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Try out PMC Labs and tell us what you think. Learn More. Information characterizing their practices, contexts where they live, and their needs is very limited, as these men are generally included as subsets of larger studies focused on gay men and other men who have sex with men MSM or even female sex workers.

MSW, regardless of their sexual orientation, mostly offer sex to men, and rarely identify as sex workers, using local or international terms instead. There are several synergistic facilitator spotentiating HIV acquisition and transmission among MSW, including biological, behavioural, and structural determinants.

These contexts, taken together with complex sexual networks among MSW, define them as a key population underserved by current HIV prevention, treatment, and care services. Dedicated efforts are needed to make those services available for the sake of both public health and human rights. Men who sell sex for money or goods MSW comprise an extremely diverse population across regions and within countries worldwide. They should be considered a completely different group from transgender women engaged in sex work, as the latter have clearly different needs from those of gender-conforming men who sell sex and are covered in the review by Poteat et al.

Moreover, the majority of studies of male sex work as a risk factor for HIV and STI have focused on typically younger, lower income men offering sex to older gay or bisexual men in exchange for food, gifts, drugs, shelter or other means of economic support. The growing HIV epidemics among gay men and other MSM are driven by a range of biological and structural factors that have been well characterized 3and HIV epidemics among men who sell sex to other men are occurring in that context, although with specificities we will seek to identify in this paper.


Moreover, communities of gay men and other MSM are emerging in an increasingly globalized world where new forms of, and strategies for, male-offered commercial sex are becoming possible in urban centers and tourist destinations, including the enormous reach and versatility facilitated by new communications technology 4. While clients of MSW include women, commercial heterosexual sex is likely a small fraction of all commercial sex offered by men, as conditions for women to buy sex are likely far more restricted around the world. In addition, HIV acquisition and transmission risks for men who sell sex only to women are also different from those affecting other MSW.

Consequently, for this review we will focus mainly on adult men who sell sex mostly to other men or to transgender women, age 18 and older, and not include transgender persons. Moreover, this synthesis of information characterizing men who sell sex leverages data from different regions of the world characterizing the forms and contexts in which men aged 18 and older sell sex, risk factors for the acquisition and transmission of HIV ranging from individual-level risk factors to structural drivers of HIV-risk, and existing and potential future HIV prevention approaches for these men.

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A limited of ethnographic studies have generated data characterizing MSW in most parts of the world, and some pioneering studies of the field were undertaken in the mid-late s 56. Historically, commercial sex for a man, selling sex either to women or to men has been less commonly documented as a social phenomenon due to a combination of likely less population-level demand and lesser social acceptability for this form of commercial sex. Importantly, others are not necessarily sexually attracted to men, and do not identify as gay or bisexual; in many locations, several men who sell sex have regular female partners or have formed heterosexual families 9 but sell sex to men for a variety of reasons.

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In some cases, this may be a last resort to deal with poverty and the lack of opportunities; in other cases, it may be a relatively easier source of income. In some cases, minors are forced or coerced into commercial sex and adapt to it. HIV among MSW should not, then, be regarded as an isolated problem; rather it is a compelling example of the need for comprehensive HIV responses that address the needs of this diverse group. Median HIV prevalence among male sex workers reported from 8 European countries between and was 7.

Data were available from five African countries, presenting a median HIV prevalence of Studies and surveillance characterizing the incidence of HIV among MSW are critical to better understanding the complex dynamics of HIV acquisition and transmission among these men across different time periods. However, the phenomenon of observing higher prevalence of HIV as compared to other MSM is not consistent across regions and possibly reflects a differential sex roles assumed by sex workers in certain regions; b differential frequencies of condom use; c diverse baseline prevalence among MSM; and d diverse levels of representativeness of those figures; and e potentially over sampling of younger men who have limited cumulative HIV acquisition periods.

These differences likely express differential risk levels among these diverse populations. MSW reported ificantly more non-work sexual partners than FSW, but were less likely Craigslist Baltimore MD sex services report unprotected anal intercourse with non-paying partners than were other MSM Garrett Prestage, personal communication.

While money boys had more male partners than MSM, they were also more likely to report consistent condom use, especially in commercial sex. Taken together, these data highlight the need for improved prospective surveillance of HIV and other STIs among male sex workers. Younger MSW may be more likely to be sampled representing potentially higher HIV incidence with limited population-level incidence. To support appropriate interpretation of comparisons of the burden of HIV among male sex workers to that of other MSM or even that of other men, age-stratified HIV incidence data are needed.


