Abstract
Purpose:
To examine how recent sex work is identified and the HIV risk factors and service needs among Thai cisgender men who have sex with men (MSM) and transgender women (TGW) who exchange sex.
Methods:
MSM and TGW in Bangkok and Pattaya who exchanged sex in the last year (n= 890) were recruited through social media, outreach, and word-of-mouth. Recent sex exchange was based on the primary question, “in the last 30 days, have you sold or traded sex”; secondary questions (regarding income source and client encounters) were also investigated.
Results:
Overall, 436 (48%) participants engaged in sex work in the last 30 days; among those, 270 (62%) reported exchanging sex by the primary question, and 160 (37%) based on secondary questions only. Recent sex exchange was associated with gonorrhea, syphilis, discussing PrEP with others, and using condoms, alcohol, methamphetamine, amyl nitrate, and Viagra®. Exchanging sex based on secondary questions only was associated with being in a relationship, social media recruitment, less recent anal intercourse, and not discussing PrEP.
Conclusions:
Thai MSM and TGW who exchange sex need regular access to HIV/STI prevention, testing, and treatment services, and multiple approaches to assessing sex work will help identify and serve this diverse and dynamic population.
INTRODUCTION
Since the 1990s Thailand has had a high burden epidemic of HIV among cisgender men who have sex with men (MSM) and transgender women (TGW) who have sex with men. HIV rates in the general population have fallen, but the epidemic among key populations has continued.1–3 HIV incidence has been particularly high among subsets of TGW and MSM, including those who are younger, who use amphetamines and other stimulant drugs, and who sell or trade sex.4,5 Epidemiologic trends in HIV infections indicate the highest rates of new HIV infections in the youngest age strata, with young MSM accounting for nearly half of all new HIV infections in Thailand in 2018.6–9 A study conducted in 3 venue-based urban settings in Thailand reported a 2.5-fold increased odds of HIV infection in those aged 13 years or younger at the time of anal sexual debut.10 A 2018 cross-sectional study of MSM and TGW in six community sites in Thailand found high HIV prevalence among TGW (8.8%) and higher HIV prevalence (17.7%) among MSM enrolled in the study than previous national reports.11 Despite current interventions and efforts to control the epidemic, such as regular HIV testing and counseling, the provision of condoms and lubricant, and a national program of free and universal ARV access, MSM and TGW continue to experience high HIV incidence.4 Notably, a 2019 Bangkok cohort study showed a high and sustained incidence rate of 11.1 per 100 person-years (95% CI: 6.7–17.4) among MSM and TGW 18–21 years of age who sold sex in the prior four months.4
Although prostitution is illegal in Thailand, sex work is common.12 Sex work in Thailand is diverse. Female, male, and transgender sex workers work in venue-based and more informal street and online settings, with both local and international clientele, and transitioning into and out of sex work is common.4,13 Efforts to meet the HIV prevention and other needs of men and TGW who sell or exchange sex may be improved through better understanding of their occupational and social environments, and understanding how they disclose sex work activities may improve program messaging and utilization.14
We examine factors associated with how sex work is identified and the HIV risk factors and service needs of those engaged in sex work using baseline data from the Combination Prevention Effectiveness (COPE) study, an HIV prevention trial for young (18- to 26-year-old) men and TGW who engage in sex work in Bangkok and Pattaya, Thailand (n = 890).15 For the purpose of this study, we define sex exchange as selling sex, and we define sex work as having sex with a man in exchange for money, drugs, or anything else of value. First, we examine whether recent engagement in sex work is associated with HIV risk, STIs, and individual and social characteristics. Second, we explore the utility of different measures of sex work by examining whether there any significant differences between those who responded positively to a primary question regarding sex work compared with those who only acknowledge sex work in response to secondary questions.
METHODS
The COPE study is a HIV prevention trial testing the effectiveness of combination prevention interventions for MSM and TGW who exchange or sell sex in urban centers in Thailand, with detailed methodology described elsewhere.15 Data from the COPE study baseline visit (October 2017 – August 2019) are used in these analyses, and baseline procedures included the following: HIV testing and counseling; condom and lubricant distribution; computer-assisted self-interview (CASI) in Thai; and screening for syphilis, rectal gonorrhea, and chlamydia.
Study sample.
Eligibility criteria for initial study enrollment include the following: assigned male sex at birth; 18 to 26 years of age; self-report being HIV-negative or of unknown serostatus; having sold or exchanged sex to cisgender men for money, drugs, or other goods in the past 12 months based on self-report; living in the greater Bangkok metropolitan area or Pattaya; Thai citizenship; and willing and able to complete study instruments.
