Commentary: Sex trade involvement and rates of HIV-positivity among young gay and bisexual men

Somewhat belatedly, the world has begun to officially acknowledge the catastrophic impact of HIV/AIDS. The Declaration of Commitment on HIV/AIDS adopted on 16 June 2001 by the United Nations General Assembly (Excerpts From the UN’s Statement on AIDS, 2001)1 brought to centre stage the need for governments, civil societies, the business community and the private sector to act in concerted fashion to combat the pandemic. The potential for devastation is particularly strong in subSaharan Africa and in countries with vast populations like India and China. As the magnitude of these events in low-income regions dawns on the international community, it is tempting to consider HIV to be all but conquered in the wealthiest nations. It is not. The epidemic continues to rage within some population groups in high-income countries, particularly on the North American continent. Young gay men are one of these groups. Recent reports of studies undertaken in seven US cities between 1998 and 2000 with men who have sex with men aged 23–29 show that HIV prevalence was 7% among whites, 14% among Latinos, and 32% among African Americans. Furthermore, while the overall incidence of HIV was 4.4%, it was 14.7% among African American young men (CDC, 2001).2 Young gay and bisexual men are the topic of the paper by Weber et al.3 in this issue of the International Journal of Epidemiology. In a prospective cohort in Vancouver, they examine which men are more likely to engage in sex trade work, a major risk factor for HIV. An important finding, though perhaps not a surprising one, is that some of the powerful determinants of social marginality and stigma are also related to sex trade work, for instance, being a former psychiatric inpatient, unemployed, or of aboriginal ethnicity. The authors’ choice of the terms ‘sex trade’ over the word ‘prostitution’ is an acknowledgement that the latter carries a strongly negative connotation. We need to understand how gay men involved in trading sex for goods view the stigma associated with the activity and how they cope with it. Indeed, trading sex is an activity that needs to be seen in its full social context. Consider the finding that aboriginal men were more likely to trade sex. Since one would be hard pressed to find a genetic relationship between ethnic origin and sex trade work, an understanding of this association requires one to consider the history of aboriginal individuals during the colonization of Canada, their current social situation, their access to education and employment, and other structural factors that may put the presented results in context. Ultimately this kind of analysis may suggest that interventions to reduce HIV transmission will fail if they overlook the mitigation of broad social and structural problems. The trading of sex plays a central role in the HIV pandemic and we should examine it with the utmost rigour as well as sensitivity. ‘Sex trade’ is one of those concepts that seem clear only until the moment we try to define it. The apparently dispassionate ‘sex trade’ nomenclature is in fact extremely difficult to operationalize. Weber et al. define sex trade as ‘exchange of money, drugs, goods, clothing, shelter, or protection for sex within the one year prior to enrolment’. Although this broad definition of sex trade may be appropriate to get an initial impression of the proportion of people in a sample who engage in these behaviours, a finer distinction is needed if we want to gain any deep understanding of this experience and its connections to other observable variables. A number of dimensions need to be considered, for example: