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Behaviour
Knowledge, attitudes, sexual practices and STI/HIV prevalence in male sex workers and other men who have sex in Tel Aviv, Israel: a cross-sectional study
  1. Zohar Mor1,2,
  2. Michael Dan2,3,4
  1. 1Ramla Department of Health, Ramla, Israel
  2. 2Levinsky STI Clinic, Tel Aviv Department of Health, Tel Aviv, Israel
  3. 3Infectious Disease Unit, Wolfson Medical Centre, Holon, Israel
  4. 4Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
  1. Correspondence to Dr Zohar Mor, 3 Danny Mass St., Ramla 72100, Israel; zohar.mor{at}rml.health.gov.il

Abstract

Objective To explore knowledge, attitudes and sexual practices of male sex workers (MSW) in Tel Aviv in comparison with men who have sex with men (MSM) classified by their risk behaviours and to outline attributes related to sexually transmitted infections (STI)/HIV prevalence.

Methods MSW were recruited for this cross-sectional study from designated street venues and gay-dating internet site. MSM were recruited from gay-related venues and divided into high-risk MSM (HRMSM) if they performed unprotected anal intercourse in the last 6 months with an HIV-discordant/unknown partner and to low-risk MSM (LRMSM). Each participant completed a questionnaire and was tested for STI/HIV.

Results Of 87 MSW and 635 MSM approached, 53 (60.9%) and 235 (37.0%) participated, respectively. Street-MSW (N=32) had more female sex partners and were more drug dependent than internet-MSW (N=21). No differences were found in their knowledge regarding STI/HIV transmission, practices and STI/HIV burden. Compared with HRMSM, MSW had different demographic attributes and demonstrated more realistic perception regarding the risk to getting STI/HIV, while no differences were found in their knowledge and sexual practices. STI burden among MSW, HRMSM (N=119) and LRMSM (N=116) were 28.3%, 23.5% and 10.3% (p=0.009) and HIV burden among MSW, HRMSM and LRMSM were 5.6%, 9.2% and 0%, (p=0.001), respectively. Multivariate models evaluating attributes associated with HIV/STI diagnosis did not find sex work to be significant if the variable used was MSW versus HRMSM, regardless of the adjustments performed. However, when MSW versus LRMSM was used in the model, sex work was associated with STI/HIV diagnosis.

Conclusions Street-MSW and internet-MSW, similar to all MSW and HRMSM, had comparable sexual practices and had no difference in their STI/HIV prevalence.

  • HIV
  • Israel
  • male sex workers
  • men who have sex with men
  • sexual behaviour
  • AIDS
  • sexual behaviour
  • gay men
  • vaginal infections
  • UTI
  • infectious disease
  • vulvovaginitis
  • vaginal candida

https://doi.org/10.1136/sextrans-2011-050290

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    Introduction

    Men who have sex with men (MSM) account for 34% of all men living with HIV/AIDS in Israel.1 The number of MSM newly diagnosed with HIV has tripled in Israel during the last decade, as well as their proportion of all new men reported annually with HIV/AIDS.2 Likewise, MSM presented higher rates of sexually transmitted infections (STI) than heterosexuals in the walk-in STI clinic in Tel Aviv,3 as has been reported from other industrialised countries.4 ,5

    Male sex workers (MSW) are not considered a distinct ‘risk group’; however, several populations indicate that MSW are often associated with a cluster of risk behaviours,6 ,7 including high rates of anal sex8 and inconsistent condom use.9 Therefore, MSW are more vulnerable to STI/HIV infections10 and may play a central role as core group transmitters, thus potentiating STI/HIV transmission in the community.

    Prostitution itself is not criminalised in Israel, however, soliciting and pimping are illegal. Tel Aviv, the largest metropolitan city in Israel, attracts most of the gay-related activities in the country: openly gay communities, gay-oriented establishments and community-based organisations. Commercial male sex is also present, mainly in a designated street venue situated in the southern part of the city and also in a popular Israeli gay-dating website.