MSM and TGW who exchange sex are often served by the same organizations and have overlapping communities and venues; thus, both populations were included in this study. Sexual orientation and gender identities are not distinct in Thailand as they are in Western cultures. In this manuscript, we use terms MSM and TGW as self-identified by participants and commonly accepted in the scientific literature, though these are composite terms in Thailand, which include approximately 15 unique identities that embody both sexual and gender preferences and expression.16,17
Participants were recruited through outreach at physical sex work venues (e.g., bars, saunas, brothels, karaoke parlors), a social media campaign, and clinic referral and peer referral. Individuals were able to schedule an appointment or to provide their phone number and be contacted by study staff, and pre-screening was conducted during the initial phone call with study staff. Potential participants were then screened for eligibility at one of the study sites. Participants meeting eligibility criteria were informed of the study procedures, risks, benefits, and alternatives, and those consenting to participate were enrolled in the study. Participants received 1000 THB (US $35) for completing the baseline visit.
Biologic testing.
HIV testing included rapid antibody testing, supplemented by a reflex pooled nucleic acid amplification test (NAAT) for antibody-negative specimens. All reactive HIV test results were confirmed by additional rapid test and/or NAAT, and participants with HIV were actively linked to HIV care and treatment. Rectal gonorrhea and chlamydia were assessed using either provider-collected or a self-administered rectal swab depending on participant preference, and participants with positive results were provided oral treatment or injection treatment. Blood specimens were tested for antibody to Treponema pallidum by rapid plasma reagin (RPR) reactivity and titer and Treponemal antibody rapid test. Persons with RPR ≥ 1:8 and T. pallidum antibody positive were considered seropositive for syphilis. Participants reporting signs or symptoms of other STIs were evaluated and either treated on site or referred to care. Participants testing positive for HIV at baseline were excluded from further study participation due to ineligibility for PrEP initiation. However, they were included in the present analyses to evaluate whether HIV status was associated with sex work at the baseline visit.
Measures.
The baseline survey included multiple measures related to recent exchange or transactional sex. During instrument development, one question was predetermined as the primary indicator of sex exchange or sex work. Additional questions were included to capture other issues related to sex work, including income and HIV risk. Based on the responses to these questions, we categorized participants as having exchanged sex in the past 30 days based on the primary question, having exchanged sex in the past 30 days based on other (secondary) questions, and no indication of having exchanged sex in the past 30 days. The primary question about sex work was, “In the last 30 days, have you sold or traded sex?” Secondary questions addressed: (1) income, “In the last 30 days, what were your sources of income?”, with responses including “sex work” and “steady partner or benefactor (sia-liang)”; (2) income from transactional sex, “Is transactional sex your primary source of income?”; (3) meeting transactional partners, “In the last 30 days, if you have sold or exchanged sex, where did you meet your partner(s)?”; and (4) number of anal intercourse partners in the last 7 days, “In the last 7 days, with how many partners did you have anal sex in exchange for money, drugs or anything else of value? This includes having sex with a ‘benefactor’ (sia-liang).” Some participants responded “don’t know” or “refuse to answer” to assessment questions, and to have conservative indicators of sex work, all such responses were treated as “no” responses. We created a binary variable of any indication of exchanging sex in the last 30 days based on a positive response to any of the above questions. For participants with any indication of sex work in the last 30 days, we created a second binary variable based on whether they had a positive response to the first question, “In the last 30 days, have you sold or traded sex?”.
Additional baseline data included study site, how participants heard about the study, sociodemographic characteristics (age, employment, education, income, and gender identity), sexual behavior, substance use, PrEP (use, knowledge, interest, and beliefs), mental health, and social support. Mental health was measured using the STOP-Distress (STOP-D), a 5-item instrument assessing depression, anxiety, stress, anger, and social support.18 The 3-item Alcohol Use Disorders Identification Test- Concise (AUDIT-C) scale was used to identify symptoms of hazardous alcohol use,19 with total scores of 4 or greater classified as potential hazardous alcohol use.20 Non-alcohol substance use was assessed via brief measures of lifetime as well as past 3-month drug use.
Statistical analyses.
Analyses were grouped by the two primary research questions: (1) what factors in this sample are associated with any indication of sex work in the last 30 days, and (2) among participants who engaged in sex work in the last 30 days, are there any significant differences between those who responded positively to the primary sex work question compared to only secondary sex work questions. For the first research question, each factor was included in a separate logistic regression of any indication of sex work in the last 30 days, and study site was included as a fixed effect to account for the clustering of observations within sites. For the second research question, the same approach was used but with indication of sex work from only secondary questions as the outcome and with the analytic sample restricted to participants engaging in sex work in the last 30 days. Factors examined in both sets of analyses included sociodemographic information, sexual behavior, HIV and STIs, mental health, substance use, and PrEP awareness, attitudes, and beliefs. As the research questions are descriptive rather than predictive, we conducted unadjusted analyses (other than study site) rather than fully adjusted analyses.
Human Subjects Considerations:
The study protocol was reviewed and approved by the Thailand Ministry of Public Health Ethical Review Committee for Research in Human Subjects, the US Centers for Disease and Control (CDC) Institutional Review Board (IRB), and the Johns Hopkins Bloomberg School of Public Health IRB.
RESULTS
The majority of the 890 participants were enrolled at the Silom Community Clinic at the Hospital for Tropical Diseases (SCC @TropMed, 57%), followed by the Rainbow Sky Association of Thailand (RSAT, 24%) and Service Workers in Group (SWING) Foundation (19% between both clinic locations) (Table 1). The most common modes of hearing about the study were through word of mouth (45%), websites or social media (33%), and outreach (24%). Slight majorities of participants had at least a university education (53%) or were currently in school (53%), and most respondents (89%) reported having sufficient money to meet basic needs at least most of the time. Most participants (89%) considered their gender to be male, and a minority of participants (9%) as a woman or transgender woman.
Table 1.
Recent sex work, sociodemographic characteristics, and study involvement at the COPE study baseline (October 2017 – August 2019) among Thai MSM and TGW who exchanged sex in the prior 12 months (n=890).
| Total | Indication of sex work in last 30 days from any question | Indication of sex work from primary or secondary questions | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No (n=460) | Yes (n=430) | Primary (n=270) | Secondary only (n=160) | |||||||||
| n | (%) | n | (%) | n | (%) | p | n | (%) | n | (%) | p | |
| Years of age | 0.28 | 0.15 | ||||||||||
| 18–20 | 200 | (22) | 110 | (24) | 90 | (21) | 50 | (19) | 40 | (25) | ||
| 21–23 | 381 | (43) | 186 | (41) | 195 | (45) | 121 | (45) | 74 | (46) | ||
| 24–26 | 308 | (35) | 163 | (36) | 145 | (34) | 99 | (37) | 46 | (29) | ||
| Currently at school | 470 | (53) | 255 | (55) | 215 | (50) | 0.15 | 126 | (47) | 89 | (56) | 0.084 |
| Completed university education | 471 | (53) | 242 | (53) | 229 | (53) | 0.64 | 150 | (56) | 79 | (49) | 0.073 |
| Income from work (not sex work; full-time or part-time) | 612 | (71) | 307 | (69) | 305 | (72) | 0.53 | 197 | (75) | 108 | (68) | 0.29 |
| Sufficient income to meet basic needs most or all of month | 781 | (89) | 404 | (89) | 377 | (89) | 0.86 | 242 | (91) | 135 | (86) | 0.12 |
| Currently in a relationship | 334 | (38) | 174 | (38) | 160 | (37) | 0.58 | 88 | (33) | 72 | (45) | 0.012 |
| Gender identity | 0.12 | 0.90 | ||||||||||
| Man, gay, or bisexual | 788 | (89) | 418 | (92) | 370 | (87) | 231 | (87) | 139 | (87) | ||
| Woman or transgender woman | 78 | (9) | 30 | (7) | 48 | (11) | 30 | (11) | 18 | (11) | ||
| Other or don’t know | 15 | (2) | 8 | (2) | 7 | (2) | 5 | (2) | 2 | (1) | ||
| Study Site | <0.001 | 0.90 | ||||||||||
| Silom Community Clinic (SCC) | 503 | (57) | 232 | (50) | 271 | (63) | 166 | (61) | 105 | (66) | ||
| Service Workers in Group Bangkok (SWING BKK) | 146 | (16) | 106 | (23) | 40 | (9) | 21 | (8) | 19 | (12) | ||
| Rainbow Sky Association of Thailand (RSAT) | 211 | (24) | 111 | (24) | 100 | (23) | 69 | (26) | 31 | (19) | ||
| Service Workers in Group Pattaya (SWING Pattaya) | 30 | (3) | 11 | (2) | 19 | (4) | 14 | (5) | 5 | (3) | ||
| Learned about study through social media* | 297 | (33) | 155 | (34) | 142 | (33) | 0.69 | 79 | (29) | 63 | (39) | 0.031 |
| Learned about study through outreach, poster, or flyer* | 216 | (24) | 110 | (24) | 106 | (25) | 0.12 | 65 | (24) | 41 | (26) | 0.66 |
| Learned about study through friend or person at venue* | 406 | (46) | 195 | (42) | 211 | (49) | 0.28 | 139 | (51) | 72 | (45) | 0.25 |
Note: MSM = men who have sex with men; TGW = transgender women. Primary question for sex work: “In the last 30 days, have you sold or traded sex?” Secondary questions for sex work: “In the last 30 days, what were your sources of income?”; “Is transactional sex your primary source of income?”; “In the last 30 days, if you have sold or exchanged sex, where did you meet your partner(s)?”; “In the last 7 days, with how many partners did you have anal sex in exchange for money, drugs or anything else of value?”
