1. Development of an Intervention for Clients of Female Sex Workers TL Patterson, S Goldenberg, S Semple, SA Strathdee University of California, San Diego

2. Clients of Female Sex Workers (FSWs) Sex work is driven by demand –3 million FSWs worldwide, and growing Most studies focus on FSWs to the exclusion of male clients Clients of FSWs: –Risk becoming infected with STI themselves –Infecting FSW with STI –Bridge to other sex partners (e.g. wives, girlfriends, MSM)

3. Worldwide estimate of number of male clients of FSWs Source: 78 national household surveys and other sources to estimate percentage of men who reported paying for sex in previous 12 months In Millions

4. Sex Work in Tijuana, Mexico Sex work is regulated in many Mexican border cities, such as Tijuana ~ 9000 FSWs in Tijuana attract clients from Mexico and US Prevalence of HIV is 6% and rising among FSWs in Tijuana HIV prevalence 5% among FSWs’ clients

5. Study setting: Tijuana, Mexico Emerging HIV epidemic: 1/116 adults are HIV+ 1 Sex work: Draws local, U.S., international clients Mobility: World’s busiest international land crossing 5 1. Iñiguez-Stevens, E., et al. (2009). [Estimating the 2006 prevalence of HIV by gender and risk groups in Tijuana, Mexico] [article in Spanish]. Gaceta Médica de México,145(3):189–195. Source: CALTRANS USA MEXICO

6. Impact of sex work depends on form, context, location 1 “Risk environment” 2 –Economic - incentives for risky sex –Policy - sex work regulation, condom availability –Physical – venues –Social - interactions with clients, alcohol and drug use 6 1.Harcourt C, Donovan B. The many faces of sex work. Sex Transm Infect 2005;81(3):201-6. 2.Rhodes T. Risk environments and drug harms: A social science for harm reduction approach. International Journal of Drug Policy 2009;20(3):193-201. Source: Wikipedia Commons, 2009 Source: Wikipedia Commons, 2007

7. Where did our work begin: Safer sex intervention for FSWs Study aim –Test a brief theory based intervention designed for Mexican FSWs in Tijuana and Cd. Juarez Source: Oralia Loza

8. Baseline Assessment Mujer Segura One 40-minute one-on-one Counseling Session Six Month Assessment Didactic Safer Sex One 40-minute one-on-one Counseling Sessions Study Design

9. Mujer Segura Counseling Topics* Topic Description Context of Unsafe Sex Develop insights into motivations/triggers of unsafe sex. Set plan and goals for safer sex Condom UseMI and skill-building to induce behavior change. Match counseling to individual ’ s stage of change Negotiation of Safer Sex MI and skill-building to teach negotiation skills to move participants into action *incorporating motivational interviewing (MI) and social cognitive theory

10. RR = 1.66 p =.04 Intervention Effect on FSWs’ Incident STIs at 6-month Follow-up

11. Incidence of HIV Infection among FSWs 0

12. Conclusions FSWs in the intervention arm significantly: –reduced incident STIs/HIV –Increased the percent of time they used condoms with clients But … this intervention puts the burden of safer sex on the sex worker when the clients are a significant part of the problem How do we develop an intervention for clients?

13. Pilot test materials and revise as needed Conduct randomized controlled trial to determine intervention efficacy Conduct implementation study to enhance dissemination of intervention to agencies and CBOs Identify risk group Gather community support (Risk group, local, state & federal officials) Conduct epidemiologic studies to determine if an individual intervention is merited Develop theory-based intervention with specific context and risk behaviors in mind and adapt to cultural context as needed Conduct qualitative study to understand the context of risk behavior Revise intervention with stakeholders Steps to developing a efficacious intervention for clients

14. 14 Qual-Quant Study: Objectives and hypotheses (1) To examine correlates of clients who meet FSWs in nightlife venues (2) To investigate clients’ perspectives on venue-based risks and bridging Source: Wikipedia Commons, 2007

15. Methods Men recruited in Tijuana’s Zona Roja, 2008-09. –paid/traded for sex with FSWs in previous 4 months –aged ≥18 years –from the U.S. or Mexico Participants underwent interviews and rapid testing for HIV and STIs. Recruited through jaladores (touts) and street outreach

16. Methods: Study population and data sources 16 In-depth qualitative interviews (n=30) Purposive sub-sample of male clients Perceived HIV/STI risk Condom use Sex purchasing experiences Social and structural factors (e.g., venues, paying more for unprotected sex) Quantitative interviews(n=400) Males≥ 18 who paid/traded for sex with a FSW in Tijuana, past 4 months Surveys Demographics, sexual behavior, substance use Venues Laboratory testing HIV, Syphilis, Chlamydia, Gonorrhea

17. Methods: Variables Dependent –Met FSW in nightlife venue (i.e. bar, cantina, nightclub, or strip club)† (yes vs. no) Independent –Socio-demographics –Sexual behavior and substance use –Physical environment (lives in US vs. Mexico) –Social environment (e.g., client and FSW alcohol use during sex†) –Policy environment (e.g., non-availability of condoms as reason for unprotected sex) 17 †Refers to past 4 months

18. Table 1: Socio-demographic, behavioral, environmental and HIV/STIs among FSWs’ clients in Tijuana, 2008 Measure% who met FSW in nightlife venue (n=301) % who did not meet FSW in nightlife venue (n=98) Socio-demographics Hispanic/Latino80.178.6 Speaks English81.777.6 Lives in Mexico52.852.0 Years of education (median, IQR)12 (9, 12)**10 (7, 12) Sexual behavior and substance use Had unprotected sex with FSW†55.1***35.1 Has ≥ 5 drinks when drinking44.9***17.3 Risk environment Offered extra money for unprotected sex19.6**8.2 Amount paid for sex in dollars (mean, IQR)36.7 (20, 40)**26.1 (20, 30) Self reported STI†19.4*9.4 18 †Refers to past 4 months; ***p<0.001, **p<0.01, *p<0.05; °IQR: Inter-quartile range