    The aims of this study were to collect data on MSW's demographic characteristics, knowledge regarding STI/HIV transmission, attitudes related to safe sex, information about their sexual practices and STI/HIV prevalence and to compare the findings with other subgroups of MSM recruited from public gay-related venues, who were classified by their risk behaviour. This is a necessary step in developing interventions that target MSW and other MSM at high risk in Tel Aviv, Israel.

    Methods

    This cross-sectional study included a questionnaire completed individually and the biological sampling of each participant.

    Setting

    The study was performed between July and December 2007. Participants were approached by the medical staff of the mobile unit (van) of the Levinsky STI clinic. The staff visited popular gay-oriented venues (bars, clubs, bathhouses, gay parks and a designated street location, where MSW searched for clients) and also private apartments of the MSW. Study participants were sampled using venue-based time-space sampling methods.11 In short, seven gay-related venues in Tel Aviv were identified as sites frequently attended by MSM and MSW, including days and the evening hours when these venues were frequented. These gay-related venues were visited randomly on a late-night weekend schedule. Each second man who entered the venue that night was approached by the researchers and invited to participate in the study. MSW who offered sex explicitly in the popular gay-dating website (http://dating.atraf.co.il/) were identified by the outreach team. Prior to each visit of the van to the gay-related street venues, the outreach team made an electronic contact with MSW who offered sex for pay in this internet site. Each second MSW who was contacted electronically was offered a home visit by our medical staff.

    Participants

    Men were eligible to participate if they were older than 18 years, reported at least one episode of oral or anal intercourse with another man during the last 6 months and could complete individually the study questionnaire in Hebrew. All study participants were divided into MSW or MSM.

    MSW were men who self-identified themselves as being currently engaged in commercial sex with men. They were classified by the location in which they searched for clients: (1) street-MSW and (2) internet-MSW. MSM were classified according to their sexual risk behaviour. MSM were asked about their sexual behaviour12–14 in the last 6 months15 ,16 and classified into: (1) high-risk MSM (HRMSM) were men who performed unprotected anal intercourse (UAI) with one or more male sex partners without knowing theirs or their partner's HIV status and also in cases in which the UAI was performed with an HIV-discordant partner and (b) low-risk MSM (LRMSM) were other eligible men who performed sex with another male/s in the last 6 months but were not HRMSM. The characteristics of street-MSW and internet-MSW, as well as HRMSM and LRMSM, were compared. In order to evaluate attributes related to risk behaviour and STI/HIV prevalence of MSW, they were further compared with those of HRMSM.

    Variables

    Two primary outcomes were assessed: risky sexual behaviour and the prevalence of STI/HIV infections. All study participants were also divided into those infected with STI/HIV and those who were STI/HIV free. A sample larger than 50 MSW was required to detect a difference >10% in STI/HIV prevalence between MSW and MSM (see web appendix 1 for sample size calculation).

    Questionnaire

    After participants provided informed consent, they individually completed a 64-question anonymous survey, which was adopted from similar studies focusing on MSW,9 ,17 ,18 adjusted to the Israeli environment and previously piloted on eight MSW who had visited the Levinsky STI clinic (see web appendix 2 for study questionnaire). The questionnaire included personal characteristics of the participants, their sex trade and their non-commercialised sexual practices, substance-use habits, self-reported domestic violence, being abused as a child, incarceration history and previously diagnosed STI. All MSW were offered US$30 vouchers to be used in a pharmaceutical chain to reimburse them for their time spent.

    Independent variables were categorised into demographic, personal history and behaviour. The knowledge regarding HIV transmission was measured by grading the response to the following four questions as 1 in case the participant responded correctly and as 2 in case the participant responded incorrectly15 ,16: ‘Anal sex without a condom is more dangerous than oral sex’, ‘Digital sex is a possible route to transmit HIV’, ‘Insertive oral sex is a safe practice regarding HIV infections’ and ‘Body massage is a safe practice regarding STI’ (α=0.74). The gradings for all the knowledge questions of each participant were summed to create a continuous composite score: the lower the score, the better was the knowledge.