Multiple response selections allowed for this question
Although all participants reported exchanging sex with cisgender men for money, drugs, or other goods in the past 12 months during eligibility screening, only 430 (48%) had indications of engaging in sex work in the last 30 days. When asked the primary question, “In the last 30 days, have you sold or traded sex,” 270 (30%) participants responded “yes”. Among those who responded “no” or “don’t know”, some participants reported sex exchange activities in response to secondary questions, including income from sex work in the last 30 days (10%), meeting sex clients in the last 30 days (13%), and having anal sex in the last 7 days with sex clients (20%). Among the 430 participants with any indication of sex work in the last 30 days, 270 (37%) had responded positively only to secondary questions regarding sex work and not the primary question.
Participation in sex work in the last 30 days was significantly associated with study site (p<0.001), but not with sociodemographic characteristics nor method by which participants became aware of the study (Table 1). Among those with any indication of sex work in the past 30 days, those responding positively to the primary question were less likely to be in a current relationship and less likely to have heard about the study through websites or social media.
Any indication of sex work in the last 30 days was significantly associated with sexual behaviors (Table 2), including anal intercourse in the last 7 days, anal intercourse in the last 30 days, condom use during last anal intercourse, and substance use during intercourse within the last 30 days. Overall, 5% of participants had a positive HIV test result and 32% of participants were diagnosed with an STI. Participants engaging in sex work in the last 30 days were significantly more likely to have a current gonorrhea infection or syphilis infection and marginally more likely to have a chlamydia infection. Among those who reported participating in sex work in the past 30 days, those responding positively to the primary question were significantly more likely to have had anal sex in the last 7 days or last 30 days, but there was no significant association with the other measures of sexual behavior or STI or HIV infection or STI history.
Table 2.
Recent sex work, sexual behavior, and sexually transmitted infections at the COPE study baseline (October 2017 – August 2019) among Thai MSM and TGW who exchanged sex in the prior 12 months (n=890).
| Total | Indication of sex work in last 30 days from any question | Indication of sex work from primary or secondary questions | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No (n=460) | Yes (n=430) | Primary (n=270) | Secondary only (n=160) | |||||||||
| n | (%) | n | (%) | n | (%) | p | n | (%) | n | (%) | p | |
| Tested for HIV in last 6 months | 581 | (65) | 295 | (64) | 286 | (67) | 0.32 | 174 | (64) | 112 | (70) | 0.28 |
| HIV infection | 44 | (5) | 24 | (5) | 20 | (5) | 0.90 | 14 | (5) | 6 | (4) | 0.54 |
| Current chlamydia infection | 143 | (16) | 67 | (15) | 76 | (18) | 0.069 | 42 | (16) | 34 | (21) | 0.16 |
| Current gonorrhea infection | 48 | (5) | 18 | (4) | 30 | (7) | 0.021 | 19 | (7) | 11 | (7) | 0.85 |
| Current syphilis infection | 92 | (11) | 34 | (8) | 58 | (14) | 0.008 | 36 | (14) | 22 | (15) | 0.90 |
| Prior diagnosis of chlamydia, gonorrhea, or syphilis | 195 | (22) | 88 | (19) | 107 | (25) | 0.25 | 66 | (24) | 41 | (26) | 0.92 |
| Anal sex in the last 7 days | <0.001 | 0.004 | ||||||||||
| No | 267 | (30) | 178 | (39) | 89 | (21) | 52 | (19) | 37 | (23) | ||