19. Correlates of meeting FSWs in nightlife venues Ever offered FSW in Tijuana more money for unprotected sex –AOR: 2.65 (1.19, 5.93)** Binge drinking –AOR: 4.13 (2.30, 7.42)*** 19 **p<0.001, **p<0.01, *p<0.05 Photo By: Oralia Loza

20. Qualitative Themes: venue- based HIV risks Clients described nightlife venues as high- risk: –Heavy alcohol consumption impairs judgment Courting rituals in nightlife venues Binges, letting go of inhibitions –Monetary incentives for unprotected sex in bars Pressure from establishments to earn $ –Less enforcement of sex work regulations than on the street Bar-based sex work less visible 20

21. Example: less enforcement of nightlife-based sex work “I prefer the ones [girls] on the street who are controlled with the paperwork than the ones who aren’t… The girls on the strip there [the Callejon] constantly get the health workers asking for their cards [sex work permits]. You know, they got to be checked [tested for STIs/HIV], or they can’t work. So I would prefer to mess with those girls….” 21 Source http://www.ericrench.com/MEXICO/TIJUANA/NORTE/INTRO/index.htm 2011

22. What proportion of clients are potential bridgers? Percent of 383 clients with wives/steady partners 134 (35%) 70 (52%) Percent of 134 clients with wives/steady partners who report unprotected sex

23. Social Cognitive Factors of Bridgers and Nonbridgers OR 3.78* OR 2.17* OR 7.75* OR 0.81 OR 0.21* Mean Score * P<0.05

24. Factors Independently Associated with Bridging Behavior Among Male Clients With Wives or Partners (n = 134) Characteristic or Behavior Adj OR95% CI Used drugs during sex with FSW, past 4 months 3.39*(1.40 – 8.23) Ever offered FSW extra money to have sex without a condom 24.52*(3.08 – 195.4) Sexual sensation seeking scale4.28*(1.41 – 13.02) * P<0.05

25. Factors Independently Associated with Bridging Behavior Among Male Clients With Wives or Partners (n = 134) Characteristic or Behavior Adj OR95% CI Used drugs during sex with FSW, past 4 months 3.39*(1.40 – 8.23) Ever offered FSW extra money to have sex without a condom 24.52*(3.08 – 195.4) Sexual sensation seeking scale4.28*(1.41 – 13.02) Client (age 26): “Once they get the drugs in them, then they don’t give a damn about a condom. It’s all about the high and the money. The condom is not important.”

26. Factors Independently Associated with Bridging Behavior Among Male Clients With Wives or Partners (n = 134) Characteristic or Behavior Adj OR95% CI Used drugs during sex with FSW, past 4 months 3.39*(1.40 – 8.23) Ever offered FSW extra money to have sex without a condom 24.52*(3.08 – 195.4) Sexual sensation seeking scale4.28*(1.41 – 13.02) Client age 23:“I am a risk junkie. It creates more excitement for me, makes it more euphoric. I figured that out about myself. The more prohibited things are, the more exciting it makes me feel….”

27. Conclusions Clients are at risk of bridging HIV/STIs to FSWs and the general population. Half of clients who have unprotected sex with a regular sex partner also report unprotected sex with FSWs Greatest risks posed by venues where: –clients have more control –alcohol/drugs are used, and –high numbers of client are encouraged Cannot generalize findings from any one culture to another, but in this context, implications for interventions indicate: –Modifiable behaviors: drug and alcohol use –More difficult to modify: sensation seeking, misogyny

28. 28 Root causes Proximal causes Implications and suggested interventions MACRO Economic and social support for clients HIV/STI prevention and testing, drug treatment services for clients 1. HIV Risk Environment framework, adapted from Rhodes, 2009 MICRO Jalador peer education, condom distribution Counseling and support for ciients SUGGESTED INTERVENTIONS DRIVERS OF HIV VULNERABILITY 1

29. Where are we now? Testing individual intervention for clients in Tijuana –Study design 200 receive Hombres Seguro, 200 didactic presentation; 6 and 12-mo FU Implementation study of Mujer Segura in 12 cities in Mexico

30. Hombres Seguro Counseling *incorporating motivational interviewing (MI) and social cognitive theory STEP 1:Determine readiness for change, and build motivation for change STEP 2:Explore participant’s attitudes toward condoms and unsafe sex STEP 3: Assess high-risk situations, explore triggers of unsafe sex, and discuss coping with cravings and urges STEP 4: Explore drug/alcohol use as triggers of sexual risk behaviors with FSWs: discuss harm reduction strategies STEP 5 Identify barriers to unsafe sex with FSWs: make plans to overcome barriers STEP 6:Condom skill-building exercise STEP 7:Communication and safer sex practices & evaluation of roleplay

31. Collaboration México collaborators M Gallardo, R. Lozada, C. Magis U.S. collaborators, A. Robertson Study Staff and Participants PREVENCASA A. C COMUSIDA A.C ISESALUD/CAPASITS Asociación de Bares and Hoteles Binational Committee on Human Rights Municipal Medical Services Volunteer bartenders, security guards

32. Acknowledgements UCSD CFAR International Pilot Grant to R. Lozada (UCSD CFAR is funded by NIH P30 AI036214) NIDA Grants: R01 DA029008;R01 DA023877-S1 San Diego County Public Health Laboratory Source: Shira Goldenberg

33. THANK YOU For more information please contact: Thomas L. Patterson Department of Psychiatry University of California San Diego Email: tpatterson@ucsd.edu