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Published in final edited form as: Glob Public Health. 2015 Jan 2;10(4):520–531. doi: 10.1080/17441692.2014.992452

The balancing act: Exploring stigma, economic need and disclosure among male sex workers in Ho Chi Minh City, Vietnam

Elizabeth F Closson a, Donn J Colby b,c, Thi Nguyen c, Samuel S Cohen a, Katie Biello a,d, Matthew J Mimiaga a,d,e
PMCID: PMC4346426  NIHMSID: NIHMS645975  PMID: 25555192

Abstract

In Vietnam, there is an emerging HIV epidemic among men who have sex with men (MSM). Male sex workers (MSWs) engage in high-risk sexual behaviours that make them particularly vulnerable to HIV infection. In 2010, 23 MSM in Ho Chi Minh City (HCMC) who recently received payment for sex with another man completed in-depth qualitative interviews exploring motivations for sex work, patterns of sex work disclosure and experiences of social stigma. Interviews were recorded, transcribed and translated into English and analysed using a qualitative descriptive approach. Low wages, unstable employment, and family remittances were motivating factors for MSM in HCMC to sell sex. Participants described experiences of enacted and felt social stigma related to their involvement in sex work. In response, they utilized stigma management techniques aimed at concealment of involvement in sex work. Such strategies restricted sexual communication with non-paying sex partners and potentially limited their ability to seek social support from family and friends. Departing from decontextualized depictions of sex work disclosure, our findings describe how decisions to reveal involvement in sex work are shaped by social and structural factors such as social stigma, techniques to minimize exposure to stigma, economic imperatives and familial responsibilities.

Keywords: MSM, sex work, stigma, Vietnam, HIV

Introduction

Globally, men who have sex with men (MSM) constitute an important risk group for HIV infection (Beyrer et al., 2012). As in other Southeast Asian countries, there is a paucity of reliable national surveillance data on Vietnamese MSM. A 2012 meta-analysis revealed that HIV prevalence among MSM in Vietnam increased from 9.4% in 2006 to 20.0% in 2010. The report also documented low levels of condom use and other risk reduction strategies (Garcia, Meyer, & Ward, 2012).

Epidemiological data from Vietnam has found that a significant number of MSM are involved in sex work. For example, Colby et al. (2003) reported that 31.0% of a sample of 219 MSM in Ho Chi Minh City (HCMC) (formerly Saigon) earned money for sex. Additionally, a study conducted in 2008 among 600 MSM in HCMC found that selling sex was associated with HIV infection (OR = 8.61; 95% CI, 1.20–61.69). The proportion of men selling sex who were HIV-infected was 33.3% (3/9), twice as high as transgender women, which was the next highest group (Nguyen, Nguyen, Le, & Detels, 2008). Male sex workers (MSWs) in HCMC are at risk for HIV infection because of multiple sex partners and inconsistent use of condoms with both paying and non-paying sex partners (Mimiaga et al., 2013).

Rapid social and economic development in the last decade has garnered more freedom of sexual expression and visibility for MSM in Vietnam (Ngo et al., 2009; Vu, Girault, Do, Colby, & Tran, 2008). Nonetheless, social and political marginalization of MSM and MSWs in Vietnam continues (Ngo et al., 2009; Thi et al., 2008). As in other contexts, co-occurring psychosocial problems, such as depression and substance use, that potentially emerge from experiences of social stigma are thought to drive HIV risk in Vietnamese MSWs (Biello, Colby, Closson, & Mimiaga, 2013).

The limited social acceptance of sex work and male-male sexual behaviour in Vietnam suggests that few MSWs openly disclose these behaviours to non-paying sex partners, peers and family members. However, public health discourse has emphasized the importance of sexual risk disclosure for HIV prevention. While it is clear that sexual and social communication support health seeking-behaviours, the effects of sexual risk disclosure on HIV transmission among MSM are mixed (Crepaz & Marks, 2003; Edwards-Jackson et al., 2012; Simon Rosser et al., 2008). In a study of MSWs in the Dominican Republic, Padilla and colleagues suggest that the ambiguities of existing research may be explained by the fact that the majority of sexual risk communication studies focus on individual and relational factors that depict a decontextualized portrayal of how disclosure is actually understood and practiced (Padilla et al., 2008).