| Yes | 440 | (49) | 191 | (42) | 249 | (58) | 171 | (63) | 78 | (49) | ||
| Don’t know or refused to answer | 183 | (21) | 91 | (20) | 92 | (21) | 47 | (17) | 45 | (28) | ||
| Last time had anal sex with man | <0.001 | 0.004 | ||||||||||
| Within 30 days | 545 | (61) | 253 | (55) | 292 | (68) | 198 | (73) | 94 | (59) | ||
| More than 30 days | 152 | (17) | 106 | (23) | 46 | (11) | 25 | (9) | 21 | (13) | ||
| Don’t know or refused to answer | 193 | (22) | 101 | (22) | 92 | (21) | 47 | (17) | 45 | (28) | ||
| Used condom during last anal sex | 0.009 | 0.52 | ||||||||||
| No | 230 | (26) | 121 | (26) | 109 | (25) | 63 | (23) | 46 | (29) | ||
| Yes | 643 | (72) | 325 | (71) | 318 | (74) | 205 | (76) | 113 | (71) | ||
| Don’t know or refused to answer | 17 | (2) | 14 | (3) | 3 | (1) | 2 | (1) | 1 | (1) | ||
| Used alcohol or drugs during anal sex in last 7 days | <0.001 | 0.13 | ||||||||||
| No | 530 | (60) | 310 | (67) | 220 | (51) | 139 | (51) | 81 | (51) | ||
| Yes | 99 | (11) | 27 | (6) | 72 | (17) | 51 | (19) | 21 | (13) | ||
| Don’t know or refused to answer | 261 | (29) | 123 | (27) | 138 | (32) | 80 | (30) | 58 | (36) | ||
Note: MSM = men who have sex with men; TGW = transgender women. Primary question for sex work: “In the last 30 days, have you sold or traded sex?” Secondary questions for sex work: “In the last 30 days, what were your sources of income?”; “Is transactional sex your primary source of income?”; “In the last 30 days, if you have sold or exchanged sex, where did you meet your partner(s)?”; “In the last 7 days, with how many partners did you have anal sex in exchange for money, drugs or anything else of value?”
The mental health measures were not significantly associated with either any indication of sex work in the last 30 days or how sex work was identified (Table 3). Engaging in sex work in the last 30 days was associated with hazardous drinking, drinking more frequently, consuming more drinks on typical drinking days, and having 6 or more drinks on one occasion more frequently, and it was significantly associated with ever using drugs, and, in the last 3 months, using any drug, using poppers (amyl nitrate), using methamphetamines, and using Viagra. Substance use was not associated with responding positively to the primary question compared with only secondary questions.
Table 3.
Recent sex work, mental health, and substance at the COPE study baseline (October 2017 – August 2019) among Thai MSM and TGW who exchanged sex in the prior 12 months (n=890).
| Total | Indication of sex work in last 30 days from any question | Indication of sex work from primary or secondary questions | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No (n=460) | Yes (n=430) | Primary (n=270) | Secondary only (n=160) | |||||||||
| n | (%) | n | (%) | n | (%) | p | n | (%) | n | (%) | p | |
| Hazardous alcohol use | 438 | (49) | 193 | (42) | 245 | (57) | <0.001 | 156 | (58) | 89 | (56) | 0.96 |
| Have ever used drugs | 211 | (24) | 79 | (17) | 132 | (31) | <0.001 | 85 | (31) | 47 | (29) | 0.66 |
| Used drugs in last 3 months | 130 | (15) | 44 | (10) | 86 | (20) | <0.001 | 59 | (22) | 27 | (17) | 0.19 |
| Used marijuana in last 3 months | 16 | (2) | 6 | (1) | 10 | (2) | 0.41 | 8 | (3) | 2 | (1) | 0.36 |
| Used poppers (amyl nitrate) in last 3 months | 86 | (10) | 31 | (7) | 55 | (13) | 0.001 | 39 | (14) | 16 | (10) | 0.090 |
| Used cocaine in last 3 months | 6 | (1) | 4 | (1) | 2 | (0) | 0.50 | 2 | (1) | 0 | (0) | 0.53 |
| Used methamphetamines in last 3 months | 52 | (6) | 12 | (3) | 40 | (9) | <0.001 | 25 | (9) | 15 | (9) | 0.99 |
| Used ecstasy in last 3 months | 7 | (1) | 4 | (1) | 3 | (1) | 0.68 | 2 | (1) | 1 | (1) | 0.99 |
