**14. Men who have paid sex with men**

Four men -- Alan, Barry, Colm and Darragh (three were gay and one was heterosexual) - were interviewed in this study. All were illicit drug users and were either having paid sex with other men, or had discontinued to do so. Men who have sex with men are at risk of contracting HIV (as are those who start having sexual relations in their adolescent (15 years) [24].

Despite embodying all these risk factors, Alan had not contracted any blood borne viral infections. He was working as an escort, and had been homeless since the age of 15. He started smoking cannabis at the age of 12, progressed to ecstasy and then used heroin as a 'come down'. At the time of the interview he was injecting heroin. His choice of drugs was: 'If money was no object, heroin and LSD or cocaine mixed in with heroin and LSD. That would be definitely the choice of drugs'. He was fully cognisant of the dangers of injecting drug use: 'I'd be very, very worried about contracting certain diseases such as hepatitis virus and HIV virus'. Consequently he always uses the needle exchange for sterile needles and ensured to dispose of his needles in a responsible way:

*R: Yes, definitely go to [X needle exchange] and get clean needles. We have "puncture bins". We call them "sin bins". I always carry one of them around with me to make sure that, you know I'd hate the idea of any syringe being left around or the thought of a child pricking themselves on a syringe, you know that kind way. I'd always have a sin bin with me as I call them.* 

He describes how he started injecting drugs and sex working.

*I: In terms of the start of that – when do you appear to have started?* 

*R: I'd say about 15, 16. I couldn't get any money off the Government whatsoever. ... I was homeless. I couldn't get any cash. No cash whatsoever. I was unprepared to go out to one of those fucking boys' homes and be locked up; you know that kind of way. It wasn't an option for me at the time. And plus I was dealing with my sexual orientation as well on top of it which is not an easy task. And to deal with your sexual orientation and actually go out to [a boy's home], it ain't a good idea. You'll end up hurting yourself more or hurting someone else. So, I'd rather hurt myself than someone else, you know that kind of way. So, I would have been about say fifteen, sixteen. ... At that time, that is when I started using heroin intravenously. That's when I started really using heroin intravenously.* 

286 Immunodeficiency

that.'

HIV.

[24].

*them.* 

Zoë said she had sex once without a condom with a customer (for €200), but bitterly regretted it afterwards: 'It was the worst thing I ever done because I had to get tests after

Although sex workers may use condoms with their customers, there is also the danger that they will not use condoms in intimate relations with their partners. Pauline reported that her partner would not use condoms thus increasing the risk of transmission of

Some participants reported being overpowered by a customer and being raped, and said that this was the only time they had sex without a condom. Angela said, 'I never had unsafe sex apart from three times when I was raped.' Similarly, Molly said, 'I always used my

Four men -- Alan, Barry, Colm and Darragh (three were gay and one was heterosexual) - were interviewed in this study. All were illicit drug users and were either having paid sex with other men, or had discontinued to do so. Men who have sex with men are at risk of contracting HIV (as are those who start having sexual relations in their adolescent (15 years)

Despite embodying all these risk factors, Alan had not contracted any blood borne viral infections. He was working as an escort, and had been homeless since the age of 15. He started smoking cannabis at the age of 12, progressed to ecstasy and then used heroin as a 'come down'. At the time of the interview he was injecting heroin. His choice of drugs was: 'If money was no object, heroin and LSD or cocaine mixed in with heroin and LSD. That would be definitely the choice of drugs'. He was fully cognisant of the dangers of injecting drug use: 'I'd be very, very worried about contracting certain diseases such as hepatitis virus and HIV virus'. Consequently he always uses the needle exchange for sterile needles

*R: Yes, definitely go to [X needle exchange] and get clean needles. We have "puncture bins". We call them "sin bins". I always carry one of them around with me to make sure that, you know I'd hate the idea of any syringe being left around or the thought of a child pricking themselves on a syringe, you know that kind way. I'd always have a sin bin with me as I call* 

*R: My partner hasn't got HIV, only Hepatitis.* 

*R: No to be honest and he said, 'No, he won't!'* 

**14. Men who have paid sex with men** 

and ensured to dispose of his needles in a responsible way:

He describes how he started injecting drugs and sex working.

*I: In terms of the start of that – when do you appear to have started?* 

*I: And so do you use condoms when you are having sex with him?* 

condoms, except for the times that I was either beaten up or whatever.'

*I: Do you think in terms of starting that it was more to do with just the fact that you were homeless and had nowhere to live.* 

*R: Well, it was everything. First of all, no stable accommodation, no cash, hungry, low selfimage in yourself, you know, all these things contribute to the fact and I just went absolutely insane like. I wasn't the only one. There were a good few of us around, you know.* 

At the time of the interview, Barry was no longer engaged in sex working and was carving out a new life for himself, he was living independently and was no longer using drugs or alcohol; he was making substantial efforts to live a healthy life with a HIV diagnosis. He commenced alcohol and illicit drug use at the age of 12.

