After studies of street youth and younger male sex workers, the other major source for information on male sex work and HIV and AIDS in Canada is prevention research studies of injection drug users. While there are some data on behaviourally identified male injection drug users who also sell sex, there are almost no data on behaviourally identified male sex workers who also inject intravenous drugs.

The number of HIV infections among injection drug users in Canada has been increasing steadily since the beginning of the HIV epidemic in the early 1980s. Of the estimated 3,000-5,000 HIV infections occurring in Canada in 1996, approximately half were among injection drug users.150

Some male injection drug users exchange sex for goods, money or drugs, yet very little is known about how men who sell sex and inject drugs may differ from either male sex workers who do not inject drugs, or men who inject drugs but do not sell sex.

Sexual behaviour and condom use of male sex workers who inject drugs

A Toronto study conducted between 1991 and 1994 looked at different groups of injection drug users entering drug treatment, as part of an international collaboration associated with the World Health Organization.151 In the years 1991 through 1994, approximately 400 male injection drug users were recruited each year from needle exchange programs and other community agencies known to serve drug users.152 Of these, between 3% and 9% had sold sex to male clients. Of the males who sold sex to women, approximately 50% said they always used condoms for vaginal intercourse, while approximately 19% said they never did. In 1991-92, 40% of male sex workers who injected drugs reported that they always used condoms for anal sex with male clients, while 10% said they never did. In 1992-93, 67% always used condoms and 0% never did, and in 1993-94, 77% always did and 12% never did.

A 1993 analysis of data from 907 injection drug users in Montreal reported that injection drug users who also sold sex used condoms at least occasionally 51% of the time with clients, 35% of the time with occasional partners and 10% of the time with regular partners.153

An Eastern Canada study published in 1994 described the evaluation of a needle exchange program through interviews with program participants. Of 552 male injection drug users, 34% indicated that they had had sex with male clients in the previous three months for either money, goods or drugs. Ninety-six percent reported having had oral sex with a same-sex client in the previous three months, and 46% reported having had anal sex with a same-sex client. Of these, 72% always used condoms for anal sex with clients and 29% never did.154

In an analysis of needle exchange program participants in Ottawa and the province of Quebec presented in 1997, 7% of 2,475 men reported having had male clients. Of these, 64% never or only sometimes used condoms with their clients. Additionally, more than 4% of males had regular male partners, and of these, 73% never or only sometimes used condoms. Almost 7% had non-regular male partners, and of these, 75% never or only sometimes used condoms.155

HIV and AIDS in male sex workers who inject drugs

Overall, in Canada, as in other parts of the developed world, the rates of HIV infection among male sex workers and among sex workers who inject drugs are higher than those found among female sex workers who do not inject drugs.156

A 1989 British Columbia report on HIV testing among 199 street-involved people, 69% of whom were male, found that of 33 tests of bisexual male sex workers who injected drugs, four (12.1%) showed HIV antibody-positive results. In addition, three of 29 bisexual sex workers who did not inject drugs were HIV antibody-positive (10.3%).157

A 1993 update of the above study of street-involved people, including injection drug users, conducted between 1988 and 1992, found that the HIV rate over five years for 825 people was 6.4%, and that sex between men was an important risk factor.158

Another British Columbia study, conducted in 1994, presented an analysis of HIV quarterly reports between 1989 and 1994. The authors reported no increase in the rate of HIV antibody-positive test results among individuals reporting sex work alone as a possible risk factor, but an increasing number of HIV antibody-positive test results in sex workers who also injected drugs between 1991 and 1993.159

A third British Columbia study, also presented in 1994, revealed that 5.3%, or 17 of 322, injection drug users followed over an 18-month period tested positive for HIV antibodies. Those who tested positive were more likely to report having had sex for money than those who tested negative.160

And a fourth British Columbia study, a consultation report published in 1996, stated:

there are serious risks associated with prostitution. Sexually transmitted diseases are increasing among prostitutes and johns; the number of identified HIV-positive cases among prostitutes has risen, particularly among those who are injection drug users.161

A Montreal analysis of 907 injection drug users who were either involved or not involved in sex work, published in 1993, found that sex work was more common in female injection drug users (51%) than in males (16%). However, HIV prevalence rates were higher in males (27.2%) than in females (15.2%). The risk behaviours that were statistically significant for both male and female injection drug users reporting involvement in sex work were: attending shooting galleries, being gay or bisexual, number of sexual partners and having been in prison. This paper concluded that male injection drug users who also sold sex were in need of additional preventative measures aside from those that are generally offered to injection drug users.162

