H. Ward

Sex workers and the control of sexually transmitted disease.

OBJECTIVES: To describe and assess measures to control sexually transmitted diseases (STDs) among sex workers and their partners. METHODS: A review of medical, historical and social literature, focusing on selected cases. RESULTS: Measures to control disease in sex workers today are often prompted by concerns about HIV transmission. However, the literature shows that prostitution varies from one place and time to another, together with the risk of sexually transmitted disease. A broad social definition of prostitution rather than a narrow reference to levels of sexual activity is important for effective disease control, as an understanding of the relation between social disadvantage and sexual activity enables the provision of occupational services that sex workers actually want and use. Social prejudice and legal sanctions cause some sex workers and their partners to avoid even the most appropriate and accessible specialist services. Therefore targeted programmes can only complement, and not replace, general measures to control STDs, which are developed for other social groups or the local population as a whole. CONCLUSIONS: Sex workers and sex work differ from one place to another and so a single model for STD control is inappropriate. None the less, occupational health risks suggest a general need for specialist services. Where these do not compound the disadvantages that sex workers already suffer, medical services are likely to offer significant benefits in prevention, early diagnosis, and treatment of STDs. As the stigma of prostitution leads many people to remain invisible to services, a general health infrastructure and anti-discriminatory measures will be equally important to effective disease control.

Prostitution and risk of HIV: female prostitutes in London.

OBJECTIVE--To measure the prevalence of HIV and to describe established risk factors in female prostitutes. DESIGN--A cross sectional survey. SETTING--A genitourinary medicine clinic, streets, and magistrates courts in London. SUBJECTS--280 female prostitutes recruited between April 1989 and August 1991. MAIN OUTCOME MEASURES--Infection with HIV-1, reported risk behaviours, and prevalence of sexually transmitted infections. RESULTS--228 of the women had HIV tests, and two (0.9% (95% confidence interval 0% to 2.1%)) were infected with HIV-1. Reported use of condoms was high for commercial clients and low for non-paying partners: 98% (251/255) of women used condoms with all clients and 12% (25/207) with non-paying partners for vaginal intercourse. Twenty two women were current or past injecting drug users. Of the 193 women examined for sexually transmitted infections, 27 had an acute infection (gonorrhoea, chlamydia, trichomonas, or primary genital herpes) at the time of interview. Infection was associated with younger age and increasing numbers of non-paying sexual partners, but not with duration of prostitution, numbers of clients, or reports of condom failures. When age and numbers of non-paying partners were analysed by logistic regression they remained significantly associated with sexually transmitted infections. CONCLUSIONS--A large and diverse sample of prostitutes had a low prevalence of infection with HIV and high levels of use of condoms in commercial sex. There was a significant risk of other sexually transmitted infections associated with prostitutes non-commercial sexual relationships, in which unprotected sex is common. Interventions to reduce the risk of sexually transmitted infections in prostitutes should address both commercial and non-commercial sexual partnerships.

Prostitution and risk of HIV: male partners of female prostitutes.

OBJECTIVE--To describe risk behaviours for infection with HIV in male sexual partners of female prostitutes. DESIGN--A cross sectional study. SETTING--Genitourinary medicine clinic, St Marys Hospital, London. SUBJECTS--112 self identified male sexual partners of female prostitutes: 101 who reported commercial sexual relationships only, five who reported non-commercial relationships only, and six who reported both commercial and non-commercial relationships. MAIN OUTCOME MEASURES--Reported risk behaviours for infection with HIV. RESULTS--Of the 40 men who had had previous HIV tests or were tested during the study, two (5%) were infected with HIV. Of the men who would answer the questions, 34/94 reported having sex with other men, 2/105 reported using injected drugs, 8/105 had a history of blood transfusion, 14/108 reported a past history of gonorrhoea, 44/102 reported paying for sex abroad, and 8/92 said that they had also been paid for sex. Of the 55 men who reported paying for vaginal intercourse in the past year, 45 (82%) said that they had always used a condom. In contrast, of the 11 non-paying partners of prostitutes, only two (18%) reported ever using a condom with their partners. CONCLUSIONS--Men who have sex with female prostitutes cannot be assumed to be at risk of infection with HIV only by this route: homosexual contact may place them at greater risk. Despite the heterogeneity among male sexual partners of prostitutes, patterns of use of condoms were uniform when they were considered as a reflection of the type of relationship a man had with a female prostitute rather than a consequence of an individuals level of risk.

