutes (Rowe and Ryan, 19871. One type of statute restricts the activities of infected individuals, and another calls for mandatory HIV testing of prostitutes. Not much is currently known about the enforcement of these laws, but both types of legislation have consequences for the implementation of AIDS prevention programs. Restriction of Infected Individuals On some locales, local health officers can "resmct" (either Trough quar- antine or isolation) individuals who have a communicable disease Hat is thought to endanger the public health. In Colorado, for example, the 24In response to public health concerns, for example, the San Francisco Police Department issued an order on April 10. 1987, that reads in part "this [Police] Department and the District Attorney's Office have examined the current practice of routine confiscation of condoms and bleach containers for evidence during prostitution and drug-related alTests. Effective immediately, . . . [they] shall not be seized as evidence, unless ... [as] evidence of a crime other than prostitution ...." (Deparunent Special Order 87-13).

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FEMALE PROSTITUTES ~ 279 statute is rather stringent and singles out HIV as an isolable condition. If a person is reasonably believed to be infected with HIV, a representa- tive of Colorado's public health office can issue a cease-and-desist order for specified dangerous conduct (in this case, prostitution); violation can result in a criminal penalty (Gostin and Ziegler, 19871. The impact of such laws on HIV transmission and on the ability to provide intervention and other services is not known. However, legal provisions for isolation are unlikely to address fundamental problems of HIV transmission, according to a report by the Institute of Medicine (IOM/NAS, 19881. Indeed, the threat of such restrictive action may cause at-risk individuals, including prostitutes, to avoid HTV testing and other help-seeking measures in order to escape identification by the authorities. Mandatory HIV Testing A few states have passed legislation or have bills pending that would require crayons convicted or arrested for prostitution to be tested for H]:V infection (Gostin and Ziegler, 1987; Rowe and Ryan, 1987~. For example, Florida requires women convicted of prostitution to undergo screening for a variety of STDs, including HIV; women who are found to be infected must submit to treatment and counseling as a condition for release (Gostin and Ziegler, 19871. In addition, some states have imposed penalties on HIV-infected persons who are convicted of exposing other individuals to the virus. Prostitutes obviously will be affected by these laws, even when they are not specific targets of the legislation (Gostin and Ziegler, 1987~. It is unclear whether mandatory testing laws are effective in reducing the rate of transmission of HIV infection. Certainly, other attempts to legislate the control of STDs have not met with great success.25 Without safeguards in place to protect individuals who are found to be infected, female prostitutes may view compulsory HIV testing as harmful, which in turn may nullify any anticipated benefits. Moreover, such laws may divert resources from educational efforts that could be more effective in reducing the epidemic's spread. Even in locales in which prostitution is legal, the benefits of manda- tory HIV testing are not entirely clear. Policies that enforce regular medical examinations of prostitutes may also foster risk taking by engen- dering a false sense of security (i.e., that one is not at risk) that in reality 25 In an effort lo stem venereal disease, Congress passed the May Act in 1941, making "vice activities" near military installations a federal offense; during World War II, the May Act served as a prod to local communities to suppress prostitution. Yet despite the ensuing incarceration of several thousand prostitutes, military physicians found no decline in the "venereal problem'. (Brandt, 1988).

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280 ~ AIDS: THE SECOND DECADE cannot be ensured by weekly or monthly checkups to detect syphilis, gonorrhea, HIV infection, or other STDs is. B. Cohen, Alexander, and Wofsy, 1988~. For example, once mandatory HIV testing was instituted in Bavana, West Germany, clients began to refuse to use condoms be- cause they felt that testing had eliminated the risk of AIDS (Pheterson, 1989~. Of course, this perception of eliminated risk does not take into account the possibility that the client could infect the prostitute. Very few countries have begun intervention efforts to educate customers about their responsibility for condom use. Other Effects of Marginality Groups such as prostitutes and Mug users who live and work on the mar- gins of society often experience subtle consequences of this marginality that may affect any attempts to facilitate behavioral change. The nature of sex work as a marginal profession, for example, creates barriers for some prostitutes that may impede their implementation of safer-sex be- haviors. In legitimate workplaces, employees are protected by law from many hazardous conditions; they are able to organize to promote occupa- tional safety and guaranteed fair wages. These patterns and practices are not necessanly available to prostitutes, even though safeguards, such as the technology currently advocated to reduce sexually transmitted HIV infection (latex condoms and spermicides with nor~oxinol-9) have been available for decades to prevent other STDs. At the same time, female prostitutes report problems persuading their partners, both paying and nonpaying, to use condoms if. B. Cohen, 1987; Shedlin, 1987; Day, Ward, and HaIris, 1988; Rosenberg and Weiner, 1988; Monny-Lobe et al., l989c; Wilson et al., 1989; Darrow et al., in press). A prostitute's precarious financial] position may make her vuIner- able to customers who offer a higher price for sex without a condom. Moreover, prostitutes are at least as vulnerable as other women in their personal relationships. In contrast to professional relationships, the way in which personal sexual relationships are defined by sex workers and their partners often precludes condom use or other protective measures (J. B. Cohen, 19891. Finally, the marginality of their profession and prostitutes' need to earn a living may engender a quite practical apprehension about AIDS education. It has been reported that streetwalkers are sometimes reluctant to accept materials labeled as "AIDS" information because the materials might be seen by others who might infer that any prostitute reading such material has already been infected. It thus becomes a wise business decision to refuse risk reduction literature (Shedlin, 19871.

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FEMALE PROSTITUTES ~ 281 Although female prostitutes do not appear to play an important role in transmitting HIV, a significant proportion of sex workers in some locales are infected with the virus, mainly from IV drug use practices and, to a lesser extent, from sexual contact with infected husbands and boyfriends. For this reason, it is important to extend to sex workers the services arid education they need to prevent acquisition of the disease. Options for future HIV prevention efforts are presented below. FUTURE NEEDS AND OPTIONS FOR HIV PREVENTION Female prostitutes as drug users mandate a specific set of HIV prevention strategies, the most prominent of which include access to drug treatment centers and, for women who continue injecting, instructions on cleaning injection equipment. These interventions were discussed at length in Chapter 3 of the committee's first report (Turner, Miller, and Moses, 1989~. In addition, prostitutes in their capacity as prostitutes have unique needs. The illegality and marginality of the sex industry raise a number of stubborn issues that resist resolution, but some of these issues can be affected by changes that would further the implementation of HIV Interventions. First, nationwide agreement is needed among enforcement and crim- inal justice personnel that the possession of condoms will not be used as evidence of intent to commit or solicit prostitution or, in the case of brothel owners and managers, as evidence of intent to commit the more serious offenses of pimping, pandenng, or procuring. Such an agreement is consistent with recommended public health practices and has already been adopted by a handful of U.S. cities. Moreover, the policy of manda- tory HIV testing for attested or convicted prostitutes is riot warranted at this time. Prostitutes' risk of HIV transmission is more closely associ- ated with drug use than with sexual activity and appears to be greater in personal relationships than in paying ones. Mandatory testing programs that focus on female prostitutes as professional sex workers are thus mistargeted and reflect an injudicious use of resources, given that most serologic studies of prostitutes who do not inject drugs find few who are infected. In addition, one-sided testing policies that do not include the clients of prostitutes are not sound public health practice. The commit- tee finds, therefore, that mandatory testing of prostitutes is unlikely to address the real sources of increased risk, which are tied to private, inti- mate relationships and clandestine use of illicit substances. Recently, the Institute of Medicine's Committee for the Oversight of AIDS Activities rejected the policy of mandatory testing and warned that tying antibody

