Experiences of interpersonal violence among a diverse sample of male sex workers.

A notable portion of men who have sex with men engage in exchange sex-i.e. the trading of sex for money, drugs, shelter or other material goods. Despite the risks for physical and sexual violence, threatening behaviour and robbery that male sex workers confront, very little is known about their experiences of such actions by clients. To gain more insight into male sex workers' experiences of interpersonal violence, we analysed qualitative interview data from 180 men who have sex with men from 8 US cities who engaged in sex work with clients they had met primarily through dating/hookup websites and apps. Participants discussed their experiences of a range of untoward behaviours by clients including physical violence, sexual violence, threats and robbery. Healthcare and social services providers can play a significant role in violence prevention among male sex workers. The decriminalisation of sex work could also potentially reduce the risks many sex workers face by facilitating their reporting of harms suffered.

Condomless Anal Sex Between Male Sex Workers and Clients in the Age of Hookup Apps.

Among men who have sex with men (MSM), those who also engage in the exchange of sex for money, drugs, shelter or other material goods (i.e., male sex workers-MSWs) have been found to have higher rates of condomless anal sex (CAS), HIV, and STIs than MSM who do not engage in exchange sex. To gain a better understanding of the factors that influence MSWs' engagement in CAS with male clients, we analyzed qualitative interview data from a diverse sample of 141 MSWs from 8 U.S. cities who met clients primarily through hookup or dating apps/websites and who reported having condomless anal sex with at least one of their exchange sex partners in the prior three months. While high client demand and financial incentives were the most frequently mentioned reasons for engaging in CAS with clients, other factors including drug and alcohol use, attraction to the client, the heat of the moment, concerns about sexual performance, and reliance on pre-exposure prophylaxis (PrEP) were also important. Participants who engaged in CAS generally felt that due to client characteristics or mitigating steps they had taken themselves, their chance of acquiring HIV/STIs was acceptably low. Hookup or dating apps/websites have provided an additional and increasingly popular venue for exchange sex to be arranged. These platforms also offer an opportunity for HIV/STI prevention through interventions and tailored messages delivered through these venues that address the motivations, misconceptions and/or situational factors that may lead to CAS.

RESUMEN: Entre los hombres que tienen relaciones sexuales con hombres (HSH), se ha encontrado que aquellos que también participan en el intercambio de sexo por dinero, drogas, vivienda u otros bienes materiales (es decir, hombres trabajadores sexuales-HTS) tienen tasas más altas de sexo anal sin condón (SASC), VIH y ETS que los HSH que no participan en relaciones sexuales de intercambio. Para obtener una mejor comprensión de los factores que influyen en la participación de los HTS en SASC con clientes masculinos, analizamos los datos de entrevistas cualitativas de una muestra diversa de 141 HTS de 8 ciudades de EE. UU. que conocieron a los clientes principalmente a través de aplicaciones/sitios web de conexión o citas y que informaron haber tenido sexo anal sin condón con al menos una de sus parejas sexuales de intercambio en los tres meses anteriores. Mientras la alta demanda de los clientes y los incentivos financieros fueron las razones mencionadas con mayor frecuencia para participar en SASC con los clientes, otros factores como el uso de drogas y alcohol, la atracción hacia el cliente, la seducción del momento, las preocupaciones sobre el desempeño sexual y la dependencia de la profilaxis preexposición (PrEP) también fueron importantes. Los participantes que tomaron parte en SASC generalmente sintieron que debido a las características del cliente o a los pasos de mitigación que habían tomado ellos mismos, su probabilidad de contraer VIH / ETS era aceptablemente baja. Las aplicaciones/sitios web de conexión o citas han proporcionado un lugar adicional y cada vez más popular para organizar el intercambio de sexo. Estas plataformas también ofrecen una oportunidad para la prevención del VIH/ETS a través de intervenciones y mensajes personalizados que se transmiten a través de estos lugares y que abordan las motivaciones, los conceptos erróneos y/o los factores situacionales que pueden conducir a SASC.

"I Want to Be Really Clear": What Male Sex Workers Want to Clarify With Prospective Clients Before Agreeing to Meet for Sex.