Globally, the sample size of data reported to UNGASS ranges from a few participants to thousands of participants, with data sources of varying quality. This complicates comparisons across countries or regions and interpretations of trends. For instance, less than ten participants were included in the reports from diverse settings including Cape Verde, Cameroon, Algeria, Romania, and Kyrgyzstan.

In addition, many of these studies include transgender women under the MSW indicator, further confounding interpretation. For example, while Pakistan reported data specifically on the indicator for MSW, the study was focused nearly exclusively on hijras considered a third gender in India and Pakistan While the extramural peer-reviewed research listed here does not share the same biases as country-reported data, there are several methodological limitations that hinder inferential conclusions drawn from these studies, including varying, often unsophisticated sampling strategies pertinent data are generally derived from convenience samples with limited generalizability to the broader population of MSW ; and the lack of a standard behavioral recall window e.

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Moreover, the increasing trend of sex work transitioning from being street-based to internet-based further complicates the identification, sampling, and assessment, limiting the scientific rigor of epidemiological research With these caveats posed by the proportion of partners of different types and risk practices by partner types, the epidemiological data suggest that MSW globally remain at very high risk for HIV acquisition and transmission, even compared to other high risk populations. In this regard, we recommend five changes to MSW-specific data collection and reporting to support country-led programming.

Second, surveillance guidelines should specifically suggest distinguishing between lifetime sex work and current past-year sex work to facilitate better estimations of MSW prevalence in communities and associations between past sex work and current HIV-related health outcomes.

Third, ensuring that risk transmission encompass multiple options will allow for better distinctions among populations with intersecting risk behaviors e,g.

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Fourth, better quantification of MSW-specific risks could be achieved by assessing commercial sexual risk by partner type and sex e. Finally, assessing career duration and sex work frequency of paid sexual acts may contribute to better understanding of dose-response associations between selling sex and HIV transmission risk, and provide useful context for optimal intervention delivery. While this level of disaggregation may not be necessary for all agencies tracking the burden of HIV, these indicators would support organizations and agencies focused on the implementation and evaluation of programs supporting male sex workers.

Several approaches are available to assess determinants of risk and vulnerability to HIV in specific populations and contexts.

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The modified social ecological model MSEM composed of multiple layers of risks for HIV acquisition and transmission ranging from individual level characteristics such as biological and behavioral factors that potentiate HIV infection, characteristics of sexual networks, community level determinants including access to HIV prevention services and potential barriers to those services, and finally the national policies that potentiate or mitigate the potential coverage of HIV prevention, treatment, and care programs for male sex workers Subsequently, syndemics theory 30 facilitates understanding of how these disparities and consequent psychosocial health conditions further predispose MSW to increased HIV risk compared to other MSM populations Table 2.

History of commercial sex and prevalent HIV infection among men who have sex with men, — These biological risks have been well characterized and include the efficient transmission of HIV during unprotected anal intercourse.

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MSW are characterized by high s and frequencies of male partnerships resulting in large and non-dense sexual networks which have both been established as risk factors for HIV among MSM 3. These risks have also been characterized in some countries among MSW such as Nigeria and Kenya 31 Similarly, the limited supply of condom-compatible lubricants CCL in many low and middle income countries may further increase risks among MSW There are several themes that emerge across regions when reviewing HIV risks affecting individual MSW including economic disparities, sexual and physical abuse, drug use, and low socioeconomic status as well as the occupation-related risks associated with commercial sex.

In many places and contexts, some MSW report high levels of background adversities, including sexual and physical abuse 18 ; homelessness 35 ; and low educational attainment Furthermore, MSW are more likely than other MSM to report racial and sexual minority statuses, 18 which are associated with higher likelihood of serodiscordant sexual partnerships in many high income settings such as the United States and the United Kingdom One of the most consistent findings among MSW is the ificant reporting of concurrent substance use among Craigslist Baltimore MD sex services men ranging from alcohol to injecting drug use.