The present study aimed to explore the process through which factors such as economic imperatives and social stigma converge to influence decisions related to sex work disclosure among MSWs in HCMC. In our attention to lived-experiences, we call upon the concepts of enacted and felt stigma. Enacted stigma refers to episodes of discrimination against individuals solely on the grounds of their social and cultural unacceptability. Felt stigma has dual referents: the shame associated with acting or being a certain way and the fear of encountering enacted stigma (Herek, 2007; Scambler, 2004). Our work draws on a more sociological understanding of social stigma. As Parker & Aggleton (2003) argue, stigma is a social process that necessarily feeds upon and reproduces existing inequalities in relation to class, ethnicity, gender and sexuality. By showing how decisions about sex work disclosure are shaped by experiences of social stigma and economic inequity, this study is responsive to calls for research that attends to sex work disclosure as a ‘dynamic social process that unfolds within specific individual, social, cultural, and economic contexts’ (Padilla et al., 2008, p. 2).

Methods

Study setting

The study was conducted in Ho Chi Minh City (HCMC) Vietnam. Located in the south-eastern region of the country, HCMC is home to 7.39 million people and is the most populous city in Vietnam (CIA, 2013). The large number of MSM involved in sex work in HCMC made it an ideal setting to study this population. The study was conducted as part of a larger multi-phase research initiative to examine individual and structural risk factors among MSWs in HCMC with an eye toward intervention development.

Participants

In 2010, semi-structured interviews were conducted with 23 MSWs in HCMC. The number of participants recruited was based on data saturation, whereby data collection no longer generated new information. Recruitment was conducted by peer educators as part of on-going outreach work at The Life Centre, a non-governmental organization that provides health services for key populations at higher risk for health harms in HCMC. Eligible men were biologically male at birth, 18 years of age or older, of Vietnamese origin, and reported exchange of sex for money in the prior month.

Study design

This study consisted of a brief 16-question demographic and sexual risk quantitative assessment followed by an hour-long semi-structured qualitative interview. The interview questions were open-ended, allowing for probing to clarify participant responses. The interview guide was based on existing epidemiologic and ethnographic literature on sexual risk behaviours of MSM in Southeast Asia and anecdotal information gathered by Vietnam-based colleagues who provide HIV prevention services to MSWs in this setting (Blanc, 2005; Clatts, Giang, Goldsamt, & Yi, 2007; Colby, 2003, 2004; Ngo et al., 2009; Nguyen et al., 2008; Vu et al., 2008).

Participants were asked questions on the following domains: (1) employment (e.g., What are the reasons that you engage in sex work); (2) sex work disclosure (e.g., What are some of your concerns about telling people whom you are close to that you are doing sex work?); (3) self-perceived risk behaviours and condom use (e.g., How do your sexual behaviours stay the same or change with different sex partners?); (4) substance use (e.g., Tell me about the last time you used alcohol during sex for pay); and (5) social stigma related to sex work and same-sex sexual behaviour (How do you think clients view you? Have you ever felt looked down upon by them?). Participants were also asked to provide a narrative history of their involvement in sex work (e.g., Tell me about the first time you had sex with a man for pay).

Data collection

Interviews were conducted in a private room by a trained, native-Vietnamese-speaking = interviewer from The Harvard Medical School AIDS Initiative in Vietnam (HAIVN). Interviews were recorded, transcribed verbatim, and then translated into English for analysis.

Ethical consideration

Verbal informed consent was obtained before data collection began. Participants received a 100,000 Vietnamese Dong incentive (approximately $4.70 USD) and provided written informed consent. Data were de-identified to preserve confidentiality. The Beth Israel Deconess Medical Centre and the HCMC Provincial AIDS Committee institutional review boards approved study procedures.

Data analysis

Qualitative data were analysed using qualitative descriptive analysis (Sandelowski, 2010). Initial themes related to the central research questions were based on the domains of the qualitative interview guide. These concepts were used to construct categories and to develop a code book comprised of a label, a definition and an illustrative quote from the data (Silverman, 2010). A trained staff member coded the transcripts facilitated by NVivo software (v.8). For the purposes of establishing reliability, several coding stability assessments were conducted to ensure that the coder was consistently re-coding the same data in the same way over a period of time (Weber, 1990). Regular discussions between the coder and study investigators allowed for further revision of the coding schema based on the interconnections between emergent themes in the data. Investigators then reviewed coded transcripts and agreed on the categorical organization of the data and final overarching themes. The questions that guided the analysis were: (1) What are the motivations and circumstances for MSWs becoming involved in sex work?; (2) How do MSWs experience social stigma in relation to sex work and same-sex sexual behaviour and how do they respond to it?; and (3) How do these responses shape sexual communication patterns with non-paying sex partners?.