A second analysis of the above data, conducted in 1996, divided the sample into 694 injection drug users receiving treatment and 213 not receiving treatment. This paper reported that more injection drug users who also sold sex and were not in treatment were HIV antibody-positive than injection drug users who also sold sex and were in treatment. The rates of HIV infection among male injection drug users who also sold sex were found to be higher than those of their female counterparts.163

Also in Quebec, researchers collected information on 831 injection drug users from the Quebec City Needle Exchange Program between 1993 and 1995. One report, published in 1994, indicated that of 212 male injection drug users, four of 14, or 28%, who sold sex were HIV antibody-positive, compared to 10%, or 18 of 186, who had not sold sex.164

A second paper from the Quebec City study, published in 1996, reported on a qualitative network analysis of 25 people reporting the heaviest risk behaviours and who spent most of their time with other drug users. The study found that the mostly bisexual male injection drug users who also reported having engaged in sex work shared the same social networks as the females in this subsample. These men had a lower rate of exposure through needle transmission than the females, but engaged in more high-risk sexual behaviours. They associated with both steady injectors and non-injectors and shared injection materials primarily with each other and occasionally with female sex workers. The paper reported that

understanding the organization at the confluence of prostitution and IDU networks yields a practical basis for social intervention aiming to reduce HIV transmission.165

Data on prison inmates who have injected drugs and also sold sex

Some Canadian studies of prison inmates also provide information on men who have injected drugs and sold sex. For example, a 1998 Ontario analysis of six provincial correctional facilities, with representation from all security levels, found that five of 432 male prison inmates (1%) reported ever having received money or drugs in exchange for sex; three of the five had done so within the previous year. Of these inmates, two were heterosexual, one homosexual, one bisexual and one transgendered. Three of the five had injected drugs in their lifetimes, and two of these had injected drugs outside prison in the previous year. Neither of the two recent injection drug users had shared needles, and none of the five inmates with sex work experience reported having had unprotected intercourse outside prison in the year prior to imprisonment. Four of the five reported ever having tested for HIV antibodies and two of these were HIV antibody-positive.166

A 1995 Quebec report found that 12% of 41 male prison inmates who reported having previously engaged in sex work were HIV antibody-positive. The authors note that all of the HIV antibody-positive individuals, including those who had sold sex, were also injection drug users.167

Peer researchers study drug-related harm among male sex workers

In 1994, Maggie's, the Toronto Prostitutes' Community Service Project, conducted a peer-driven needs assessment of drug-related harm among sex workers. In total, 161 people involved in both sex work and drug use consented to be interviewed. One-third of these were men who, on average, had spent more than five years in sex work.

Asked if they had ever done work they would otherwise turn down because they needed to get high, male sex workers said:

I've engaged in riskier sexual behaviour than I might have otherwise. Or, I've done tricks for many hours longer than I normally would have

A couple of times, to get drugs, I let a date fuck me to get more money.

I'm always very safe. I want to live too much to be stupid.

I do everything with a condom except for a hand job ... I think I have a better head on my shoulders than a lot of people turning tricks on the street. It's hard to imagine a lot of these men and women working on the street and they are totally fucked up and that's how they usually work, and I wonder if they would suddenly realize they had no condoms on them, [and] they needed a fix, would they go to the trouble of finding somewhere they could go get [a condom] before doing their next trick? Myself and all the people I know are safe in everything [we] do.168

Footnotes

150. Health Canada, Risk Behaviours among Injection Drug Users in Canada, HIV/AIDS Epi Update, Bureau of HIV/AIDS and STD, Laboratory Centre for Disease Control, Health Protection Branch, Ottawa, Health Canada, 1997. [back]

152. The Toronto Drug Injection and Risk of HIV Study included subsamples of male sex workers, investigating their behaviours with both male and female clients, recruiting 372 to 414 injection drug users per year.

153. Lamothe, F., Bruneau, J., Soto, J., Lachance, N., Vincelette, J. and Brabant, M., Behaviours of Male and Female Intravenous Drug Users (IVDUs) Involved in Prostitution in Montreal, Quebec, Canada, paper presented to the IXth International Conference on AIDS, Berlin, Germany, June 1993.

154. Baskerville, B., Leonard, L. and

Hotz, S., Evaluation of the SITE: A Pilot HIV Prevention Program for Injection Drug Users, Ottawa, Ottawa-Carleton Health Department, 1994.