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282 ~ AIDS: THE SECOND DECADE status to criminal activity might also discourage voluntary testing, coun- seling, and medical referral (IOMINAS, 19881. The committee concurs with that position and urges the rejection of such policies. Second, the connection between HIV infection and prostitution needs to be better understood. The known facts about this diverse population are few. There is currently some sense of the prevalence of HIV infection among female prostitutes, although studies to date have relied on small, geographically discrete groups that may or may not be representative of the larger population. Although some information is available on how and why women enter prostitution, little is known about how and why they leave this work (see, for example, Potterat and colleagues El98511. Most existing studies are based on discrete groups of prostitutes and are outdated. In addition, support is needed for studies of men who are clients of prostitutes. For the purposes of understanding both HIV transmission and the design and implementation of intervention programs, data are needed on the work contexts of prostitutes, their personal social networks, their occupational histories, and their clients. The committee believes such research efforts will benefit from input by women who have actually worked as prostitutes. Especially important are investigations of individuals who report behaviors recently found to be associated with HIV transmission, such as the young women who are exchanging sex for drugs but do not define themselves as being "in the business"—and so do not protect themselves against any STDs, including HIV infection. The relationship between crack use and sexual transmis- sion of HIV is just beginning to be understood; a fuller understanding requires careful study of the subpopulation of women and men who ex- change sex for crack to shed light on emerging patterns and risks. It is likely, however, that IV drug use will continue to be the major route of infection for prostitutes in the industnalized countries. Finally, there is little information about the effectiveness of recently begun intervention efforts for this population, and He committee urges that this situation be corrected. Longitudinal studies of planned variations accompanied by rigorous evaluation are just as necessary and desirable for this population as for others at risk for HIV infection. Strategies for evaluating He risk reduction projects of community-based organizations have been laid out in Coyle, Boruch, and Turner (1990) and could prove to be useful in this arena as well. Without some evaluation of the effects of a project, be they positive or negative, planners lose the opportunity to understand what best facilitates change and where resources are best expended.

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FEMALE PROSTITUTES | 283 REFERENCES Abramowitz, A., Guydish, J., Woods, W., and Clark, W. (1989) Increasing crack use among drug users in an AIDS epicenter: San Francisco. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Alexander, P. (1987) Prostitution: A difficult issue for feminists. In F. Delacoste, and P. Alexander, Sex Work: Writings by Women in the Sex Industry. San Francisco: Cleis Press. Alexander, P. (1988) Prostitutes Prevent AIDS: A Manual for Health Educators. San Francisco: California Prostitutes Education Project. Altman, R., Grant, C. M., Brandon, D., Shahied, S., Rappaport, E., and Costa, S. (1989) Statewide HIV-1 serologic survey of newborns with resultant changes in screening and delivery system policy. Presented at the Fifth International AIDS Conference, Montreal, June =9. Becker, M. H. (1970) Sociometnc location and innovativeness: Reformulation and extension of the diffusion model. American Sociological Review 35:267-282. Benjamin, H., and Masters, R. E. L. (1964) Prostitution and Morality. New York: Julian. Brandt, A. M. (1988) AIDS in historical perspective. In C. Pierce, and D. VanDeVeer, eds., AIDS: Ethics and Public Policy. Belmont, Calif.: Wadsworth Publishing Co. Carmen, A., and Moody, H. (1985) Working Women: The Subterranean World of Street Prostitution. New York: Harper and Row. Castro, K. G., Lifson, A. R., White, C. R., Bush, T. S., Chamberland, M. E., et al. (1989) Investigations of AIDS patients with no previously identified risk factors. Journal of the American Medical Association 259:1338-1342. Centers for Disease Control (CDC). (1987) Antibody to human immunodeficiency virus in female prostitutes. Morbidity and Mortality Weekly Report 36:157-161. Centers for Disease Control (CDC). (1989) HIV/AIDS surveillance: AIDS cases reported through July 1989. Centers for Disease Control, Atlanta, Ga. Chiasson, M. A., Stoneburner, R. L., Lifson, A. R., Hildebrandt, D., and Jaffe, H. W. (1988) No association between HIV-1 seropositivity and prostitute contact in New York City. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Chiasson, M. A., Stoneburner, R. L., Telzak, E., Hildebrandt, D., Schultz, S., and Jaffe, H. (1989) Risk factors for HIV-1 infection in STD clinic patients: Evidence for crack-related heterosexual transmission. Photocopied materials distubuted at the Fifth International Conference on AIDS, Montreal, June =9. Cohen, B. (1980) Deviant Street Networks: Prostitution in New York City. Lexington, Mass.: Lexington Books. Cohen, J. B. (1989) Condom promotion among prostitutes. In Condoms in the Prevention of Sexually Transmitted D'seases. Research Tnangle Park, N.C.: American Social Health Association. Monograph. Cohen, J. B., Alexander, P., and Wofsy, C. (1988) Prostitutes and AIDS: Public policy issues. AIDS and Public Policy 3:1~22. Cohen, J. B., Poole, L. B., Dorfman, L. E., Lyons, C. A., Kelly, T. J., and Wofsy, C. B. (1988a) Changes in risk behavior for HIV infection and transmission in a prospective study of 240 sexually active women in San Francisco. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16.

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FEMALE PROSTITUTES ~ 285 Friedman, S. R., Dozier, C., Sterk, C., Williams, T., Sotheran, J. L., and Des Jarlais, D. C. (1988) Crack use puts women at risk for heterosexual transmission of HIT from intravenous drug users. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Friedman, S. R., Serrano, Y., Torres, L., Sufian, M., Nelson, P., et al. (1989) Orga- nizing intravenous drug users against AIDS. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Froschl, M., and Braun-Falco, O. (1988) Women and AIDS. In H. Jager, ea., AIDS and AIDS Risk Patient Care. New York: John Wiley and Sons. Fullilove, R. E., Fullilove, M. T., Bowser, B. P., and Gross, S. A. (1989) Crack use and risk for AIDS among black adolescents. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Fullilove, R. E., Fullilove, M. T., Bowser, B. P., and Gross, S. A. (1990) Risk of sexually transmitted disease among black adolescent crack users in Oakland and San Francisco, Calif. Journal of the American Medical Association 263:851-855. Gagnon, J. H., and Simon, W. (1973) Sexual Conduct: The Social Sources of Human Sexuality,. Chicago: Aldine Publishing Co. Goldstein, P. J. (1979) Prostitution and Drugs. Lexington, Mass.: Lexington Books. Gostin, L., and Ziegler, A. (1987) A review of AIDS-related legislative and regulatory policy in the United States. Law, Medicine and Health Care 15:5-16. Hooykaas, C., van der Pligt, J., van Doornum, G. J. J., van der Linden, M. M. D., and Coutinho, R. A. (1989) Heterosexuals at risk for HIV: Differences between private and commercial partners in sexual behavior and condom use. AIDS 3:525-532. Horton, J., Alexander, L. and Brundage, J. (1989) HIV prevalence among military women: An examination of military applicant, active duty, and reserve testing data. Presented at the Fifth International AIDS Conference, Montreal, June =9. Institute of Medicine/National Academy of Sciences (IC)M/NAS) (1988) Confronting AIDS: Update 1988. Committee for the Oversight of AIDS Activities. Washington, D.C.: National Academy Press. Jaget, C., ed. (1980) Prostitutes~ur Life. Bristol, U.K.: Falling Wall Press. James, J. (1977) Prostitutes and prostitution. In E. Sagann and F. Montanino, eds., Deviants: Voluntary Actors in a Hostile World. Morristown, N.J.: General Leaming Press. Khabbaz, R. F., Barrow, W. W., Hartley, T. M., Witte, J., Cohen, J. B., et al. (1990) Seroprevalence and risk factors for HTLV-I/II infection among female prostitutes in the United States. Journal of the American Medical Association 263:60~4. Kinnell, H., and Griffiths, R. K. G. (1989) Measuring and reducing risks of HIV transmission amongst female prostitutes in Birmingham, England. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Kloser, P., Bais, P., Lynch. A., Lombardo, J., and Kapila, R. (1989) Women with AIDS: A continuing study 1988. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Laws, J., and Schwartz, P. (1977) Sexual Scripts: The Social Construction of Female Sexuality. Hinsdale, Ill.: The Dryden Press. Locking, K. C. (1988) Prostitutes as AIDS educators. Presented at the Fourth Interna- tional Conference on AIDS, Stockholm, June 12-16.