| Used Viagra in last 3 months | 45 | (5) | 15 | (3) | 30 | (7) | 0.006 | 20 | (7) | 10 | (6) | 0.58 |
| Injected any drugs in last 3 months | 31 | (4) | 10 | (2) | 21 | (5) | 0.053 | 12 | (4) | 9 | (6) | 0.95 |
| Feeling down, sad or uninterested in life, mean (SD) | 2.55 | (2.32) | 2.46 | (2.32) | 2.64 | (2.31) | 0.24 | 2.69 | (2.22) | 2.58 | (2.47) | 0.64 |
| Feeling anxious or nervous, mean (SD) | 2.81 | (2.23) | 2.78 | (2.16) | 2.83 | (2.30) | 0.89 | 2.82 | (2.17) | 2.86 | (2.52) | 0.76 |
| Feeling stressed, mean (SD) | 3.53 | (2.41) | 3.47 | (2.39) | 3.60 | (2.44) | 0.45 | 3.67 | (2.36) | 3.50 | (2.57) | 0.50 |
| Feeling angry, mean (SD) | 2.48 | (2.11) | 2.46 | (2.14) | 2.50 | (2.08) | 0.92 | 2.52 | (2.02) | 2.47 | (2.17) | 0.99 |
| Not having social support, mean (SD) | 2.53 | (2.50) | 2.38 | (2.41) | 2.69 | (2.58) | 0.071 | 2.74 | (2.56) | 2.62 | (2.62) | 0.76 |
Note: MSM = men who have sex with men; TGW = transgender women. Primary question for sex work: “In the last 30 days, have you sold or traded sex?” Secondary questions for sex work: “In the last 30 days, what were your sources of income?”; “Is transactional sex your primary source of income?”; “In the last 30 days, if you have sold or exchanged sex, where did you meet your partner(s)?”; “In the last 7 days, with how many partners did you have anal sex in exchange for money, drugs or anything else of value?”
At baseline, 17% of participants had previously taken PrEP, 84% were aware of PrEP, 45% knew at least one person who have taken PrEP, and 77% were willing to take PrEP every day (Table 4). Having discussed PrEP with other young men or TGW who trade sex was significantly associated with sex work in the last 30 days and with responding positively to the primary question about sex work.
Table 4.
Recent sex work and PrEP awareness, use, and interest at the COPE study baseline (October 2017 – August 2019) among Thai MSM and TGW who exchanged sex in the prior 12 months (n=890).
| Total | Indication of sex work in last 30 days from any question | Indication of sex work from primary or secondary questions | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No (n=460) | Yes (n=430) | Primary (n=270) | Secondary only (n=160) | |||||||||
| n | (%) | n | (%) | n | (%) | p | n | (%) | n | (%) | p | |
| Know young men who exchange sex with men | 259 | (29) | 95 | (21) | 164 | (38) | <0.001 | 117 | (43) | 47 | (29) | 0.006 |
| Have ever heard of PrEP | 746 | (84) | 386 | (84) | 360 | (84) | 0.85 | 228 | (84) | 132 | (83) | 0.29 |
| Know people who have taken PrEP | 403 | (45) | 201 | (44) | 202 | (47) | 0.25 | 132 | (49) | 70 | (44) | 0.15 |
| Have discussed PrEP with other young men who exchange sex | 186 | (21) | 59 | (13) | 127 | (30) | <0.001 | 91 | (34) | 36 | (23) | 0.010 |
| Willing to take PrEP everyday | 685 | (77) | 350 | (76) | 335 | (78) | 0.36 | 208 | (77) | 127 | (79) | 0.67 |
| Know where to get PrEP | 718 | (81) | 375 | (82) | 343 | (80) | 0.87 | 220 | (81) | 123 | (77) | 0.15 |
| Have ever taken PrEP | 153 | (17) | 80 | (17) | 73 | (17) | 0.73 | 43 | (16) | 30 | (19) | 0.65 |
Note: MSM = men who have sex with men; TGW = transgender women. Primary question for sex work: “In the last 30 days, have you sold or traded sex?” Secondary questions for sex work: “In the last 30 days, what were your sources of income?”; “Is transactional sex your primary source of income?”; “In the last 30 days, if you have sold or exchanged sex, where did you meet your partner(s)?”; “In the last 7 days, with how many partners did you have anal sex in exchange for money, drugs or anything else of value?”
