Male sex workers: practices, contexts, and vulnerabilities for HIV acquisition and transmission Stefan D Baral, M Reuel Friedman, Scott Geibel, Kevin Rebe, Borche Bozhinov, Daoude Diouf, Keith Sabin, Claire Holland, Roy Chan, Carlos Cáceres

Overview  Objectives  Methods  Male sex workers or men who sell sex?  Epidemiology of HIV among male sex workers  Burden of HIV, HIV Acquisition and Transmission Risks  HIV Surveillance Limitations  Advancing HIV Prevention, Treatment, and Care  Moving Forward

Objectives  Synthesize available ethnographic and HIV epidemiologic and prevention science studies focused on male sex workers  Provide justification for dedicated advocacy, funding, definitional consistency for surveillance, and research initiatives for male sex workers

Methods  Systematic Reviews  Peer reviewed/non-peer reviewed literature from  HIV Epidemiology (Burden/Risks)  Male Sex Workers specifically or Male Sex Workers examined separately within larger studies of MSM or FSW  HIV Prevention Science Studies  Lower and Middle Income settings supported by regional consultations with sex workers, government, and academia  Latin America and the Caribbean  Eastern Europe/Former Soviet Union  Sub-Saharan Africa (West/Central, Eastern, and Southern Africa)  Asia (South/South East Asia)  Review of UNGASS ( ) and GARPR (2014) Data

Male Sex Workers or Men Who Sell Sex  Complex Identities  Small proportion of men who sell sex identify as male sex workers  Sexual orientation ranges from gay to straight  Male sex Workers are less visible than female sex workers  Smaller population  Male sex work generally less socially accepted than female sex work  Far less documentation in the scientific literature and public domain  Evolving Modalities of Sex Work  In some settings, male sex work has moved nearly exclusively to online marketing approaches with decreased reliance on street or venue-based commercial sex

Burden of HIV Among Male Sex Workers  Data Availability  Systematic Review of the Literature   81 different studies across 19 countries  UNAIDS Review   UN General Assembly Special Session on HIV/AIDS Indicators/Global AIDS Response Progress Reporting  27/192 countries reporting HIV prevalence among male sex workers  44 countries with any HIV prevalence data among Male Sex Workers

Global HIV prevalence among male sex workers, Source: Baral, Friedman, Geibel, Rebe, Bozhinov, Diouf, Sabin, Holland, Chan, Caceres. The Lancet, 2014

Limited Studies Focused on Male Sex Workers Source: Baral, Friedman, Geibel, Rebe, Bozhinov, Diouf, Sabin, Holland, Chan, Caceres. The Lancet, 2014  Male Sex Workers often represent a small subsample of studies focused on MSM or Female Sex Workers  Male Sex Workers are often included in samples with transgender sex workers

Data Quality Limitations  Sample size and data quality vary greatly in UNGASS/GARPR Data  Many countries report less than 10 participants in nationwide surveys  Male Sex Work has not been clearly defined  Multiple settings, including USA, do not identify male sex work as a behavioral category necessitating HIV surveillance  Inconsistency in the definition of male sex workers and recall windows for sex work behaviors challenge interpretation Source: Centers for Disease Control and Prevention (CDC). HIV surveillance: United States, 1981–2008. MMWR Morb Mortal Wkly Rep 2011; Global AIDS Response Progress Reporting 2014.

Vulnerabilities for HIV HIV RisksIndividualBehavioralBiologicNetworkSizeDensityStructuralStigma/Criminalization Social Determinants of Health

Individual and Networks Level Risk  Individual  Behavioral Risks  Higher numbers of sexual partners  Significant variability in access to and use of appropriate condoms and condom compatible lubricants among male sex workers  Biological Risk  High efficiency of HIV transmission during anal intercourse with serodiscordant and viremic partners  High levels of untreated anal and penile sexually transmitted infections  Network Level  Large sexual network  People living with HIV (including acutely infected), people who inject drugs  Non-Dense Sexual Network  Limited awareness of HIV status of other members of sexual network

Criminalization and Stigma Layers of Criminalization Layers of Stigma

Behavioral HIV Intervention Studies 17 Specific HIV intervention studies since Formative Studies 8 Impact Studies Key Themes  Drop-in centers w/ multiple services available  Strengths-based approaches  Material and social resources  Brief interventions  Harm reduction, RESPECT model Key Themes  Locale, context, & stakeholders are essential considerations  Individual- and network-level  Harm reduction, HIV/STI testing and treatment  Multiple services  Jobs, housing, legal, substance use  Community-level  Stigma reduction specific to male sex workers

Advancing HIV Prevention and Treatment and Care  Engage male sex workers where they are working  Characterize local dynamics of commercial sex ranging from the streets to the web  Integrate behavioral, biomedical, and structural approaches  With high force of HIV transmission, consider ART- based approaches including  Universal access to treatment for those living with HIV  PrEP, PEP, and rectal microbicides when available  Engage country-level, regional, and global networks supporting sex workers  Address policy failures that potentiate risks and undermine HIV prevention, treatment, and care programs

Male sex workers are a diverse, complex and unique key population for HIV prevention, treatment, and care  Improved HIV surveillance and prevention science data informing rights-affirming, evidence-based services specifically for male sex workers are needed to improve health outcomes among these men and the people within their sexual networks Moving Forward