Men who have sex with men (MSM) and engage in sex work (MSW) frequently meet clients through dating/hookup apps. This provides an opportunity to discuss the parameters of the exchange prior to meeting and to learn things about the prospective client and the risks he might pose. Limited research has examined the specific issues or topics MSWs discuss with clients before agreeing to meet. We analyzed interview data from a sample of 180 MSWs from eight U.S. cities who engaged in exchange sex with clients they had primarily met through dating/hookup apps and websites. Participants typically asked about clients' sexual interests and expectations regarding what will transpire when they meet to make sure they were compatible with their own boundaries and limitations. Most participants inquired about clients' sexual health and often discussed condom use. Assertiveness and communication skills training might help MSWs negotiate encounters with clients that promote health and safety.

Male Sex Workers' Strategies to Manage Client-Related Risks of Violence.

A substantial minority of men who have sex with men (MSM) engage in the exchange of sex for money, drugs, shelter, or material goods. This work carries risks for violence, sexual assault, and other kinds of harm such as robbery and threatening behavior by clients. Yet limited research has focused on the strategies that male sex workers (MSWs) use to prevent or manage these risks. To gain more insights into this matter, we analyzed qualitative interview data from 180 MSM recruited from eight U.S. cities who engaged in sex work with clients they had primarily met through dating/hookup websites and apps. Participants described the strategies they used to manage risks of interpersonal violence, both prior to meeting their clients and at the time of their encounters. Many of the strategies used ahead of the encounter relied upon information and communication technologies, such as negotiating the parameters of the exchange encounter, screening clients, sharing information about the client and meeting place with others, identifying safe meeting locations, and gathering information from social networks about problematic clients. Strategies employed during the encounter included: receiving payment up front; being prepared to protect oneself with a weapon or self-defense techniques; staying alert and sober; and planning an exit route from the location. Technology-based interventions through dating/hookup apps could play an important role in providing resources and skill building for MSWs to help them protect themselves during sex work.

Young people who use drugs engaged in harm reduction programs in New York City: Overdose and other risks.

BACKGROUND: Little is known about the engagement of young people who use drugs (PWUD) in harm reduction programs (HRPs), and few studies have included non-opioid users and non-injectors. While HRPs have effectively engaged PWUD, young people are under-represented in their services. METHODS: The Injection Drug Users Health Alliance Citywide Study (IDUCS) is the largest community-based study of PWUD in HRPs in the US. From 2014-2015, 2421 HRP participants across New York City (NYC) completed a cross-sectional survey. We investigated differences in socio-demographics, service utilization, and risk behaviors between young (aged 18-30) and older participants and examined factors associated with overdose among young participants. RESULTS: The study included 257 young participants. They were significantly more likely than older participants to be white, educated, uninsured, unstably housed or homeless, and have a history of incarceration and residential drug treatment. They were more likely to report recent overdose but less likely to report knowledge of naloxone. Young participants also had higher rates of alcohol, marijuana, benzodiazepine, and injection drug use, and related risk behaviors such as public injection. Factors associated with past year overdose among young participants included experiencing symptoms of psychological distress (AOR=9.71), being unstably housed or homeless (AOR=4.39), and utilizing detox (AOR=4.20). CONCLUSIONS: Young PWUD who access services at HRPs in NYC differ significantly from their older counterparts. New York City and other urban centers that attract young PWUD should consider implementing harm reduction oriented services tailored to the unique needs of young people.

Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review.

BACKGROUND: Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide. OBJECTIVES: We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation. SEARCH METHODS: We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature. SELECTION CRITERIA: We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure. DATA COLLECTION AND ANALYSIS: Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding. RESULTS: Searches yielded 5528 references from which we included 152 studies, representing 139,757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics. CONCLUSIONS: Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.

HIV-positive men sexually active with women: sexual behaviors and sexual risks.

This study examines patterns of sexual behavior, sexual relating, and sexual risk among HIV-positive men sexually active with women. A total of 278 HIV-positive men were interviewed every 6-12 months between 1994 and 2002 and reported considerable variability in sexual behaviors over time. Many were not sexually active at all for months at a time; many continued to have multiple female and at times male partners. Over one-third of the cohort had one or more periods when they had engaged in unprotected sex with a female partner who was HIV-negative or status unknown (unsafe sex). Periods of unsafe sex alternated with periods of safer sex. Contextual factors such as partner relations, housing status, active drug use, and recently exchanging sex showed the strongest association with increased odds of unsafe sex. A number of predictors of unsafe sex among African American men were not significant among the Latino sub-population, suggesting race/ethnic differences in factors contributing to heterosexual transmission. Implications for prevention interventions are discussed.