DISCUSSION
This study demonstrates that using multiple primary and secondary questions can improve identification of sex exchange among MSM and TGW. We found that although all participants reported selling or trading sex in the last year per study eligibility requirements, only 30% responded “yes” when asked, “In the last 30 days, have you sold or traded sex?” The use of additional measures that address sources of income, meeting clients, and sexual behavior identified sex work among an additional 18% of participants.
Several factors may account for inconsistences in responses across questions. First, although sex work may be tolerated more in Thailand than in many other countries, cognitive dissonance between stigmatization of sex work and self-identification as a sex worker may be stronger when asked direct questions about sex work.21 In contrast, secondary questions about sources of income or more technical questions about where one meets clients may be less “labeling” and less problematic vis-à-vis self-identity. Second, sex work is illegal in Thailand, albeit tolerated if conducted within specific settings. Participants may have been reticent to disclose illegal behavior early in the interview schedule, but more willing to disclose it later or indirectly. Third, the variation in responses could reflect measurement error. Native Thai speakers experienced with qualitative research on sex work in Thailand were involved in developing and pilot testing the questionnaire but, nonetheless, there may been ambiguities in the questions or responses. Alternatively, measurement error could have occurred if participants were not thoughtful about their responses. Exchanging sex is a manifold, multifaceted, and poorly defined construct with often weighty implications for personal identity, income, interpersonal relationships, substance use, and sexual health. Researchers may aim to provide a clear definition of exchanging sex, transactional sex, or sex work to study participants, but how these terms may be interpreted by participants can vary and their interpretation may be shaped by negative and positive attributes attached to these terms either by themselves or others.
Many participants were at high risk of HIV infection at the time of their participation. The HIV prevalence was 4.9% despite pre-screening for self-reported HIV-negative status, and 31% of participants had gonorrhea, chlamydia, or syphilis. Young Thai MSM and TGW who exchange sex may have special needs for tailored HIV and STI prevention, testing, and treatment services that are gender identity-specific, effective, and acceptable, and multiple approaches may be needed to serve this diverse and dynamic population. For instance, recent literature indicates differing demographics and sexual behaviors of MSM and TGW persons in Thailand: compared to MSM, TGW reported lower education and income levels and higher proportions of TGW reported engaging in sex work.11 In addition, HIV prevention programming tailored to TGW individuals has been shown to increase uptake of HIV testing and decrease number of sexual partners among TGW in Thailand.22,23 Given this, programs designed to address specific population needs may enhance HIV prevention efforts by targeting specific behaviors while promoting access to healthcare. Further investigation into the effectiveness of tailored programming and services for TGW and MSM in Thailand is warranted.
Exchanging sex was also significantly associated with alcohol and drug use and particularly associated with drugs associated with sex, including methamphetamines, poppers, and Viagra. In Thailand and the US, concerns about methamphetamines as a risk factor for HIV acquisition have been renewed. One-third of seroconversions among MSM and TGW in a recent US cohort study were among methamphetamine users,24 and in Bangkok, the use of club drugs, including methamphetamines, has been associated with HIV incidence among MSM.25 The increased prevalence of alcohol and drug use among those exchanging sex may be due to a number of factors, including the substance use during sex exchange encounters, the availability of alcohol and drugs at sex work venues, and the benefits of Viagra and stimulants for increasing occupational productivity. These issues underscore the importance of finding optimal ways to identify and engage those who work in environments of greater risk to provide access to HIV prevention and services for other substance use needs.
MSM and TGW in Thailand have contributed extensively to multi-country PrEP trials, including those testing daily oral, intermittent, and long-acting injectable forms.26–28 As a result, the most recent national guidelines now recommend daily oral and intermittent PrEP for MSM and TGW and, since 2019, PrEP has been offered as part of Universal Health Coverage.29 Thailand implemented one of the first key populations-led programs in six provinces, Princess PrEP, to provide access to prevention services among MSM and TGW.30 However, analysis of data collected by the program in 2019 found that among those eligible for PrEP, less than half of TGW and MSM accepted PrEP. Separate analyses for MSM and TGW both found that those who were younger (<25 years old) were less likely to accept PrEP and also had lower 1 month and 3-month retention.31 Retention was also lower for TGW compared to MSM.30 MSM and TGW who reported prior engagement in sex work were more likely to accept PrEP, but small sample sizes for these groups leave questions about overall uptake and adherence for those engaged in sex work.31 While these studies lay out important considerations for MSM and TGW, broadly, less is known about uptake and retention for those who exchange sex. Our study findings, however, highlight the importance of identifying and considering the diversity of contexts and methods in which people exchange sex so as to tailor PrEP programs and engagement strategies to ensure that those who can most benefit from PrEP are aware of and able to access these services.