Alcohol use in Kenya and injecting and non injecting drug use in Asia have been shown to be associated with higher risk sexual acts among MSW Occupational health risks among MSW have been shown in North America to include conditions of economic necessity fomenting unprotected sex 43 ; sex with multiple partners; sexual role versatility, depending on client preferences; and sex with male, female, and transgender partners, as well as reciprocal sex exchange — purchasing sex from other sex workers Potentiating the high acquisition and transmission risks associated with UAI are the high burden of prevalent and incident genital ulcerative diseases.

In some countries of Latin America and the Spanish speaking Caribbean, sex workers are often offered free medical check-ups at public health clinics Consequently, there may be ificant levels of non- or minimally symptomatic STIs among these men given that condom use is less effective in preventing these infections as compared to HIV.

While there is limited research of youth and adolescent men selling sex because of the complexity in ensuring appropriate informed consent, and the additional legal issues involved, many MSW across a of regions report initiating sex work at young ages, sometimes under coercion or force The high prevalence of HIV observed among men in their late teens and early twenties in many places, suggests that HIV acquisition risks are likely ificant during adolescence for some of these men.

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At the community level, risk may be mitigated by available HIV prevention, treatment, and care services if barriers to the uptake of those services are removed. Stigma acts by devaluing, labeling, and stereotyping MSW resulting in the loss of status, unfair and unjust treatment, and social isolation of these men MSW often face intersecting stigmas: having sex with other men; engaging in illegal sexual activity; presumption of HIV infection, drug use; and differential socioeconomic status among racial minorities.

The illegal nature of sex work in much of the world, coupled with the likelihood of male sexual partners, engenders an environment of multi layered marginalization.

Even in locales with high acceptance of sexual diversity, the commercial nature of sex work creates a milieu removed from traditional gay community norms, which according to power dynamics may favor riskier sexual practices The majority of public policies affecting MSW represent structural barriers to care rather than improving access to it.

Broadly, there are three main of criminalization that intersect with male sex work including the criminalization of sex work, the criminalization of same-sex practices, and the criminalization of non-disclosure of HIV infection. These policies or stigmatizing contexts may also drive emigration of MSW to countries with supportive legislation and improved working environments The relationship between criminalization of same-sex practices and difficulty in researching and addressing the HIV prevention, treatment, and care needs of MSM has been well described in the literature.

Finally, the criminalization of non-disclosure of HIV infection is relevant to MSW in many countries as a potential barrier to the uptake of HIV-related services including testing A recent report from Human Rights Watch in Tanzania found multiple s of rape of male sex workers by police further highlighting the limited repercussion of rights violations affecting these men The general lack of legal recourse after violence observed in numerous settings, limited economic resources, and increasing tendency to use condom-carrying as evidence of sex work all further complicate safer male sex work.

Despite the high burden of HIV infection and elevated risk status, limited intervention studies have specifically addressed the needs of MSW Table 3. Few randomized controlled trials have assessed interventions developed to help MSW reduce their HIV Craigslist Baltimore MD sex services, though many interventions for MSM and female sex workers have been tested.

There is a pressing need for HIV prevention programs targeting MSW given the efficient transmission of HIV during anal intercourse and the persistent necessity of high s of sexual partnerships to support income. Given the complex risk environment for these men and akin to other populations, the most effective intervention des likely represent combinations of behavioral, biomedical, and structural approaches. Intervention approaches should probably be very specific to the local contexts, paying attention to the legal framework, levels of visibility as well as specific identities of MSW, and the availability of both general and MSM-focused HIV services.

By no means should interventions expose MSW to public sight — beyond their own choices, and legal threats should be specifically prevented. In various contexts, formative research suggests that individual- and network-level interventions incorporating incentivized harm reduction approaches 53 and access to social services and resources, and medical including mental health care 44 could be coupled with community-level anti-stigma campaigns 54 for maximal effectiveness.

Bio-behavioral approaches that incorporate the use of antiretroviral drugs for pre-and post-exposure prophylaxis PrEP and PEP, respectively likely represent options with ificant utility among MSW As described earlier, some MSW report difficulties negotiating condom use during anal sex with clients or may accept higher rates for unprotected sex. ZIP: 21218 21211 21210 21213 21212 21215 21214 21217 21216 21231 21230 21239 21251 21209 21202 21206 21207 21205 21226 21201 21223 21224 21225 21229 21203 21233 21263 21264 21270 21273 21275 21278 21279 21281 21287 21290 21297 21298

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