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Sex Work as an Emerging Risk Factor for Human Immunodeficiency Virus Seroconversion Among People who Inject Drugs in
Karine Blouin1, Pascale Leclerc, Carole Morissette
1From the *Unité des Infections Transmissibles Sexuellement et par le Sang, Institut National de Santé Publique du Québec, Québec, Canada; †Département de Médecine Sociale et Préventive, Université Laval; ‡Axe Santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada; §Direction de Santé Publique du Centre intégré universitaire de santé et de service sociaux du Centre-Sud-de-l'Île-de-Montréal, Montréal, Canada; ¶Université de Sherbrooke à Longueuil, Département des Sciences de la Santé Communautaire, Longueuil, Canada; ‖Laboratoire de santé publique du Québec, Institut National de Santé Publique du Québec, Sainte-Anne de Bellevue, Canada.
Background:
Recent analyses have shown an emerging positive association between sex work and human immunodeficiency virus (HIV) incidence among people who inject drugs (PWIDs) in the SurvUDI network.
Methods:
Participants who had injected in the past 6 months were recruited across the Province of Quebec and in the city of Ottawa, mainly in harm reduction programs. They completed a questionnaire and provided gingival exudate for HIV antibody testing. The associations with HIV seroconversion were tested with a Cox proportional hazard model using time-dependent covariables including the main variable of interest, sexual activity (sex work; no sex work; sexually inactive). The final model included significant variables and confounders of the associations with sexual activity.
Results:
Seventy-two HIV seroconversions were observed during 5239.2 person-years (py) of follow-up (incidence rates: total = 1.4/100 py; 95% confidence interval [CI], 1.1-1.7; sex work = 2.5/100 py; 95% CI, 1.5-3.6; no sex work = 0.8/100 py; 95% CI, 0.5-1.2; sexually inactive = 1.8/100 py; 95% CI, 1.1-2.5). In the final multivariate model, HIV incidence was significantly associated with sexual activity (sex work: adjusted hazard ratio [AHR], 2.19; 95% CI, 1.13-4.25; sexually inactive: AHR, 1.62; 95% CI, 0.92-2.88), and injection with a needle/syringe used by someone else (AHR, 2.84; 95% CI, 1.73-4.66).
Conclusions:
Sex work is independently associated with HIV incidence among PWIDs. At the other end of the spectrum of sexual activity, sexually inactive PWIDs have a higher HIV incidence rate, likely due to more profound dependence leading to increased vulnerabilities, which may include mental illness, poverty, and social exclusion. Further studies are needed to understand whether the association between sex work and HIV is related to sexual transmission or other vulnerability factors.
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