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The Prostitute Paradox

By Robert Root-Bernstein
Rethinking AIDS March 1993

Female prostitutes often have 200-300 sexual partners per year and are therefore assumed to have much higher rates of exposure to HIV and AIDS than the vast majority of heterosexuals. Indeed, many AIDS researchers initially assumed that female prostitutes would be the vectors (or means of transmission) of HIV and AIDS to the heterosexual community. After all, a single HIV-infected intravenous drug user or bisexual man could infect one female prostitute, who in turn could infect dozens or perhaps even hundreds of non-drug using heterosexual men. These men could, in turn, infect their other sexual partners, and an explosion of HIV and AIDS could occur among people without any obvious risk for AIDS. Paradoxically, no heterosexual epidemic has occurred, and no evidence of female prostitutes transmitting HIV or AIDS into the heterosexual community exists for any Western nation. Reports by prominent researchers in the United States, Britain, and Germany have all concluded that acquisition of HIV by men from female prostitutes is almost always drug related. In fact, sexual acquisition of HIV and AIDS among female prostitutes themselves is almost unknown in the absence of concomitant intravenous drug use.

The statistics are striking. In New York City, for example, 40 to 50 percent of streetwalkers (a very low caste of prostitute) who have used IV drugs over the past decade are HIV seropositive. (Whether these streetwalkers had other immunosuppressive risks such as non IV drug use, unprotected anal intercourse, multiple sexually transmitted diseases, and/or anemia and malnutrition that may have predisposed them to HIV and other infections has never been studied.) Among call girls in New York City (a higher caste of prostitute), no seropositivity was found among those who were drug free. These figures were constant between 1984 and 1989.

The same sorts of figures have been found in all Western nations. In Seville, Spain, 20 percent of intravenous drug users are HIV seropositive and 2.5 percent of the non-needle using prostitutes. Only 8 in 10,000 non-needle-using prostitutes are HIV seropositive in the Philippines. Studies of drug-free prostitutes in Amsterdam, London, Zurich, Paris. Vienna, Athens, Pardenone (Italy), Callao (Peru), Reno (Nevada), Tijuana (Mexico), and Central Tunisia over the last eight years have found only a handful of cases of HIV infection. Thus, American researchers M. J. Rosenberg and J. M. Weiner concluded in 1988 that "HIV infection in non-drug using prostitutes tends to be low or absent, implying that sexual activity alone does not place them at high risk, while prostitutes who use intravenous drugs are far more likely to be infected with HIV." Similarly, British researchers concluded in the same year that "sexual activity alone has not been described as the principal risk [outside of Africa]....The most important risk factor for prostitutes in the West is sharing needles and syringes for drugs." Every subsequent study has confirmed these conclusions.

It is important to note that the almost complete absence of HIV among non-drug using prostitutes is not due to safer sex practices. The same studies that found an absence of HIV documented low rates of condom use and very high rates of infection with classical sexually transmitted diseases. Twenty-five to fifty percent of the prostitutes were seropositive for syphilis; the same approximate percent were seropositive for hepatitis B virus (with about 5 percent actively infected); and antibodies against chlamydia, herpes simplex 1, herpes simplex II, and gonorrhea were present in 95 to 100 percent.

HIV, in short, is not behaving like a typical sexually transmitted disease. Sexual promiscuity, per se, does not put female prostitutes at risk for either HIV or AIDS. There is only one possible conclusion: vaginal intercourse and oral forms of sex (which are by far the most common forms practiced by the prostitutes interviewed in the studies summarized above) are not high risk activities for either the acquisition or transmission of HIV and AIDS. As Japanese physician Y. Shiokawa has suggested, it is probable that drug use, multiple concurrent diseases, malnutrition, and other immunosuppressive factors are required to increase susceptibility. Thus, healthy individuals do not contract HIV or AIDS, and even HIV seropositive, drug-abusing female prostitutes have not been and cannot be vectors for transmitting HIV or AIDS to a healthy, drug-free heterosexual population. *

Selected References

Cameron DW, Simonesen JN, Costa IJ, et at., "Female to male transmission of human immunodeficiency virus type 1: risk factors for seroconversion in men," Lancet ii: 403-407,1989.

Ward Day M. Harris JRS, "Prostitute women and public health," British Medical Journal 297: 1585, 1988.

Hyams KC, Escamilla J, Papadimos TJ, et at., "HIV infection in a non-drug abusing prostitute population," Scandinavian Journal of infectious Diseases 21: 353-354, 1989.

Piot P, Laga M, "Prostitutes: A high-risk group for HIV infection?" Sozial- und Praeventativemedicin 33: 336-339, 1988.

Rosenberg MJ, Wiener JM, "Prostitutes and AIDS: A heath department priority' /American Journal of Public Health 78: 418423, 1988.

Wallace J, "Case Presentations of AIDS in the United States" in: Ma P. and Armstrong D. AIDS and Infections of Homosexual Men 2nd Edition. Boston: Butterworths, 285-295,1989.

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