Characterizing sex work among male and transgender STI clinic clients in Lima, Peru K.A. Konda 1, J.L. Clark 1, E. Segura 2, J. Salvatierra 2, J. Galea 1, S.R. Leon 2, E.R. Hall 3, J.D. Klausner 4, C.F. Caceres 2, T.J. Coates 1 1 David Geffen School of Medicine at UCLA, Division of Infectious Diseases, Program in Global Health, Los Angeles, United States, 2 Universidad Peruana Cayetano Heredia, Unidad de Salud Sexual y Reproductivo y Derechos Humanos, Lima, Peru, 3 Naval Medical Research Center Detachment, Bacteriology, Lima, Peru, 4 San Francisco Department of Public Health, STD Prevention and Control Services Section, San Francisco, United States

Introduction HIV transmission in Peru primarily occurs among men who have sex with men (MSM) Increased risk for HIV/STI infection among male and transgender sex workers has been suggested, but not confirmed Additional vulnerabilities among sex workers have not been adequately described

Goals of this study Evaluate the association between compensated sex and HIV/STI infection Describe condom use among male and transgender sex workers Describe vulnerabilities and needs of male and transgender sex workers in Lima

Methods Study conducted from May – Dec 2007 Convenience sample recruited at a referral center for STI/HIV management in Lima, Peru Specifically for gay, bisexual, and transgender individuals Inclusion criteria: male or transgender individuals who report sex with a man in the past year

Methods, cont. Key study variables –Sexual identity –Compensated sex and sex work including condom use with clients –Police treatment and NGOs working with male and transgender sex workers Blood specimens –HIV ELISA (Vironostika) / HIV WB (Genetic Systems) –HSV-2 ELISA (Focus Diagnostics) –RPR (RPRnosticon) with TPPA Serodia (Fujirebio) –Recent syphilis defined as RPR >1:8 Associations assessed using X 2 tests

Results The study enrolled n=547 male and transgender individuals 169 (31%) reported having sex for compensation 129 (76%) of those 169 self-identified as sex workers

Table 1 Participant characteristics comparing those reporting and not reporting compensated Sex, 6 months Compensated sex (n=169) No compensated sex (n=378) P-value Age, median (IQR)28 ( )28.5 (23-36)0.541 Graduated from High School70%82%0.002 Report sex work as their occupation 42%-- HIV risk perception<0.001 High/Moderate65%54% Low/None23%41% Refused to answer13%6%

Table 2 Participant characteristics comparing those reporting and not reporting compensated Sex, 6 months Compensated sex (n=169) No compensated sex (n=378) P-value Sexual Identity<0.001 Gay23%43% Bisexual5%14% Transgender51%10% Heterosexual21%33% Have previously been tested for HIV infection 91%82%0.009 Drank alcohol more than once a week, last month 49%33%0.001 Drug use, last month*36%15%<0.001 * Drugs included primarily Marijuana (11%) and Cocaine (19%), others included ecstasy (2%) and amphetamines (0.5%)

Table 3: Sexually transmitted infections associated with reporting compensated sex Compensated sex (n=169) No compensated sex (n=378) p- value Herpes66%53%0.005 Syphilis32%20%0.005 Recent syphilis14%8%0.040 HIV24%21%0.462

Table 4: Characterizing sex work reported by participants (n=129) Age began sex work, median (IQR*)19 ( ) No. clients per week, median (IQR)10 (5 - 20) No. work days per week, median (IQR)4 (3 - 6) Where most sex workers work Street67%86/128 Contacted by phone13%16/128 Other (park, bar/disco, movie theater, etc) 20%26/128 *Interquartile range

Condom use Condom use with clients among sex workers (n=129): –Insertive anal sex 39% never / 14% sometimes / 47% mostly or always –Receptive anal sex 8% never / 7% sometimes / 84% mostly or always 92% reported that clients have asked them not to use condoms for sex –59% sometimes / 33% mostly or always

Police Mistreatment Almost half of the sex workers reported police mistreatment, 52/127 (40%) –Only 9/52 (17%) informed authorities or NGO about this mistreatment Know of any organization that could help in case of police mistreatment, 21/123 (17%)

Conclusions Compensated sex, sex work and police mistreatment were common Compensated sex was associated with higher STI prevalence, but not HIV infection Condom use was inconsistent and likely influenced by clients requests for unprotected sex Participants were all seeking health care and may not be representative of all male and transgender sex workers

Future plans Study to measure number of male and transgender sex workers in Lima, Peru Working with male and transgender sex workers to design interventions based on their needs are warranted Human rights approach

Acknowledgements We would like to thank the staff of the CERITS Barton and the laboratory of the U.S. NMRCD, Lima, Peru for their invaluable work in completing the study. Barton Counselors: Vicky Solari and Patty Arana Lab Techs: Rene Gutierez, Antonio Tamayo; Virgina Bedon; Director: Dra Doris Chunga NMRCD Dr. Silvia Montano Dr. Ben Espinosa UPCH Julio Cuadros

Gracias Thank you

Sex work based on location Many more transgender sex workers reported street based sex work (78% vs. 22% among gay/bi/male sex workers, p- value <0.001)

HIV/STI prevalence based on sexual identity of sex workers Trans sex workers have higher rates of all STIs –The difference is only statistically significant for HSV (80% vs. 52%) and Syphilis (40% vs. 25%) –For HIV the rate of infection is 29% among trans sex workers and 21% among gay/bi/hetero sex workers –Some of the lack of statistical difference is due to sample size limitations