Results

Table 1 summarizes the socio-demographic and sexual behaviour characteristics of the 23 MSWs in the study. Participants’ mean age was 24 (SD = 3.9) and equal numbers of participants self-identified as ‘heterosexual/straight’, ‘homosexual/gay’ and ‘bisexual’. Our qualitative findings are presented according to the four themes: (1) Economic need as a main reason to engage in sex work; (2) Experiences of social stigma; (3) Stigma management techniques: non-disclosure and emphasizing economic imperatives; and (4) Stigma management as a challenge to sexual communication.

Table 1.

Self-reported socio-demographic characteristics and sexual behaviors of study participants (N = 23)

n (%) Mean (SD) Median (IQR)
Age -- 24 (3.9) --
Income -- 5,600,000 VND (6,055,275) --
Income from sex work -- 6,870,000 VND (7,719,834) --
Gender
Male 22 (95.7) -- --
Other gender identity 1 (4.3) -- --
Sexual orientation identity
 Heterosexual/straight 7 (30.4) -- --
 Homosexual/gay 7 (30.4) -- --
 Bisexual 7 (30.4) -- --
 Other sexual orientation identity 2 (8.7) -- --
Education
 Middle school (grade 6–8) 7 (30.4) -- --
 Secondary (grade 9–12) 14 (60.9) -- --
 Undergraduate/Four-year college 2 (8.7) -- --
Marital status
 Unmarried 21 (91.3) -- --
 Legally married 2 (8.7) -- --
Employment
 Full-time (30+ hours per week) 21 (91.3) -- --
 Part-time (<30 hours per week) 2 (8.7) -- --
Sex work disclosure
 Homosexual/gay friends 7 (30.4) -- --
 Heterosexual/straight friends 4 (17.4) -- --
 Family members 4 (17.4) -- --
 Female partner 2 (8.7) -- --
 Male partner 6 (26.1)
 Have not disclosed to anyone 3 (13.0) -- --
Sexual risk behaviors
 # of male non-paying sex partners -- 156.5 (406.3) 60.0 (70.0)
 Unprotected anal sex with male non-paying sex partner 11 (47.8) -- --
 # of male clients -- 158.5 (405.6) 60.0 (70.0)
 Unprotected anal sex with male non-paying sex partner 9 (39.1) -- --
 # of female non-transactional sex partners -- 5.8 (8.3) 3.0 (5.0)
 Unprotected vaginal/anal sex with female non-paying partner 7 (30.4) -- --
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VND = Vietnamese Dong (21,099 VND is equal to $1 USD)

Economic need as a main reason to engage in sex work

All participants cited economic reasons for doing sex work. This, despite the fact that 91.3% (n = 21) were employed in another job more than 30 hours a week and 60.9% (n = 14) were educated through secondary school. For those who were employed, job insecurity and low wages were cited as the primary reasons for pursuing additional income through sex work. Some participants said that they left their homes in rural areas in search of work in HCMC. As a 23-year-old participant described, ‘I come from the rural area. I do not have a stable job here. I am always jobless and do not have money to cover my expenses. It’s inhumane to rob, so I decided to do this job’.

Participant’s reflections suggest that initiation into sex work was often preceded by a period of economic vulnerability due to limited employment opportunities. For example, when ask about why he got into sex work, a 21-year-old participant responded, ‘I worked as a worker but the work was not stable. Work changed often because my salary was not enough for food to eat. I am living here for a period of time, so I have friends. I stepped into this job (sex work) because of those friends’.

For some participants, the economic motivation for doing sex work was two-fold. While they relied on the money earned from sex work to cover their own daily living expenses, men also provided financial support to their parents, siblings and relatives. This was especially true for those from impoverished families living in rural areas. As a 20 year-old MSW reflected:

My family lost their business. [My] parents and cousins are sick. They don’t have money to go to hospitals. So I have to work to earn money. I send home three to four million Dong (~144–194 USD) per month. It (sex work) cannot make me a better-off or rich man but it helps me to support and contribute something to my family. It’s impossible for me to become a wealthy man and show off. It can only help my two siblings’ education so that they can have money to buy books next month or have 50,000–100,000 Dong (~2.40–4.80 USD) in their pockets like the other children.

