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Epidemiologic Notes and Reports Antibody to Human Immunodeficiency Virus in Female Prostitutes

Seroprevalence surveys for antibody to human immunodeficiency virus (HIV) in women with histories of prostitution have shown varying results since testing began in 1984. In sub-Saharan Africa, where HIV is thought to be transmitted primarily through heterosexual exposure (1-3), one (1%) of 98 prostitutes tested in Accra, Ghana (4), to 29 (88%) of 33 prostitutes in Ngoma, Rwanda (5), had HIV antibody (3-7). In Europe, where homosexual exposure and abuse of intravenous (IV) drugs are major risk factors for HIV infection (8), none of 50 prostitutes tested in London (9), none of 56 in Paris (10), and none of 399 in Nuremberg, West Germany (11), had antibody to HIV. However, 10 (71%) of 14 prostitutes who abused IV drugs in Pordenone, Italy (12), and 14 (78%) of 18 who abused IV drugs in Zurich, Switzerland (13), were infected. Seventeen (1%) of nearly 2,000 registered prostitutes in six West German cities were HIV-antibody positive; half of these infected women abused IV drugs (14). In Athens, Greece, 12 (6%) of 200 registered prostitutes were HIV-antibody positive; none abused IV drugs (15).

As of March 10, 1987, 2,159 women in the United States were reported to have met the CDC surveillance case definition for AIDS. The cumulative incidence of AIDS in black and Hispanic women was more than 10 times that for white women (16). Over 70% of these women reported with AIDS resided in New York, New Jersey, or Florida (17). Over half (51%) had abused IV drugs; 27% were sexual partners of men with AIDS or at risk for AIDS; and 10% had received transfusions of blood or blood products. No risk factors have as yet been reported for the remaining 12% (18).

To assess HIV-antibody prevalence and determine risk factors in U.S. prostitutes, CDC is collaborating with others in an ongoing, cross-sectional study of women who have engaged in prostitution in seven geographic areas: Atlanta, Colorado Springs, Las Vegas, Los Angeles, Miami, Newark-Jersey City-Paterson, and San Francisco. Some collaborators are recruiting primarily incarcerated women (Los Angeles and Miami). Others are recruiting primarily through sexually transmitted disease (STD) clinics (Colorado Springs and Las Vegas); methadone maintenance clinics (the three northern New Jersey cities); or outreach efforts, such as newspaper advertising, circulation of pamphlets, and direct contacts on the street (Atlanta and San Francisco). Study participants are not necessarily representative of all female prostitutes in these areas.

For this study, prostitution is defined as the exchange of physical sexual services for money or drugs. Any woman greater than or equal to 18 years of age who has engaged in prostitution at least once since January 1, 1978, is eligible. Participation entails voluntary, informed consent; names and other personal identifiers are not recorded. Participants are interviewed for their medical histories and sexual and other exposures. They are also examined for signs of HIV infection and IV-drug abuse and are asked to provide 10 ml of blood for serologic testing. Serum is tested for HIV antibody by enzyme immunoassay and Western blot methods.

The analysis reported here has been restricted to the 835 study participants who were tested for HIV antibody and the 568 study participants for whom an interview form was submitted to CDC before March 10, 1987. The prevalence of HIV antibody in prostitutes so far tends to parallel the cumulative incidence of AIDS in women in the seven research sites (Table 1), suggesting that risk factors for AIDS in female prostitutes may be similar to those in other women living in these geographic areas. The prevalence of HIV antibody in prostitutes and the cumulative incidence of AIDS in women are highest in northern New Jersey and Miami. In southern Nevada, where only one woman has been reported with AIDS, none of 34 prostitutes have had HIV antibody.

In the seven areas, reported rates of AIDS were higher for black women (359.6/1,000,000) and Hispanic women (40.2/1,000,000) than for white (25.3/1,000,000) and other (Asian and Native American) women (16.2/1,000,000). Similarly, black and Hispanic prostitutes in these areas had a higher prevalence of HIV antibody (15%) than white and other prostitutes (7%) (odds ratio (OR) = 2.5; 95% confidence interval (CI) = 1.4-4.4).