    The attitudes reflecting risk perceptions were measured by grading the responses for the following six questions as 1 in case the participant chose the preferable answer and as 2 in case the participant chose the unfavourable response15 ,16: ‘I am not using condoms because I am too horney’, ‘I may not use condoms because the treatment for HIV is reliable’, ‘I am afraid of getting HIV’, ‘Sex with a condom may be enjoyable’, ‘I am a risk taker’ and ‘Condoms are the best way to protect myself’ (α=0.82). The gradings for all the attitude questions were summed to create a continuous composite score: the lower the score, the more conscious was the participant with the potential risks he takes.

    Measurement

    All respondents were offered anonymous STI/HIV testing and provided us their mobile phone numbers for notification in case the results were positive. Each participant was identified by a unique code, which was used for the questionnaires and for the biological samples. Laboratory tests taken at the venue included HIV and syphilis serology, urine PCR for urethral Neisseria gonorrhoea and Chlamydia trachomatis and pharyngeal culture for N gonorrhoea (see web appendix 3 for laboratory procedures). Participants could contact the clinic to get their testing results, and those who had positive laboratory results were actively contacted by the clinic and were offered free treatment at the clinic.

    Statistical methods

    Comparisons of risk behaviour and morbidity between MSW and MSM were performed using χ2 tests for association of categorical variables or the Fisher's exact test. Continuous variables were analysed by Student t test or by Mann–Whitney non-parametric test for variables distribution abnormally. In order to identify variables predicting to remain STI/HIV free, the factors associated with STI/HIV diagnosis in the bivariate analysis at two-sided p values ≤0.05 were retained in the multivariate analysis in four blocks after assessing for collinearity and normal distribution. First block included engagement in sex work (MSW or MSM), type of MSM (HRMSM or LRMSM) and risk perception; the second block composed of demographic variables; the third block consisted of life history events and the fourth block included sexual behaviour in the last 6 months. These variables were eliminated one by one in a backward fashion, based on the adjusted ORs in order to develop a model with the strongest relationships, generating ORs and 95% CIs. Logistic regression for the risk of testing positive for STI/HIV after examining for possible interactions was performed by adjusting the model into different determinants to find if sex work is related to morbidity. Analysis was conducted by SPSS V.14.0 package for Windows Software (SPSS Inc.). The study was approved by the E. Wolfson Medical Centre review board (approval number: WOMC-802/07).

    Results

    During the study period, the mobile STI unit performed 34 late-night visits and approached 87 MSW and 635 MSM. Of those, 53 (60.9%) MSW and 235 (37.0%) MSM finally participated in the study.

    Male sex workers

    Of all MSW, 32 (60.4%) were recruited while searching for clients in the designated street venue, while 21 (39.6%) had offered commercial sex only on the internet. Compared with internet-MSW, a greater proportion of those who were street-MSW were born outside of Israel (nine in the former Soviet-Union (Russia, the Baltic states and the Euro-Asiatic Republics separated from the Soviet Union) and four in the Palestinian National Authority), did not have stable housing, used substances and were previously incarcerated (table 1). Street-MSW were also more likely to identify themselves as heterosexuals and more likely to report female steady partners with whom they performed unprotected vaginal sex than internet-MSW, while they generally felt less comfortable about their sex work. No statistical differences between internet- and street-MSW were found in their reported sexual practices with the clients or with STI/HIV prevalence (table 2).

    View this table:
    Table 1

    Demographics and personal history characteristics of MSW, by venue of recruitment and of other MSM, by risk group

    View this table:
    Table 2

    Behaviour, attitudes and STI/HIV prevalence of MSW, by venue and other MSM, by risk group

    Men who have sex with men

    Compared with LRMSM, a greater proportion of HRMSM lived in Tel Aviv, were less educated, had lower income, were more likely to be attracted to both sexes and were exposed to domestic violence and reported previous diagnoses with STI (table 1). In addition, HRMSM were less knowledgeable about HIV transmission routes, less likely to identify themselves as gays, reported more UAI and also had anal or oral ejaculation, defined themselves as risk takers and had higher prevalence of HIV or infectious syphilis (table 2). More than 8% of all MSM reported ever having been paid for sex, although they did not consider themselves as MSW.