A small number of participants expressed satisfaction with the benefits of sex work, citing the flexible schedule and high hourly rate. As a 26-year-old participant described:

In the past, I used learn [sic] tailoring; however, this job was not good for earning money and working time was strict, so I decided to leave. Then I started learning drawing. I joined my elder brother to draw in An Dong market. After some time of learning, I got tired, so I gave it up. It was followed with my job as a driver assistant. However, that work was not easy for me. I started working in the dancing hall where I can get money. At day time, I stay at home for rest and serve my clients if they are in need. At night, I work in the dancing hall for several hours.

Experiences of stigma

The social stigma surrounding sex work was a thematic undercurrent across the interviews. Almost all participants described experiences of enacted and felt social stigma in connection with being paid to have sex with other men and male-male sexual behaviour. As an example of enacted stigma, many men said that offensive words like ‘male whore’, ‘pederast’, and ‘scrubber’ were commonly used to refer to MSWs. Interactions with clients also prompted experiences of felt stigma. Like others, a 31-year-old participant perceived client stigma through non-verbal cues: ‘They (clients) show their disappointment and do not talk much with me. They talk with me for the sake of formality. They often look down upon this group because this group is not so popular’.

The desire to be ‘normal’ was mentioned by many participants and was related to the belief that they were falling short of social expectations regarding appropriate modes of work and masculine behaviour. Even among participants whose experience had been relatively neutral or acceptable, many experienced felt stigma and emphasized the adverse mental, physical or moral effects of sex work. As a 26-year-old MSW explained:

Some time I feel so sad while thinking about myself, ‘Why am I in such situation? I do not understand what kind of person I am!’ I will buy those medicines if they are available so that the female gene will exit from my body and only the male gene stays. By that time, I will play (have sex) with only one sex instead of two to avoid misery. When I lived in my home village, my life was terrible. When I started working in this area, I felt very happy as I can help my family with much money I earn from this work. However after that when I am more deeply involved in this work, I thought if I had not worked in the dancing hall, I would have never known about this world. I am only interested in working in a company where I can work and meet a wife. It would have been so good now if I was a pure company worker! I would have gotten married, and now we would have our houses and kids with a happy life. It’s a misfortune to become a 50:50 (bisexual).

Stigma management techniques: Non-disclosure and emphasizing economic imperatives

Participants described a tension between economic dependence on sex work and the social stigma of sex work and same-sex sexual behaviour. As a way to cope, men engaged in strategies aimed at avoiding or minimizing their exposure to enacted and felt stigma with family members and primary non-paying sex partners (Goffman, 1963). We use four cases (Ha, Chien, Tai, and Lanh) to illustrate some of the complex ways that participants managed social stigma in a range of social contexts and situations. All names and some places have been changed to preserve anonymity of participants.

Ha

Ha, 24, had been a sex worker in a massage parlour for one year. Ha attempted to keep his involvement in sex work concealed from his peers, girlfriend and family. While out with his girlfriend or peers, Ha said that he avoided walking by places known for attracting MSM just in case someone were to recognize him: ‘I will be very sad if my family comes to know my secret. I may be distressed completely. It does not only affect my own virtue, but also my family such as my parents, siblings, and my cousins. Selling sex is one thing that will ruin people’s virtue. So I have to keep it secret’.

As Ha described, the desire to preserve family honour was a significant theme. When participants discussed real or potential moments of disclosure, they often described the intense embarrassment and disgrace that would result. Being open with family about their involvement in sex work was unthinkable, since it would represent a great shame on the family name. Like Ha, many participants who were not open to their partners or peers avoided going with them to public places near cruising sites where they might be recognized as MSWs. This was viewed as an additional safeguard against unintentional disclosure.

Chien

Chien, 34, had been working at a massage parlour for four months, and was married to a woman who lived in Nha Trang. Chien said that his greatest fear was his family or his wife finding out about his participation in sex work. When asked about why he did not work as a MSW in Nha Trang, Chien responded:

It sounds too frightening to mention Nha Trang because I come here for working. I dare not to come back to Nha Trang. In Nha Trang they will recognize if I am called like that. In cases of my friends here, I do not accept to work if they are from Nha Trang because I am afraid of being discovered. I am afraid the people from Nha Trang or maybe from [neighbouring town] may know it and tell the people there. I would die if that were the case.

Chien uses two common stigma management techniques. Like a number of participants in the study, Chien began engaging in sex work after he had moved to HCMC. Because he lived away from his wife and family, Chien could assume a relative level of anonymity as a sex worker in HCMC, which may have dispelled his worry about being found out. As an additional precautionary measure, this participant, like others, also used a pseudonym with clients.