This study has important limitations. First, measures of sex work are based on self-report, and responses may have been influenced by social desirability or reluctance to reveal illegal or labeling behaviors. Second, for many assessment questions we presented participants with “don’t know” or “refuse to answer” as response options, and these responses were more common than we expected; this may have led to misclassification or non-response bias. Third, while this study reveals variation in how people differentially respond to questions about exchanging sex, it reveals less about the social and psychological dynamics that underlie this variation. In-depth interviews, ethnography, and other qualitative research will continue to be instrumental in understanding changing conceptions and practice of sex work and its relationship with personal and occupational health. In addition, engagement in sex work in the past year was an eligibility criterion for enrollment. Therefore, factors associated with sex work in the past 30 days would be generalizable to a limited population of people who would have been eligible for the study.
Conclusions.
“Exchanging sex” does not have a singular definition. How researchers and public health practitioners choose to ask about and discuss exchanging sex would be better informed and shaped by the perspectives of those we are seeking to serve. Transactional sex is often stigmatized within societies, and self-reporting exchanging sex in the research setting may be imbued with implications about self-identity and social standing. Whether individuals consider themselves to be engaging in the exchange of sex for financial or material gain may be shaped in part by whether they work at sex work venues, meet exchange partners through social media, or have transactional sex within longer term relationships. “Exchanging sex” may have different meanings to different people depending on their perspectives and depending on whether the attribute is being applied to them. From a measurement perspective, the use of multiple questions may better reflect the multiple possible domains of exchanging sex, and the development and validation of scales or indices to identify, measure, and characterize sex work could be important contributions to both research and practice. Medical and social service providers and researchers may consider how perceptions and practices around exchange sex could vary across individuals and social environments in which transactional sex occurs. By better understanding how different types of transactional sex shape HIV risk and relate to group affiliations, we may be able to tailor acceptable HIV prevention and other services.
Acknowledgments
This study is a collaborative effort between Johns Hopkins Bloomberg School of Public Health, U.S. CDC Division of HIV/AIDS Prevention (DHAP), the Thailand Ministry of Public Health, Mahidol University, APCOM, and the community-based organizations RSAT and SWING. This work would not have been possible without the hard work and contributions of the COPE Study Team. We also thank Gilead Sciences for their generous donation of the study drug, Truvada®.
Research reported in this publication is supported by the National Institute of Allergy and Infectious Diseases (NIAID) of the US National Institutes of Health (NIH) under Award Number R01AI118505 (PI: Beyrer) and direct funding support from CDC/DHAP. This research has been facilitated by the infrastructure and resources provided by the Johns Hopkins University Center for AIDS Research, an NIH funded program (P30AI094189), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA, FIC, NIGMS, NIDDK, and OAR.
Conflicts of Interest
The study drug, Truvada®, was donated to the project by Gilead Sciences. Gilead Sciences were provided the opportunity to provide comments on the manuscript but had no role in the interpretation of study results. Andrea Wirtz and Chris Beyrer also received separate research funding support from Gilead Sciences and ViiV Healthcare. All other authors declare no conflicts of interest.
Footnotes
Disclaimer
The content, findings and conclusions presented in this paper are those of the authors and do not necessarily reflect the official position of the NIH, the CDC, and U.S. Public Health Service.
Contributor Information
Combination Prevention Effectiveness (COPE) Study Team:
S Baral, C Beyrer, B Cadwell, T Chemnasiri, W Chonwattana, B Chua-Intra, MR Decker, C Dun, EF Dunne, AC Hickey, TH Holtz, S Janyam, H Jin, K Kaewboonta, N Kamchaithep, D Linjongrat, PA Mock, SHH Mon, S O’Connor, S Pattanasin, K Pawong, A Phunkron, M Poonkasetwattana, N Qaragholi, JF Rooney, K Satumay, RK Shrestha, P Sirivongrangson, A Sriinsut, S Sriplienchan, J Suksamosorn, W Sukwicha, P Sullivan, MC Thigpen, C Ungsedhapand, A Varangrat, A Warapornmongkholkul, P Wasinrapee, BW Weir, AL Wirtz, and J Woodring
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