    MSW compared with HRMSM

    Relative to HRMSM, a greater proportion of MSW were born outside of Israel, were less educated, reported lower income and were exposed to domestic violence (table 1). MSW reported more unprotected vaginal intercourse, while HRMSM reported more UAI. Additionally, MSW used substances more often, paid for sex themselves and were more conscious with the potential risks they took than HRMSM. No statistical differences were found between MSW and HRMSM in their knowledge regarding STI/HIV transmission or in their STI/HIV infection rates.

    STI/HIV among participants

    Study participants who were STI/HIV infected were older than those who were not infected and also were more likely to be born outside of Israel, were more commonly exposed to domestic violence, had prior STI, were previously incarcerated, had a greater number of sexual partners, performed riskier sexual practices, used substances and had a more realistic risk perception (table 3).

    View this table:
    Table 3

    Characteristics of men diagnosed with STI* or HIV

    Multivariate models evaluating attributes associated with HIV/STI diagnosis did not find sex work to be significant if the variable used was MSW versus HRMSM, regardless of the adjustments performed. However, when the variable MSW versus LRMSM was used in the model, sex work was then found to be associated with STI/HIV diagnosis in all the adjustments performed (table 4).

    View this table:
    Table 4

    Logistic regression model for HIV/STI infection in different risk groups

    Discussion

    MSW who search for clients on the street had different personal and behavioural characteristics from MSW who solicit on the internet. Yet, both types of MSW performed similar sexual practices, exposing them to the same risks for acquiring STI/HIV.

    While this study depicts the sexual health of MSW in Israel for the first time, it is subject to several limitations. First, MSW and other MSM recruited from the streets and gay-related venues were sampled, thereby the findings may not be representative of the larger community of MSW or MSM. Second, those who were self-identified as transsexuals were excluded from this research, as we felt it needs specialised study instruments and a different approach. Third, the study is subject to reporting or to recall bias. We therefore shortened the original classification of HRMSM from 1 year12–14 to 6 months.15 ,16 Fourth, the results of this study are limited by the small sample size due to stigmatisation of sex work, which is hidden in most instances. Fifth, the questionnaire was available in Hebrew only, thus missing individuals who were not able to read the questions individually. Lastly, the issue of temporality should be considered while interpreting the results due to the cross-sectional nature of this study. Limitations notwithstanding, there is value in assessing the local commercial sex environment in Israel, including MSWs' practices, risk behaviours and STI/HIV burden relative to other MSM for initiating crucial STI/HIV prevention interventions.

    While internet-MSW commonly used ‘recreational’ drugs, street-MSW were most likely to be drug dependent, which was probably the main motivation for their engagement in sex work, as expressed by the MSW themselves in our study, a lucrative endeavour used as a survival strategy. They also reported additional social complexities than the internet-MSW, such as prior imprisonment, consistent with another study performed in Israel focusing on MSW.19

    MSW in our study reported high rate of UAI with the clients (60.4%), while their STI/HIV prevalence was lower than studies performed elsewhere.18 ,20–22 Although condom use among MSW in our study was inconsistent, it seems that the overall lower HIV burden in Israel in comparison to other countries23 and the high rate of circumcision may have reduced their odds of infection. Our findings are compatible with another study performed among female sex workers in Tel Aviv, Israel, indicating low HIV rate (0.9%).24

    Street-MSW more commonly reported steady female partners and more likely to identify themselves as heterosexuals, which may explain their complex attitudes towards sex work. Both types of MSW reported inconsistent condom use with their non-commercial steady partners during anal or vaginal intercourse, exposing their partners to possible STI/HIV, if acquired during sex trade, as found in other studies.25 Internet-MSW were more likely to have higher education and were more commonly identified as gays than street-MSW. It seems that the attitude of internet-MSW towards sex work was more tolerant, as their feelings towards the clients were less negative than that of street-MSW, and they considered themselves to be more mobile to leave sex work at their discretion. It is also that internet-MSW could be more selective about their clients, charge more for their services and have a greater control of their ‘work’ schedule.25

    The most frequent practice performed by MSW was fellatio and more commonly involved customers performing oral sex on the sex worker, as found in other studies.19 Although oral sex is considered a relatively safe sex practice, it may expose the MSW to STI, such as syphilis and pharyngeal gonorrhoea, and even to HIV in cases when buccal ulcers or gingivitis are present, conditions that may be common among street and drug-dependent individuals.26 No statistical difference was found in STI/HIV prevalence between the two types of MSW, even though street-MSW were exposed to HIV and other blood-born STI also by drug injection in addition to the sexual risk. All study participants who were diagnosed with STI received counselling and treatment by the medical staff in the van, while those who had positive HIV result were referred to the AIDS clinic.

