THE PROSTITUTE PARADOX
By Robert Root-Bernstein
Rethinking AIDS March 1993
Female prostitutes 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.
The statistics 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. *
Cameron DW, 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,
Rosenberg MJ, Wiener JM, "Prostitutes and AIDS: A
heath department priority' /American Journal of Public Health 78:
Wallace J, "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.