A) Many sex workers have HIV.
B) More are using condoms to prevent the spread.

Non-paradox.

    George M. Carter

**
J Infect Dis. 2005 Feb 1;191(3):333-8. Epub 2004 Dec 22.
Related Articles, Links
   Click here to read
   Contribution of HIV-1 Infection to Acquisition of Sexually
Transmitted Disease: A 10-Year Prospective Study.

   McClelland RS, Lavreys L, Katingima C, Overbaugh J, Chohan V,
Mandaliya K, Ndinya-Achola J, Baeten JM.

   Department of Medicine, University of Washington, Seattle,
Washington, USA; Department of Medical Microbiology, University of
Nairobi, Nairobi, Kenya. mcclell@u.washington.edu.

   Background. Sexually transmitted diseases (STDs) enhance human
immunodeficiency virus (HIV)-1 susceptibility, but few studies have
examined the reciprocal effect of HIV-1 on STD acquisition.Methods.
Data from a prospective cohort study conducted among female sex
workers in Mombasa, Kenya between 1993 and 2003 were used to determine
the effect of HIV-1 infection on STD susceptibility. The cohort
included 1215 HIV-1-seronegative women who underwent monthly HIV-1 and
STD screening, of whom 238 experienced seroconversion to HIV-1 during
follow-up. Andersen-Gill proportional-hazards models were used to
compare the incidence rates for genital-tract infections (syphilis,
genital ulcer disease [GUD], Neisseria gonorrhoeae infection,
Chlamydia trachomatis infection, Trichomonas vaginalis infection,
vulvovaginal candidiasis, and bacterial vaginosis) in
HIV-1-seropositive versus HIV-1-seronegative women, after controlling
for sexual behavior and other potential confounding factors.Results.
HIV-1 infection was associated with a significantly higher incidence
of GUD (hazard ratio [HR], 2.8; 95% confidence interval [CI],
2.0-3.9), gonorrhea (HR, 1.6; 95% CI, 1.1-2.2), and vulvovaginal
candidiasis (HR, 1.5; 95% CI, 1.3-1.8). The risks of GUD and
vulvovaginal candidiasis increased with progressive levels of
immunosuppression.Conclusions. The increased incidence of
genital-tract infections among HIV-1-seropositive women could promote
the spread of both HIV-1 and other STDs, particularly in areas where
these conditions are highly prevalent.

**
Blanchard JF, O'neil J, Ramesh BM, Bhattacharjee P, Orchard T, Moses
S.    Understanding the Social and Cultural Contexts of Female Sex
Workers in Karnataka, India: Implications for Prevention of HIV
Infection. J Infect Dis. 2005 Feb 1;191(Suppl 1):S139-146.

   Department of Community Health Sciences, University of Manitoba,
Winnipeg, Canada; India-Canada Collaborative HIV/AIDS Project,
Bangalore, Karnataka, India. james_blanchard@umanitoba.ca.

   Background. The objective of the present study was to compare the
sociodemographic characteristics and sex work patterns of women
involved in the traditional Devadasi form of sex work with those of
women involved in other types of sex work, in the Indian state of
Karnataka.Methods. Data were gathered through in-person interviews.
Sampling was stratified by district and by type of sex work.Results.
Of 1588 female sex workers (FSWs) interviewed, 414 (26%) reported that
they entered sex work through the Devadasi tradition. Devadasi FSWs
were more likely than other FSWs to work in rural areas (47.3% vs.
8.9%, respectively) and to be illiterate (92.8% vs. 76.9%,
respectively). Devadasi FSWs had initiated sex work at a much younger
age (mean, 15.7 vs. 21.8 years), were more likely to be home based
(68.6% vs. 14.9%), had more clients in the past week (average, 9.0 vs.
6.4), and were less likely to migrate for work within the state (4.6%
vs. 18.6%) but more likely to have worked outside the state (19.6% vs.
13.1%). Devadasi FSWs were less likely to report client-initiated
violence during the past year (13.3% vs. 35.8%) or police harassment
(11.6% vs. 44.3%).Conclusion. Differences in sociobehavioral
characteristics and practice patterns between Devadasi and other FSWs
necessitate different individual and structural interventions for the
prevention of sexually transmitted infections, including human
immunodeficiency virus infection.