    MSW were different from HRMSM in most components related to their demographics and life history events. However, unlike preliminary assumption of most researchers studying MSW, their sexual risk behaviour as demonstrated in our study was not different from that of HRMSM. Moreover, no significant differences in STI/HIV burden were found between MSW and HRMSM. These findings shed a light on the sexual behaviour of this subset group of HRMSM, which is not less risky than that of MSW. HRMSM in our study take risk in their promiscuous sex life, while MSW usually use condom with their clients. It seems that condom provides MSM protection against STI/HIV and also detaches them from the clients' body and gives them a sense of control. Yet, MSW are at risk of their sexual behaviour outside of the context of sex work, which is often less safe, as they engage in other risk activities, like illicit drugs, which is linked to increased sexual risk.27

    High-risk sexual behaviours among MSM were described in the previous studies performed in Israel.15 ,16 The findings that 8.1% of all MSM reported that they have ever received pay for sex sometime in the past, conveying the mobility between prostitution and ‘normative’ gay life and the intermittent participation of MSW in sex work.

    It may be that MSW are not a risk group per se, as many similarities in risk behaviour and in STI/HIV burden were found between MSW and HRMSM. Optimal prevention interventions aiming to change sexual risk and to decrease UAI should therefore address other behavioural determinants and social vulnerability related to the risk of STI/HIV infections. For example, substance use and additional contextual and psychological issues, such as particular life events (violence, being abused during childhood), lower socioeconomic status and education should be addressed rather than focusing the intervention.

    Finally, more than 20% of all study participants have never been tested for HIV. This study demonstrates the achievement of our community mobile unit to draw out the hard-to-reach populations, who otherwise may have not been tested.28 As the study was performed in public venues rather than a medical setting, its findings can be used as a rough estimation of the prevalence of STI/HIV among MSM in Tel Aviv.

    In conclusion, street-MSW and internet-MSW shared comparable sexual practices and no difference was found in their STI/HIV burden. Likewise, MSW and HRMSM had comparable sexual practices and no difference in STI/HIV prevalence. Future studies should focus larger sample of MSW and assess behavioural changes and STI/HIV incidence longitudinally. Prevention interventions aiming to decrease STI/HIV in MSM should focus on personal characteristics, knowledge and attitudes towards safe sex rather than concern about their involvement in commercial sex.

    Key messages

    • Street-MSW were more likely to be non-Israeli born, not having stable housing, used substances, previously incarcerated and had steady female partners than internet-MSW.

    • STI/HIV-infected participants were relatively older, non-Israeli born, had prior STI, previously incarcerated, used substances and had a more realistic risk perception than non-infected participants.

    • A subset of gay men, who performed high-risk practices, had higher STI/HIV prevalence than MSW.

    Acknowledgments

    The authors would like to thank the field workers Shlomi Unger, Yfat Ben-David, Uri Yanetz, the van driver Natan Bonfiesse and the clinic staff: Raya Pozayluv and Anna Bar-Natan. We express our gratitude to Professor Tamy Shohat for her professional advices and to Ms Yael Goor for her support. We are also indebted to Dr Nira Koren-Morag for her exceptional statistical assistance. We wish to extend our appreciation for Ms Judy Brandt for her English editing, word processing expertise and contributions.

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    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

      Files in this Data Supplement:

    Footnotes

    • Funding This study was financially supported in part by a grant from the Institute of International Education, Washington, DC, USA.

    • Competing interests None.

    • Patient consent Obtained.

    • Ethics approval Ethics approval was provided by the Wolfson Hospital, Holon, Israel.

    • Provenance and peer review Not commissioned; externally peer reviewed.