155. Parent, R., Alary, M., Hankins, C., Nöel, L., Blanchette, C., Claessens, C., HIV among IDUs: Second Surveillance Year of the SurvIDU Network, paper presented to the Sixth Annual Canadian Conference on HIV/AIDS Research, Ottawa, June 1997.

156. Jackson, L. and Highcrest, A., "Female Prostitutes in North America: What Are Their Risks of HIV Infection?" in Sherr, L., Hankins, C. and Bennett, L. eds., AIDS as a Gender Issue: Psychosocial Perspectives, London, Taylor and Francis, 1996, cited in de Bruyn, T., HIV/AIDS and Discrimination: A Discussion Paper, Joint Project on Legal and Ethical Issues Raised by HIV/AIDS, Montreal, Canadian HIV/AIDS Legal Network, and Ottawa, Canadian AIDS Society, 1998.

157. Rekart, M. L., Chan, S., James, E. and Barnet, J., HIV Testing "on the Street," paper presented to the Vth International Conference on AIDS, Montreal, June 1989.

158. Rekart, M. L., Trends in HIV Seroprevalence among Street-Involved Persons in Vancouver, Canada, 1988-1992, paper presented to the IXth International Conference on AIDS, Berlin, Germany, June 1993.

159. Patrick, D. M., MacDougall, R. G., Knowles, L. J. and Rekart, M. L., "Report on an Outbreak of HIV Infection Among Injection Drug Users in British Columbia," Health Canada, The Proceedings of the Meeting on HIV Infection among Injection Drug Users in Canada, Montreal, Quebec, Laboratory Centre for Disease Control, Ottawa, Health Canada, 1994.

160. Health Canada, The Proceedings of the Meeting on HIV Infection among Injection Drug Users in Canada, Montreal, Quebec, Laboratory Centre for Disease Control, Ottawa, Health Canada, 1994, p. 59.

161. British Columbia, Community Consultation on Prostitution in British Columbia: Overview of Results, Victoria, Ministry of the Attorney General B.C., 1996, p. 4.

162. Lamothe, F., Bruneau, J., Soto, J., Lachance, N., Vincelette, J. and Brabant, M., Behaviours of Male and Female Intravenous Drug Users (IVDUs) Involved in Prostitution in Montreal, Quebec, Canada, paper presented to the IXth International Conference on AIDS, Berlin, Germany, June 1993.

163. Lamothe, F., Bruneau, J., Franco, E., Lachance, N., Desy, M., Soto, J. and Vincelette, J., Risk Factors for HIV Seroconversion among Injection Drug Users in the Saint-Luc Cohort, Montreal, 1988-1995, paper presented to the XIth International Conference on AIDS, Vancouver, July 1996.

164. Parent, R., Nöel, L., Alary, M., Claessens, C., Marquis, G., Gagnon, M., Deslauriers, D. and Marcoux, N., "Évaluation de la prévalence des infections au VIH et de certains comportements d'injection et sexuels chez les utilisateurs de drogues par injection fréquentant le programme Point de repères," in Health Canada, The Proceedings of the Meeting on HIV Infection among Injection Drug Users in Canada, Montreal, Quebec, Laboratory Centre for Disease Control, Ottawa, Health Canada, 1994.

165. Nöel, L., Lachance, C., Alary, M. and Marquis, G., Social Network in a Community of Injecting Drug Users Attending a Needle Exchange Program in Quebec City, paper presented to the XIth International Conference on AIDS, Vancouver, July 1996.

166. Calzavara, L., Burchell, A., Schlossberg, J., Myers, T., Wallace, E., Millson, M., Major, C. and Escobar, M., HIV Risk Related to Sexual Activity Within Ontario Provincial Correctional Centres, paper presented to the Seventh Annual Canadian Conference on HIV/AIDS Research, Quebec City, April/May 1998.

167. Dufour, A., Alary, M., Poulin, C., Allard, F., Nöel, L., Trottier, G., Hankins, C. and Lepine, D., HIV Prevalence and Risk Behaviours among Inmates of a Provincial Prison in Quebec City, paper presented to the Fifth Annual Canadian Conference on HIV/AIDS Research, Winnipeg, June 1995.

168. Maggie's, the Toronto Prostitutes' Community Service Project, Report on Assessing the Need to Reduce Drug-Related Harm Among Prostitutes Who Use Drugs, Ottawa, Health Promotion and Social Development, Health Canada, File #6552-2-371, 1994.