"PaulKing" <aimulti@aimultimedia.com> wrote in message

As I have said before, transmission between men and women is low.
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Can HIV Prevention Make a Difference for Men Who Have Sex With Men?

Have we made any progress in the gay community?
Absolutely. Men who have sex with men (MSM) were hit hard with HIV early in
the epidemic, and remain the group predominantly affected by AIDS
nationally. Recent publications have highlighted increased HIV infection in
certain MSM populations, drawing the dangerous conclusion that prevention is
not working in the gay community. Prevention does work, and many
gay/bisexual men would not be alive today if it weren't for rigorous
prevention efforts. In the second decade of this epidemic, it's extremely
important to balance anecdotes with the weight of scientific evidence that
prevention can, indeed, make a difference.

In 1990, MSM accounted for 73.2% of AIDS cases, but declined to 68.7% in
1994. Clearly, most of the decline occurred in White MSM, whose percentages
declined from 51.2% to 45.5%. No such declines were observed for
African-American, Asian-American, or Native-American MSM.(1)

While AIDS cases among certain segments of MSM have declined, another wave
of infection threatens the gay community if commitment to HIV prevention
should falter. We can learn a lesson from the public health experience with
tuberculosis. In 1969 the federal government provided $20 million for
prevention efforts. Tuberculosis cases went down and with the decrease came
further decreases in funding, until twenty years later tuberculosis cases
had increased past the level from 1969. This is called a "u-shaped curve of
concern", where public health improvements lead to diminished funding, which
leads to increased new cases.(2) Funding and dedication to HIV prevention
efforts must not follow a similar route.

Why are some men still taking risks?
J ust because safer sex is effective at preventing HIV, doesn't mean it's
easy. Continuing safer sex behavior over a long time is difficult; we all
know that it's easier to start a diet than to stay on one. For many men in
the gay community, the challenge is not to start having safer sex, but to do
so consistently and for the long haul.(3)

In the second decade of the epidemic, the gay community is struggling with
the fact that AIDS is here to stay, and that the prospect of a cure is far
away. Overwhelming psychological, cultural and spiritual issues surrounding
living in the midst of an epidemic often overcome the ability or desire to
remain uninfected.(4)

Can prevention reduce new infections?
Yes. Significant and substantial reductions in HIV incidence, risk
behaviors, incident AIDS cases, and surrogate markers for risk behaviors
(like rectal gonorrhea) have been observed, especially among White MSM aged
30 or beyond.(5)

In San Francisco, CA, new HIV infections reached a high of 8,000 in 1982. In
1992, the estimated number of new HIV infections was 1,000. Comprehensive
community-based HIV prevention programs targeted towards gay and bisexual
men in the early to mid-1980s certainly contributed to this dramatic
reduction in new HIV infections.(6)

Rates of rectal gonorrhea, an indicator of male-to-male transmission, have
declined significantly across the US. In New York City, rates declined from
1,577 in 1982 to 50 in 1994. In Denver, CO, rates declined from 354 in 1985
to 10 in 1994.(5)

What's working now?
HIV prevention programs using small group counseling, community outreach,
community mobilization, stress reduction counseling, peer education, and
skills training have been effective among all segments of MSM: men in
epicenter cities, men in rural communities, young men, adolescents, men of
color, and bisexual men.

AIDS education led by peers on a community level is effective at reaching
higher-risk men. In several medium-sized towns, the most popular people in
social settings were trained to deliver AIDS risk-reduction messages to
their friends and acquaintances in gay bars. As a result, fewer men
practiced unprotected sex.(7)

The STOP AIDS Project, which grew out of focus groups conducted early in the
epidemic in San Francisco, CA, uses community outreach and small group
counseling to reduce HIV risk. About 8,000 men are reached annually, and
about 1,800 attend workshops. Self-reported rates of unprotected anal
intercourse declined after the workshops, from 25.1% to 19.4%, with even
greater differences among HIV positive men.