Half the prostitutes interviewed in this multicenter collaborative study gave histories of IV-drug abuse; 47 (76%) of 62 with antibody to HIV have injected drugs (OR = 3.6; 95% CI = 2.0-6.7). IV-drug abuse is associated with HIV infection in prostitutes and with AIDS in women regardless of racial and ethnic background (Table 2).

Over 80% of prostitutes interviewed through January 1987 reported that at least one of their partners had used a condom. Husbands or boyfriends of the respondents were much less likely to use condoms during vaginal exposure than clients (16% as compared with 78%, p = 0.005). Twenty-two (4%) prostitutes reported condom use with each vaginal exposure during the past 5 years. Eleven percent of 546 prostitutes with unprotected vaginal exposure were HIV-antibody positive; none of 22 prostitutes whose partners always used condoms were seropositive (p = 0.10 after controlling for IV-drug abuse). Reported by: JB Cohen, PhD, C Wofsy, MD, Association for Women's AIDS Research and Education (AWARE), University of California, San Francisco; P Gill, MD, S Aguilar, University of Southern California Cancer Center, Los Angeles, California. J Witte, MD, W Bigler, PhD, Florida Dept of Health and Rehabilitative Svcs, Tallahassee, Florida. RK Sikes, DVM, T Leonard, MA, Georgia Dept of Human Resources, Atlanta, Georgia. J French, MA, J Massey, C Sterk, Drs, New Jersey State Dept of Health, Trenton, New Jersey. O Ravenholt, MD, R Reich, C Campbell, PhD, Clark County Health District, Las Vegas, Nevada. J Potterat, L Phillips, El Paso County Health Dept, Colorado Springs, Colorado. AIDS Program, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: The collaborative study reported here was designed to determine the prevalence of HIV infection in female prostitutes in selected U.S. cities and the risk factors for infection in these women. Seroprevalence in study participants so far has varied widely from city to city and tends to parallel the cumulative incidence of AIDS in women in these areas. The major risk factor for HIV infection in prostitutes appears to be IV-drug abuse. Women with unprotected vaginal exposures also appear to be at greater risk than those whose male partners always used condoms. When used properly and consistently with each sexual exposure, latex condoms should greatly reduce the sexual transmission of HIV (7,11,19).

Efforts to stop the spread of HIV infection in prostitutes and to their sexual partners require multiple approaches. These might include counseling and HIV-testing programs for individuals at risk for infection, additional control measures by local public health and law enforcement agencies, and the involvement of voluntary and other social service organizations.

Persons who continue to engage in prostitution remain at risk for acquiring and transmitting HIV. Prostitutes and their consorts should be provided counseling services and voluntary testing for HIV antibody (20-22). Seronegative persons who continue to engage in prostitution should insist on the use of condoms to reduce their own chances of infection. Seropositive prostitutes should know that the only certain way of preventing sexual transmission of the virus is to abstain and not engage in prostitution. Seropositive persons who continue to engage in prostitution should insist on the use of condoms to prevent transmission of the virus to others. IV-drug abusers should be offered treatment for their addictions and warned not to share needles or syringes.

State and local governments are approaching the problem of HIV infection in prostitutes in a variety of ways. Since March 1986, the Nevada Board of Health has required prostitutes in county-licensed brothels to be tested for HIV antibody as a condition for employment and monthly thereafter. If a woman is seropositive, she is denied employment as a prostitute. Since October 1986, Florida has required convicted prostitutes to be tested for STDs, including HIV. It is a misdemeanor in Florida for anyone who has tested positive for HIV and has been informed of the result to engage in prostitution. In Atlanta, the Mayor's Task Force on Prostitution has recommended educational materials for prostitutes, clients, and law-enforcement officers as well as voluntary testing for STDs (including assays for HIV antibody) for everyone arrested for sexual offenses and their steady partners.

Traditionally, medical care, therapy for drug addiction, welfare benefits, and vocational rehabilitation have not been routinely offered to women apprehended for prostitution (23-25). Now some organizations are introducing innovative approaches to male, as well as female, prostitutes. The California Prostitutes Education Project attempts to warn prostitutes about the dangers of unprotected exposures and provides educational sessions on how to prevent infection. Children of the Night (Los Angeles), Covenant House (New

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