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HIV Risk among Adult Sex Workers in the United States

Sex work is defined as the use of sexual activity for income or employment or for non-monetary items, such as food, drugs, or shelter (“survival” sex). Sex work can increase a person’s risk of becoming infected with or transmitting HIV and other sexually transmitted infections (STIs) by engaging in unsafe sexual behaviors and/or substance use.

Sex work crosses many socioeconomic groups. Adults who engage in such activities include high-end escorts; people who work in massage parlors and the adult film industry; exotic dancers; state-regulated prostitutes (in Nevada); and street-based men, women, and transgender people who participate in survival sex.

Reaching sex workers is a critical effort for public health. Not only are sex workers at risk for higher rates of HIV and other STIs, sex workers who are unaware of their HIV status can endanger their own health and increase their risk of transmitting HIV or STIs to others.

Prevention Challenges

Lack of Data

There are few population-based studies of sex workers in the United States or globally because sex work is a stigmatized occupation and is illegal throughout most of the United States and the world. Further, sex workers who work in settings where sex is encouraged and indirectly sold, such as massage parlors, the adult film industry, and exotic dance clubs, are often not included in studies. This lack of data and understanding around sex work creates a significant barrier to HIV prevention efforts and other services.

Socioeconomic Factors

Many sex workers face discrimination, poverty, and lack of access to health care and other social services—all of which pose obstacles to receiving HIV prevention efforts. Available research shows that

  • Sex workers may have a history of homelessness, mental health issues, incarceration, emotional/physical/ sexual abuse, and drug use. They may also be at risk for HIV infection or STIs because of multiple high-risk male partners.
  • Male-to-female transgender sex workers may view sex work as a viable option to earn money because of gender-based/societal discrimination and lack of employment. They may also use sex work to generate income for rent, drugs, hormones, gender-related surgeries, and to feel desired and feminine.

High-Risk Drug and Alcohol Use

There is a strong link between sex work and drug and alcohol use. Drug and alcohol use have been reported as coping mechanisms in response to stressful working conditions. Sex workers may have impaired judgment and difficulties negotiating safer sex (condom use, for example) with their customers while under the influence of drugs and alcohol.

Exchanging sex for drugs carries greater HIV risk than exchanging sex for money because sex workers often engage in riskier forms of sex work while under the influence of drugs. Specifically, sex workers who trade sex for drugs have more clients, use condoms less often, and are more likely to share needles and other drug works.

Knowledge of HIV Status

Nationally, approximately 18.1% of US adults and adolescents living with HIV infection in 2009 were unaware of their HIV infection, according to the Centers for Disease Control and Prevention (CDC). Many sex workers are not aware of available services such as HIV/STI testing and may not know if they are infected with HIV or other STIs, according to one study. They may also be uncomfortable with being tested for HIV or other STIs if questioned about their sexual and substance use histories. Some sex workers may know that they are living with HIV but may be reluctant to seek care or reduce their risk behaviors because of mistrust of the health care system, loss of income, drug dependency, and mental health issues.

Inconsistent Condom Use

Sex workers may not use condoms consistently. Several factors, including economics, partner type, and power dynamics contribute to this behavior. For example, sex workers may receive more money for unprotected than protected vaginal and anal sex. Further, sex workers report lower condom use with steady partners than with new or casual partners. Additionally, the unequal relationship between sex workers and clients, and substance use that is often associated with sex work, may make condom use challenging. Finally, in some jurisdictions in the United States, suspected sex workers who are caught with condoms in their possession can be arrested for suspicion of prostitution.

What CDC Is Doing

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

  • Support and technical assistance to help community-based organizations with implementing or sustaining structural interventions for sex workers (e.g., condom distribution, community mobilization, HIV testing, and coordinated referral networks).
    • Research to develop effective interventions to respond to a shortage of proven behavioral HIV interventions for sex workers. Examples include Motivational Interviewing-based HIV Risk Reduction, intended for recently incarcerated HIV-negative women who are at risk for HIV infection because of sex work, drug use or intercourse with a male drug user, or sex with 10 or more partners.
    • Women’s Co-Op, a risk-reduction intervention for African American women who smoke crack cocaine and who are not in drug treatment.
    • Community PROMISE, a community-level HIV/STI prevention intervention that uses role-model stories and peer advocates to promote and distribute prevention materials within social networks.
  • Act Against AIDS (AAA), a national campaign that focuses on raising awareness, fighting stigma, and reducing the risk of HIV infection among at-risk populations. AAA also supports the Act Against AIDS Leadership Initiative, a network of national organizations that focus on African American and Latino communities and black men who have sex with men.
  • The Comprehensive Human Immunodeficiency Virus (HIV) Prevention Programs for Health Departments (Funding Opportunity Announcement [FOA] PS 12-1201), a 5-year, $339 million HIV prevention initiative for health departments in states, territories, and select cities, including those serving clients at risk for HIV infection via sex work.

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