Tai

Tai, 22, had been working at a massage parlour and as a street-based MSW for one year. Tai engaged in sex work to supplement his income as a part-time tailor, which was not enough money to cover his daily expenses. Tai’s mother and sister know that he does sex work. As Tai explained:

Only my mother and younger sister know the truth (about sex work). She (mother) encouraged me to work so that I have money to buy things. My mother complained that the job is unhealthy and has high risk of HIV infection. But when she thought it through, she told me it was acceptable to do because I could have money for my daily expenses. My mother is in a difficult circumstance. My father married another woman so my family is in crisis. Each time when she comes here to give me money, she knows my job and she often cries. Sometimes she looks so sorrowful. I work and earn money from my work. I am happy and share with my mother. I told her that I would save money to buy things so she felt happy.

In this case, both Tai and his mother felt ashamed about his involvement in sex work. Through focusing on the financial needs of the family, each of them seeks to justify the behaviour to the other person and alleviate their own discomfort with this socially unsanctioned behaviour. As reflected in this narrative, defining sex work strictly in terms of economic benefit was a strategy participants used to distance themselves from the social stigma associated with sex work. Similarly, Lanh, a 19-year-old participant, explained his lack of concern about sex work disclosure in terms of financial imperatives. ‘It’s not important when you live in Saigon (HCMC). You have everything if you have money. Am I right? Because of money, the thieves have to punch and the heroin sellers have to pay for their heads. So, everybody is the same. Everything is normal’.

Stigma management as a challenge to sexual communication

While non-disclosure about sex work was a way for men to avoid exposure to enacted and felt stigma, for many participants it was also a barrier to sexual communication with non-paying primary sex partners. Despite reporting high levels of unprotected sex with clients and non-paying partners, less than a quarter of participants had spoken to their non-paying sex partners about their involvement in sex work. Not talking with their partners about sex with clients was associated with guilt and distress for a number of participants. As a 24-year-old participant described: ‘I feel guilty toward my wife when I behave in such way because we have been married just for two years. For about one year, I always feel sad because I do not tell her about what I have been doing (sex work)’. Similarly, a 28-year-old explained that despite worrying about putting his girlfriend at risk, he could not tell her about his involvement in sex work. ‘My girlfriend and I have loved each other for three years and now we have sex without condoms. I am upset to think about giving her disease. But telling her about what I do would not be easy. I am afraid of being degraded’. Several men described this kind of dilemma.

Discussion

Economic deprivation and sexual risk behaviours are often the focus of public health narratives on male sex work (Lorway, Reza-Paul, & Akram, 2009). Departing from de-contextualized depictions of sex work, the present analysis explores decisions about sex work disclosure and how these choices are shaped by economic needs and experiences of enacted and felt stigma. Qualitative interviews evidenced that MSWs used strategies to minimize their exposure to social stigma related to sex work and same-sex sexual behaviour. However, as a stigma management technique, sex work concealment was the source of anxiety for MSWs and was a barrier to sexual communication with non-paying sexual partners.

Citing job insecurity and low wages, all participants said that money was one of the primary motivations for doing sex work. The dominant economic theme underpinning motivations to engage in sex work suggests that the income generated from this activity plays an integral role in participants’ ability to meet their financial responsibilities. Unskilled workers make up a significant part of the workforce in Vietnam, which has exacerbated unemployment, especially among young adults (Assad & Levinson, 2013). As underemployed men in a time of declining opportunities for unskilled wage labour, sex work is a viable option to generate income. The earning power of sex work may have been particularly alluring for those who were expected to support families in rural areas. While a few participants described sex work as a relatively undemanding job compared to other lower paying opportunities, views like this must be understood in the context of significantly limited employment opportunities.

Participants experienced enacted and felt social stigma due to both their involvement in sex work and engagement in same-sex sexual behaviour. The enacted stigma that men described is consistent with data from a recent quantitative study of 300 MSWs in HCMC, which found that 28.0% had been ‘made fun of’ for engaging in sex work and 35.0% often heard people referring to sex work as ‘not normal’ (Oldenburg et al., in press). The experience of social stigma increases the susceptibility of a variety of negative outcomes including family rejection and harassment by peers (Berlan, Corliss, Field, Goodman, & Bryn Austin, 2010; Rosario, Schrimshaw, & Hunter, 2009; Ryan, Huebner, Diaz, & Sanches, 2009). Such victimization can have both immediate and long-term psychosocial and physical health effects, including internalized stigma, social isolation, traumatic stress, HIV sexual risk behaviour and substance use (Bontempo & D’Augelli, 2002; D’Augelli, Grossman, & Starks, 2006; Meyer, 2003; Stall, Friedman, & Catania, 2007; Whitbeck, Chen, Hoyt, Tyler, & Kurt, 2004).

