Characterization of patients seeking care at a Sexual Health Clinic who report engaging in exchange sex

Background: People who exchange sex (PWES) for money or drugs are at increased risk of HIV and other sexually transmitted infections (STIs) and may need tailored prevention and care services. Our objective was to characterize patients in the Public Health – Seattle & King County Sexual Health Clinic who reported engaging in exchange sex and identify opportunities for improved service.

Methods: We conducted a cross-sectional analysis of patient encounters for new problem visits October 2010 – March 2020 with a completed computer assisted self-interview, including sex assigned at birth, gender identity, and receipt of money or drugs in exchange for sex, ever or in the past year. Individual patient data was the unit of analysis. We analyzed demographics, history of STIs, HIV and Hepatitis C (HCV) testing and treatment history, and HIV Pre-exposure Prophylaxis (PrEP) use among PWES and PWES stratified by gender. We also analyzed the reason and outcome of the visit among PWES. Our analysis focused on people who reported a lifetime history of exchange sex because the characteristics of this group represented people who reported exchange sex in the past year. We compared characteristics of PWES ever vs. never using chi-square tests. Results: During the study period, 30,327 patients attended the clinic. Of these, 1,611 (5%) were PWES, and 700 (2%) reported exchange sex in the past 12 months. Compared to people who never exchanged sex, PWES were more likely to report homelessness (29% vs. 7%, p<0.001), injection drug use (IDU) (39% vs. 4%, p<0.001), STIs in the past 12 months (36% vs. 19%, p<0.001), prior HIV diagnosis (13% vs. 5%, p<0.001), and prior HCV diagnosis (13% vs. 2%, p<0.001). PWES were less likely to report HIV viral suppression (67% vs. 73%, p=0.04) and HCV treatment (24% vs. 37%, p<0.001) than people who never exchanged sex. Among PWES there were 981 (61%) cisgender men, 545 (34%) cisgender women, and 85 (5%) transgender/genderqueer/non-binary persons. Compared to cisgender men and transgender/genderqueer/non-binary persons, cisgender women were more likely to report homelessness (41%) and prior HCV diagnosis (17%) but less likely to have received HCV treatment (42%). Cisgender men were more likely to report multiple sexual partners (48%-50%), IDU (37%), STIs in the past 12 months (42%), and prior HIV diagnosis (20%) than cisgender women and transgender/genderqueer/nonbinary persons. Among PWES, the most common reasons for coming to the clinic were wanting an STI test (60%) or HIV test (45%) and having STI symptoms (38%). At the clinic visit included in the analysis, evaluation of the clinic visit outcome for PWES showed 320 (20%) were diagnosed with one or more STI, 15 (1%) were newly diagnosed with HIV, and 15 (1%) initiated PrEP.

Conclusion: Many PWES in the Sexual Health Clinic had complex barriers to care, including homelessness and IDU, and a higher prevalence of previously diagnosed STIs, HIV, and HCV. Clinic visits are an opportunity to increase HIV viral suppression, HCV treatment, and PrEP uptake for PWES.