Thrombolysis in patients with diabetes

Any junior doctor treating a patient with diabetes mellitus and an acute myocardial infarction faces a dilemma. Lists of cautions and contraindications for thrombolytic treatment usually include diabetic retinopathy. The reasonable fear of precipitating a vitreous or retinal haemorrhage helps to explain why fewer diabetic than non-diabetic patients are given thrombolysis.1 2 Funduscopy is not, however, easy in a brightly lit receiving room after the administration of opiates. Even after mydriatic drops are given it may not be possible definitely to exclude changes in the eye. The next hurdle to face after making the decision to give thrombolysis—or not—is to justify ones actions on the post-take ward round.nnThe British National Formulary states that diabetic retinopathy is a contraindication to thrombolysis, …

Violence towards female prostitutes

Editor—Edwards et al point out that the main cause of HIV in prisoners is injecting drug use.1 Work done in Scottish prisons indicates that 4% of the male prison population have continued their previous community injecting practices and 8% of male prisoners start injecting in prison.2,3 n nMeasures for reducing viral transmission in the community, such as needle exchange, are not available in British prisons. It is possible, therefore, that many of the prisoners referred internally had contracted HIV by sharing injecting equipment while incarcerated. The recommendation by Edwards et al that HIV status should be confirmed in all prisoners should therefore be qualified with a recommended frequency. Although, as Edwards et al point out, prison provides an opportunity for inmates to receive care for bloodborne viral disease, which is provided, it also provides an opportunity for prevention which is not provided beyond advice and bleach tablets. I demonstrated the feasibility of a behavioural technique by using buprenorphine in a secure delivery device successfully to prevent injecting in a Scottish prison in 2000; further evaluation of this (or any other harm reduction measure) has been eschewed by those who have the administrative authority to address this important issue. It is admirable that Kings College Hospital provides care for prisoners with HIV, but prisoners will continue to be at risk until the government admits that prisons are state sponsored culture media for bloodborne viruses.

Widespread use of condoms and low prevalence of sexually transmitted diseases in Danish non-drug addicts.

Dr. Kim Krogsgaard and colleagues (December 6 p. 1473) document the low prevalence of human immunodeficiency virus (HIV) infection among a group of prostitutes studied in Copenhagen. The study is limited because the authors investigated only those women working in massage parlors and escort agencies. These women represent only a small number of the workplaces generally associated with prostitution. Because sexual practices and the potential range of infection vary with the type of prostitution it would be inaccurate to draw any very general conclusions from this study. Notably lacking are any investigations into the most common infections Chlamydia trachomatis and Neisseria gonorrhea. Consequently it is hard to find any evidence for the conclusion that there is a low prevalence of sexually transmitted diseases in Danish nondrug addict prostitutes. The authors conclude further that the widespread use of condoms may be responsible for the low rates of infection. They mention that only 3 of the 101 women studied engaged in vaginal intercourse without a condom which means that all the other 98 do use condoms during intercourse. Since this is unusually high a comment would have been expected. Any information about condom use requires detailed prospective records because reports of 100% condom use in 1 random interview are rarely supported in records created over a number of meetings. Finally nothing is said about prostitutes other sexual relationships. In our own studies very few women report condom use with their nonpaying partners (unpublished data). (authors modified)

Prostitution and risk of HIV: Female prostitutes in London

OBJECTIVEnTo measure the prevalence of HIV and to describe established risk factors in female prostitutes.nnnDESIGNnA cross sectional survey.nnnSETTINGnA genitourinary medicine clinic, streets, and magistrates courts in London.nnnSUBJECTSn280 female prostitutes recruited between April 1989 and August 1991.nnnMAIN OUTCOME MEASURESnInfection with HIV-1, reported risk behaviours, and prevalence of sexually transmitted infections.nnnRESULTSn228 of the women had HIV tests, and two (0.9% (95% confidence interval 0% to 2.1%)) were infected with HIV-1. Reported use of condoms was high for commercial clients and low for non-paying partners: 98% (251/255) of women used condoms with all clients and 12% (25/207) with non-paying partners for vaginal intercourse. Twenty two women were current or past injecting drug users. Of the 193 women examined for sexually transmitted infections, 27 had an acute infection (gonorrhoea, chlamydia, trichomonas, or primary genital herpes) at the time of interview. Infection was associated with younger age and increasing numbers of non-paying sexual partners, but not with duration of prostitution, numbers of clients, or reports of condom failures. When age and numbers of non-paying partners were analysed by logistic regression they remained significantly associated with sexually transmitted infections.nnnCONCLUSIONSnA large and diverse sample of prostitutes had a low prevalence of infection with HIV and high levels of use of condoms in commercial sex. There was a significant risk of other sexually transmitted infections associated with prostitutes non-commercial sexual relationships, in which unprotected sex is common. Interventions to reduce the risk of sexually transmitted infections in prostitutes should address both commercial and non-commercial sexual partnerships.