The vast majority of HIV studies and preventive programmes directed to commercial sex workers have centred on women. Many female sex workers in western Europe are immigrants.¹ In Spain, HIV prevalence among those who have never injected drugs is below 1%, and no differences have been detected in relation to the country of origin.²

Male sex workers are neither visible nor easy to access. In Spain there are no specific preventive programmes directed to this population group, which may be partially covered by programmes aimed at female sex workers or homosexual men. HIV prevalence among male sex workers has hardly been studied, nor has the presence of immigrant populations. Both aspects need to be investigated in order to design and implement programmes aimed at approaching these groups and preventing HIV among their members.³

We thus aimed to assess HIV prevalence and predictive factors for this infection among male sex workers in Spain.

METHODS

This study is based on a network of 20 HIV counselling and testing clinics, of which 14 also diagnose and treat other sexually transmitted diseases. These clinics are situated in 19 cities with a population of over 100 000 inhabitants throughout the Spanish territory (Alicante, Barcelona, Bilbao, Cartagena, Castellón, Granada, Gijón, Logroño, Madrid, Málaga, Murcia, Oviedo, Pamplona, San Sebastián, Santa Cruz de Tenerife, Santander, Sevilla, Valencia, and Vitoria).

All of them offer voluntary, confidential, and free HIV testing, and some also offer anonymous testing. No legal documents are required, and this facilitates access for immigrants or other groups having difficulties in using the national health service, which is the case with commercial sex workers.

In the present analysis we included all male sex workers who attended these clinics during the years 2000 to 2002. The information was obtained during the examination using a brief questionnaire which included age, country of origin, previous HIV test, heterosexual practices, homosexual practices, transvestite or transsexual, current or previous injecting drug use, and HIV infected sexual partner.

Blood specimens were tested for HIV by an enzyme linked immunosorbent assay, and reactive sera were confirmed by western blot or immunofluorescence. For repeating testers only the last confirmed result was taken into account.

Comparisons of proportions were done with Fisher’s exact test; p<0.05 was considered significant. To measure the association between HIV infection and risk factors, odds ratios (OR) and their 95% confidence interval (CI) were calculated. Logistic regression was used to assess the independent influence of each factor. In this analysis, data were grouped in order to avoid categories with no cases.

RESULTS

Out of 47 922 patients who were HIV tested during the period 2000–2, 11 098 (23.2%) were sex workers, of whom only 418 (3.7%) were men. The average age of male sex workers was 29.2 years (SD 7.3); 67% came from a country of origin other than Spain, the majority from Latin America (91.4%); 41.9% had previously undergone the HIV test in the same clinic, and this situation was more frequent among Spaniards (55.7%) than among immigrants (33.1%) (p<0.001); 96.2% declared they had sex with men; 7.2% that they had had sexual intercourse with a person they knew to be infected with HIV; and 3.3% that they had used injected drugs, a behaviour which was more common with Spaniards (9.2%) than with Latin Americans (0.8%; p<0.01). Seventy six (18.2%) transvestites or transsexual males were identified, of which 40% were Spaniards and 59% Latin Americans.

Among sex workers who attended these clinics, 147 HIV infections were diagnosed, of which 51 (34.6%) concerned men. HIV prevalence among male sex workers was 12.2% (95% CI, 9.3 to 15.8%), and rose to 16.9% with first time testers, versus 5.7% with repeating testers (p<0.0001). The highest HIV prevalence was found among men who knew they had an HIV infected partner (20.0%) (table 1). No differences in HIV prevalence were found concerning transvestites or transsexuals (14.5%) compared with all other male sex workers (11.7%, p = 0.561). The small numbers of injecting drug users, heterosexual men, and individuals from countries other than Spain or Latin America, do not enable us to reach conclusions about the influence of these characteristics. In the multivariate analysis, the HIV prevalence was greater among men who visited the respective clinics for the first time (adjusted odds ratio (OR), 5.2; 95% CI, 2.2 to 12.4) and among those who said they had had sexual intercourse with an HIV infected person (OR, 2.9; 95% CI, 0.9 to 8.9), although this last result was not statistically significant (table 2).

DISCUSSION

Men represented only a very small percentaje of all sex workers who visited HIV testing clinics in Spain; however, they accounted for a third of HIV infections among commercial sex workers. It is known that men use health services less than women,⁴ and that they show a higher tendency to hide their commercial sexual relations. Nevertheless, these results support the idea that male prostitution is a lot less frequent than female prostitution, but that it represents a much higher risk for HIV infection.