Who is prevention missing?
Young MSM continue to be at high risk for HIV infection. In California
between 1987 and 1991, HIV incidence among men born 1960-64 increased 216%
in Los Angeles County and 206% in San Francisco. One study estimated that a
20-year old MSM has a 20.2% chance of seroconverting before reaching age
25.(8)

MSM of color in the US are disproportionately affected by the HIV
epidemic.(9) By March 1993, Latinos comprised 17% of all diagnosed AIDS
cases in the US, yet represented only 9% of the general population.(10) In
Washington, DC, White MSM showed a 16% decrease in AIDS incidence between
1988 and 1993, while African-American MSM showed a 63% increase.(11)

Men who use alcohol or drugs are at a much higher risk for contracting HIV.
A recent study of gay men in substance abuse treatment found alarming levels
of high-risk sex, levels that approached those recorded before the AIDS
epidemic.(12)

What needs to be done?
Clearly, the scope of HIV among MSM calls for a national effort to reduce
new infections. In Canada, the federal government sponsored a simultaneous
survey of 4,803 men in 35 cities across the country. Results were published
for the public, and based on this, a national intervention project for MSM i
s being sponsored by the Canadian AIDS Society.(13) The US is more than
ready for a similar national effort.

Maintenance of safer practices must be encouraged and examined. Without
assistance otherwise, return to unsafe practices should be expected. Service
providers and scientists need to study this phenomenon and be prepared to
assist those who might or have already relapsed from safer sexual practice
either occasionally or altogether.

Better surveillance systems are needed. Vital and important HIV data should
be much easier to find. Regular systems of surveillance that keep closer
track of changes in the epidemic are needed, so that rapid responses can be
mobilized in target groups where the spread of HIV is occurring.

Interventions targeted to "missed" populations are urgently needed. Although
programs exist across the country, shamefully few have been evaluated for
effectiveness. A comprehensive HIV prevention strategy uses multiple
elements to protect as many of those at risk of HIV infection as possible.
Continued funding, evaluations, and controlled trials of HIV prevention
interventions for diverse groups of MSM must become a priority.(14)

----------------------------------------------------------------------------
----

Says who?

Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report: US
HIV and AIDS cases reported through June, 1994.

Reichman LB. The u-shaped curve of concern. American Review of Respiratory
Diseases. 1991;144:741-742.

Stall R. How to lose the fight against AIDS among gay men: declare victory
and leave the field. British Medical Journal. 1994;309:685-686.

Van Gorder, D. Building community and culture are essential to successful
HIV prevention for gay and bisexual men. AIDS & Public Policy Journal. 1995;

Coates TJ, Faigle M, Koijane J, et al. Does HIV prevention work for men who
have sex with men? Report prepared for the Office of Technology Assessment,
Congress of the United States. February 1995.

Stryker J, Coates TJ, DeCarlo P, et al. Prevention of HIV infection: looking
back, looking ahead. Journal of the American Medical Association.
1995;273:1143-1148.

Kelly JA, St. Lawrence JS, Stevenson LY, et al. Community AIDS/HIV risk
reduction: the effects of endorsements by popular people in three cities.
American Journal of Public Health. 1992;82.1483-1489.

Hoover DR, Mu-oz A, Carey V, et al. Estimating the 19878-1990 and future
spread of human immunodeficiency virus type 1 in subgroups of homosexual
men. American Journal of Epidemiology. 1991;134:1190-1204.

Peterson JL, Coates TJ, Catania JA, et al. High-risk sexual behavior and
condom use among gay and bisexual African-American men. American Journal of
Public Health. 1992;82:1490-1494.

Centers for Disease Control and Prevention. Update: trends in AIDS diagnosis
and reporting under the expanded surveillance definition for adolescents and
adults: United States, 1993. Morbidity and Mortality Weekly Report.
1994;43:826-831.

Government of the District of Columbia HIV Planning Community Planning
Committee & Agency for HIV/AIDS, Commission of Public Health, Department of
Human Services. Comprehensive HIV prevention plan. Submitted to the Centers
for Disease Control and Prevention; October 3, 1994.

Canadian AIDS Society. Gaily Forward. Toronto; 1993.

Proceedings from the Summit on HIVPrevention for Gay Men, Bisexuals, and
Lesbians at Risk. Dallas, TX; 1994.

Prepared by Pamela DeCarlo