The Prostitute Paradox
Rethinking AIDS March 1993
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.
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. *
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.
Wiener JM, "Prostitutes and AIDS: A heath department priority'
/American Journal of Public Health 78: 418423, 1988.
"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.