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286 ~ AIDS: THE SECOND DECADE Luxenberg, J., and Klein, L. (1984) CB radio prostitution: Technology and the displace- ment of deviance. Journal of Offender Counseling, Services, and Rehabilitation 9:7 1-87. Magana, R., and Carrier, J. (In press) Mexican and Mexican American male sexual behavior and the spread of AIDS in California. Social Sciences and Medicine. Monny-Lobe, M., Nichols, D., Zekeng, L., Salla, R., and Kaptue, L. (1989a) HIV in- fection and prostitution in Yaounde-Cameroon. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Monny-Lobe, M., Nichols, D., Zekeng, L., Salla, R., and Kaptue, L. (1989b) Prostitutes as health educators for their peers in Yaounde: Changes in knowledge, attitudes and practices. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Monny-Lobe, M., Nichols, D., Zekeng, L., Salla, R., and Kaptue, L. (1989c) The use of condoms by prostitutes in Yaounde-Cameroon. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Ngugi, E. N., Simonsen, J. N., Bosire, M., Ronald, A. R., Plummer, F. A., et al. (1988) Prevention of transmission of human immunodeficiency virus in Afnca: Effectiveness of condom promotion and health education among prostitutes. Lancer 2:887-890. Nichols, D. J., Mor~ny-Lobe, M., Koumare, B., Neequaye, A., DeBuysscher, R., et al. (1989) Impact of pilot interventions to reduce the spread of HIV infection among high risk women in Africa. Presented at the Fifth International Conference on AIDS, Montreal, June ~9. Overs, C., and Hunter, A. (1989) AIDS prevention in the legalized sex industry. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Paalman, M. E. M., and de Vries, K. J. M. (1988) Condom promotion in The Netherlands: Prostitution. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Padian, N., Carlson, J., Browning, R., Nelson, L., Grimes, J., and Marquis, L. (1989) Human immunodeficiency virus (HIV) infection among prostitutes in Nevada. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Perkins, R., and Bennett, G. (1985) Being a Prostitute: Prostitute Women and Prostitute Men. Boston, Mass.: Allen and Unwin, Inc. Pheterson, G. (1989) Vindication of the Rights of Whores. Seattle: Seal Press. Pittman, D. J. (1971) The male house of prostitution. Trans-Action 8:21-27. Plummer, F. A., Scarth, J., Ngugi, E. N., Waiyaki, P., Ndinya-Achola, J. O., et al. (1989) Effectiveness of condom promotion in a Nairobi community of prostitutes. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Potterat, J. J., Phillips, L., Rothenberg, R. B., and Darrow, W. W. (1985) On becoming a prostitute: An exploratory case-comparison study. Journal of Sex Research 21:329-335. Potterat, J. J., Woodhouse, D. E., Muth, J. B., and Muth, S. Q. (In press) Estimating the prevalence and career longevity of prostitute women. Journal of Sex Research. Rogers, E. M. (1962) Diffusion of Innovations. New York: Free Press. Rogers, E. M., and Adhikarya, R. (1980) Diffusion of innovations: An up-to-date review and commentary. In D. Nimmo, ea., Communication Yearbook 3. New Brunswick, N.J.: Transaction Books.