The free and easy access to the clinics may have led to an over-representation of the immigrant population, a group with more difficulties in approaching other healthcare facilities. Nevertheless, in a previous study undertaken in Madrid among male sex workers recruited in the street, 35% were found to be immigrants, but in this case, they came predominantly from North Africa.⁵ When compared to Spaniards, immigrants had a lower level of education, made less use of condoms and, in their private lives, a greater proportion reported sexual relationships exclusively with women.⁵ Another article that analysed 132 male transgender street sex workers in Madrid found a proportion of 44% of immigrants, mostly from Ecuador.⁶

The HIV prevalence found among the men included in this study (12.2%) was much larger than that observed among female sex workers (0.8%; p<0.001) and homosexual men (5.1%; p<0.001) analysed in the same network of clinics. Other studies have also described high levels of HIV seroprevalence among male prostitutes contacted in the streets (25%)⁵ or in sexually transmitted infection clinics (11%).⁷ In other cities of the developed world, high but disparate levels of infection have been reported (5%–29%), with variations depending on the proportion of injecting drug users, on work place and sexual practices.^8,9–14

Among sex workers analysed in these clinics, men made up a third of the cases diagnosed with HIV. This shows that although we are dealing with a small population group it can play a significant part in HIV transmission.

The prevalence of HIV infection was greater with men who were tested for the first time than with repeating testers. This must be taken into account when results from different studies are compared. First tests detect both prevalent and recent infections, whereas repetitions only detect recent infections among individuals who had probably received counselling along with the previous tests. The greater proportion of immigrants among first time testers may reflect their recent arrival in Spain.

In the female sex worker category, a greater risk of HIV infection has been reported when a sexual partner is diagnosed with HIV, and this has been attributed to the infrequent use of condoms in non-commercial sexual relations. This circumstance may also hold for the men in this study,^5,6 although the information necessary to evaluate this was not available.

In conclusion, although male sex workers constitute a small population group, they seem to be exposed to high risk situations and may have a relevant role in the transmission of HIV infection among homo/bisexual men, this being supported by their very high prevalence of HIV infection. Thus, male sex workers should be the target of specific preventive activities. Seemingly, the high proportion of sex workers that we found to be immigrants requires the development of educational, social, preventive, and healthcare strategies that are culturally adapted to this group. Studies concerning knowledge, attitudes, and behaviours of male sex workers are necessary to assess appropriate interventions.¹⁵

APPENDIX

The EPI-VIH Study Group: ML Junquera, M Cuesta (Hospital Monte Naranco, Oviedo); JA Varela, C López (Unidad de ETS, Gijón); M Vall, E Arellano, P Saladié, B Sanz, P Amengol, MJ Villena, MJ Alcalde, E Loureiro (Unidad de ETS, CAP Drassanes, Barcelona); MM Cámara, J López de Munain, G Larrañaga, MJ Oiarzabal (Servicio de ETS-Infecciosas, Hospital de Basurto, Bilbao); JM Ureña, JB Egea, C García, E Castro, AM Calzas, M Lorente (Centro de ETS, Granada); JM Lorenzo, X Camino (Plan del Sida, San Sebastian); ME Lezaun, E Ramalle, M Perucha, MJ López, V Ibarra, JA Oteo (Servicio de Epidemiología y Promoción de la Salud, Logroño); FJ Bru, C Colomo, R Martín, A Comunión (Programa de Prevención del Sida, Ayuntamiento de Madrid); J del Romero, C Rodríguez, J Ballesteros, P Clavo, S García, S Del Corral, MA Neila, N Jerez (Centro Sanitario Sandoval, Madrid); MV Aguanell, F Montiel, AM Burgos (Centro de ETS “Costa del Sol”, Málaga); JR Ordoñana, JJ Gutiérrez, J Ballester, F Pérez (Unidad de Prevención y Educación Sanitaria sobre Sida, Murcia); J Balaguer, J Durán (Centro de Salud Área II, Cartagena); MC Landa, P Sanchez-Valverde, H Yagüe, I Huarte, E Sesma, A Gaztambide (COFES, Pamplona); C Fernández-Oruña, D Valencia, T Pelayo (Unidad de Prevención de Sida, Santander); I Pueyo; MA Mendo, M Rubio (Centro de ETS, Sevilla); C de Armas, E García-Ramos, MA Gutiérrez, J Rodríguez-Franco, L Capote, L Haro, D Núñez (Centro Dermatológico, Tenerife); J Ortueta, LM Sáez de Vicuña (Dirección Territorial de Álava); I Alastrué, C Santos, T Tasa (CIPS de Valencia); J Belda, E Fernández, R Martínez, R Alonso (CIPS de Alicante); J Trullén, A Fenosa, C Altava, A Polo (CIPS de Castellón); P Sobrino, A Barrasa, MJ Belza, J Castilla (Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Madrid).