Like sex workers from the Dominican Republic and England (Padilla et al., 2008; Scambler & Paoli, 2008), participants sought to cope with marginalization through the use of stigma management techniques, which were often aimed at complete concealment of sex work. Given the importance of sex work income, it is not surprising that participants used strategies to conceal sex work activity. Although MSM peers were a source of social support for some participants, non-disclosure to family or friends may have left MSWs feeling particularly isolated. Additionally, for most of the men, active concealment of involvement in sex work brought with it a tremendous worry and anxiety about being found out. Blanc (2005) asserts that socio-economic groups may have different levels of acceptance of homosexuality in Vietnam. As compared to those with greater resources, poor families may be more willing to accept same-sex sexual behaviour, since male-male sex in the context of sex work can help with economic survival. Although Tai’s case suggests that a family’s economic need may soften their disapproval of male sex work, the extent to which this compares with MSWs from families with greater economic resources remains unclear.

While many of the men expressed worry and guilt about not talking to their non-paying primary sex partners about being involved in sex work, these concerns were trumped by their investments in the stigma management techniques used to conceal involvement in sex work. Although there have been an increasing number of studies on sexual communication among same-sex and heterosexual couples (Bui et al., 2012; Poppen, Reisen, Zea, Bianchi, & Echeverry, 2005; Sheeran, Abraham, & Orbell, 1999; Simon Rosser et al., 2008), few have focused on how sex work figures into disclosure patterns of sexual risk. Considering the high levels of unprotected sex reported by the sample, the lack of sexual communication between MSWs and their non-paying sex partners is concerning. Open communication about sexual activity (outside of the relationship) enhances the ability of non-paying sex partners to make informed decisions about sexual safety.

These findings should be viewed in the context of some limitations. This study was conducted using semi-structured interviews and did not include an ethnographic or story-telling component. As such, details may be missing related to the participant’s life events that would have enriched our understanding of their experiences. We were also unable to make clear distinctions between stigma associated with sex work and that which pertained to same-sexual behaviour. Further research is needed to explore how these types of social stigma overlap for MSWs in this context and others. The sample was diverse with respect to sub-categories of sexual identity and sex work venue type (e.g., massage parlour, street, and internet). Due to the explanatory aims of the study, the sample was small and recruited from The Life Centre only. Participants may represent a group that is different from MSWs who are not exposed to health prevention messaging. This may be particularly true for Vietnam, where ‘Vietnamese homosexualities’ have a wide regional variation (Blanc, 2005).

Conclusion

To address the factors that contribute to HIV risk among MSWs in developing world contexts, our findings support the need for a combination of structural and individual-level interventions. Skills that build competencies, self-determination, and enhance optimism for the future may assist MSWs to better cope with social stigma (Catalano, Berglund, Ryan, Lonczak, & Hawkins, 2002). For MSWs in HCMC, supportive social relationships and positive definitions of self may enhance their ability to speak openly more about involvement in sex work. Moreover, the sense of responsibility to family and strong familial ties that some participants described could be a potentially valuable source of social capital to be integrated into future health promotion programming for this population, as family relationships have been shown to indirectly facilitate health behaviours and deter risk-taking (Burg & Seeman, 1994).

However, the effectiveness of HIV prevention programming to address individual behaviour change among sex workers will depend on the level of commitment to increasing social, political and economic empowerment within and across communities of sex workers. This population in particular may benefit from assistance with obtaining living wage employment opportunities. Personal agency presupposes a defiance of and resistance to enacted and felt stigma and deviance. These concepts therefore play an important role in the success of bottom-up initiatives that seek to promote positive health behaviours through empowerment of MSWs (Scambler & Paoli, 2008).

Acknowledgments

This work was supported by a pilot grant from Harvard University Catalyst/The Harvard University Clinical and Translational Science Center (PIs: Colby and Mimiaga); NIH Grant #1 UL1 RR 025758-02; and financial contributions from participating institutions.

Footnotes

The authors have no conflict of interests.

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