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FEMALE PROSTITUTES ~ 287 Rosario, S., Guerrero, E., DeMoya, E. A., Volquez, C., and Alcantara, R. (1989) The agglutinating approach to joint STD/AIDS prevention and control in female sex workers in the Dominican Republic. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Rosenberg, M. J., and Weiner, J. M. (1988) Prostitutes and AIDS: A health department pnority? American Journal of Public Health 78:418~23. Rowe, M., and Ryan, C. (1987) AIDS: A Public Health Challenge: State Issues, Policies and Programs. Volume 1: Assessing the Problem. Washington, D.C.: Intergovernmental Health Policy Project. Sanchez, L. (1988) You have to know street talk. In I. Rieder and P. Ruppelt, eds., AIDS: The Women. San Francisco: Cleis Press. Seidlin, M., Krasinski, K., Bebenroth, D., Itn, V., Paolino, A.M., and Valentine, F. (1988) Prevalence of HIV infection in New York call girls. Journal of Acquired Immune Deficiency Syndromes 1: 15(}154. Shaw, N. S. (1988) Preventing AIDS among women: lithe role of community organizing. Socialist Review 18:76-92. Shedlin, M. G. (1987) If you wanna kiss, go home to your wife: Sexual meanings for the prostitute and implications for AIDS prevention activities. Presented at the Annual Meeting of the American Anthropological Association, Chicago, Ill., November 18-22. Silbert, M. H., Pines, A. M., and Lynch, T. (1982) Substance abuse and prostitution. Journal of Psychoactive Drugs 14:193-197. Stephens, P. C., Hayes, B. J., Adams, R., and Gross, M. (1989) Women working as prostitutes: Participatory/consensus-based planning for provision of mobile prevention, risk reduction and seroprevalence activities. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Stevens, R., Wethers, J., Berns, D., and Pass, K. (1989) Human immunodeficiency (HIV) and human T-lymphotropic (HTLV-I/II) viruses in childbearing women: Tests of 24,569 consecutive newborns. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Turner, C. F., Miller, H. G., and Moses, L. E., eds. (1989) AIDS, Sexual Behavior, and Intravenous Drug Use. Report of the National Research Council Committee on AIDS Research and the Behavioral, Social, and Statistical Sciences. Washington, D.C.: National Academy Press. Wallace, J. I., Mann, J., and Beatnce, S. (1988) HIV-1 exposure among clients of prostitutes. Presented at the Fourth International Conference on AIDS, Stockholm, June 12-16. Weissman, G. (1988) Community outreach and prevention: A national demonstration project. Presented at the 116th Annual Meeting of the American Public Health Association, Boston, November 16. Wilson, D., Sibanda, B., Mboyi, L., Msimanga, S., and Dube, G. (1989) Health education among commercial sex workers in Zimbabwe, Africa. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Withum, D. G., LaLota, M., FIoltzman, O., Buff, E. E., Chan, M. S., et al. (1989) Prevalence of HIV antibodies in childbearing women in Florida. Presented at the Fifth International Conference on AIDS, Montreal, June =9.

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288 ~ AIDS: THE SECOND DECADE Wofsy, C. W., Cohen, J. B., Hauer, L. B., Padian, N. S., Michaelis, B. A., et al. (1986) Isolation of AIDS-associated retrovirus from genital secretions of women with antibodies to the virus. Lancer 1:527-529. Wolfe, H., Keffelew, A., Bacchetti, P., Meakin, R., Brodie, B., and Moss, A. R. (1989) HIV infection in female intravenous drug users in San Francisco. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Worth, D., Drucker, E., Eric, K., Chabon, B., Pivnick, A., and Cochrane, K. (1989) An ethnographic study of high risk sexual behavior in 96 women using IV heroin, cocaine, and crack in the South Bronx. Presented at the Fifth International Conference on AIDS, Montreal, June =9.