*R: I found myself being abused from the age, the very early age of seven up to 14. I started getting into alcohol, drug taking, so I found with the alcohol, the drug taking that it was much easier to go out and sell myself, cos I was already after being abused and had no value on meself. ...Other male prostitutes, would have introduced me to, there was a group of 12 of us, now, there is only 3 of us left alive out of the group, there was 2 actually murdered there, in the field of prostitution, a lot of them died, HIV related and myself, I was diagnosed as HIV in 1990, and that still wasn't me turning point, I was still addicted, I was still in prostitution, and still addicted at that time.* 

*I: But would you think it is separate between, you weren't doing the prostitution in terms of the money for the drinking or the tablets? Were the two connected?* 

*R: No, I was doing prostitution for the money, 'cause I was going off, literally going off where anything that would pay me, and in male prostitution, which is also on the female side, of when you are addicted, it is a whole different story, when you are on the game. Punters and clients are working on your vulnerability, say I am with a punter one night and he is giving me €50, he will see me the next night, and say he'll know I am that desperate, he will offer me a tenner (€10).* 

He discussed the difficulties for male sex workers in terms of their own low self-esteem, their addiction issues and the difficulties of negotiating condom use with clients.

*R: Condoms! And it is still a big issue today, condoms can be introduced into prostitution but most prostitutes with addiction, if they are asked not to use it, they won't use it. It's not an issue on the game, that would be like: "We're addicts", mm people like myself having no value on myself, like "Fuck it, I want to die anyway", like "I don't like this life", "I don't like myself" "I*  *don't even wanna be here", you know, you just have no value like, 'cause when I was diagnosed, before I was diagnosed HIV, I was diagnosed negative, and they told me, they said "You're clean", like, it's the tip of the iceberg with you, like you are going to come back positive". Three months later, then I came back positive then.* 

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Irish Drug Using Sex Workers Accounts of How They Contracted HIV and Hepatitis C 289

He was currently sex working in well known places in Dublin city centre:

*centre] buildings, find a little spot and do what you have to do, like.* 

*I: And how many times would you go to the Park?* 

*only get €70 or €80 off him. That's the way it goes, like.* 

*they make up an excuse like, they are not interested. I: Have you fucked anybody without a condom?* 

*I: And you can't charge more though for that, can you?* 

*I: Would you have regular people?* 

*cops, top people, you know what I mean?* 

*R: Most nights* 

reason for agreeing to do so.

*R: I have, yea.* 

*mean?* 

**15. Discussion** 

*you when you go to the Park?* 

*R: I'd be going to the Park from about four up to till half nine, ten. After that then you head into town like and you meet people coming out of the [X Pub]. Then you go into the [X city* 

*R: In a night? It all depends, sometimes I would meet one client and he would give me €500, just for being with him for half an hour. And then sometimes I would meet a client and I would* 

*R: Ah yea, yea I have at the moment regular people that ring me. These are all barristers, and* 

*I: In terms of sexual health, do you bring condoms with you or would you bring condoms with* 

*R: Mmm, no. They would say: "Ah no, I'm not into using them condoms", this, that and all,* 

*R: You can, yea, they say I'll give you x amount if you do it without the condom, you do be saying to yourself, that extra few quid will save me coming up tomorrow like, you know what I* 

The three categories of high risk behaviour (sex working, injecting drug use, men having sex with men) identified by the UNAIDS *Report on the Global AIDS Epidemic 2010* associated with the transmission of HIV are also the risk behaviours which emerged from the analysis of our data. These risks are similar in low, middle-income and higher income countries. Engaging in unsafe injecting (and sexual) practices facilitates the spread of the HIV and HCV viruses [25, 26]. For the participants in this study, blood borne viral infections (HIV, HCV) were transmitted as a result of accidents (sharing works, having a friend administer the injection, unwittingly using another's works, re-using old syringes), and of ignorance of the

If offered more money for sex without a condom, Darragh had a pragmatic and practical

*I: And how many clients would you see, how many clients would you see a night?* 

Colm was also sexually abused as a young boy of 12 by a twenty year old male neighbour; he started using heroin at the age of 15 and started sex working at 16 to make money to buy drugs. He had contracted HCV before the introduction of needle exchanges.

*R: I tell you, the needle exchanges have really, really been fantastic, because they have changed. I'm telling you a lot of people would be infected with HIV or Hepatitis C only for them. Whoever got that brought in may God bless them, I'm telling you, because I'm Hepatitis C, 'cause I was unlucky because I was using well before they allowed that, pass that agreement, you know.* 

He was unsure of his HIV status: 'One time they told me I had it and one time they told me I hadn't got it, I don't know'. There were occasions in the past when he didn't use condoms, but now always does so.


*R: He gives you plenty of, gives you more money if you don't. But then, then, it's not my fault like I didn't know.* 

*I: You know you said you still occasionally would do people? Would they know your status or would you know their status?* 

*R: No, I always bally [use a prophylaxis] up, I always use condoms, always.* 

In addition to receiving opiate substitution treatment (90 mg methadone) he was also injecting a quarter gram of heroin twice a week and taking both prescribed and unprescribed benzodiazepines.

Darragh commenced drug use at the age of 12: 'I started off smoking hash, and then taking a few tablets like Upjohns, Roache 5, and things like that and napps then, and start banging up napps'. Unlike the three other men who were gay he was heterosexual and was the father of two children. He was currently in opiate substitute treatment and was prescribed 190 milligrams of methadone, but in addition he was also buying tablets on the street: 'But I do buy tablets as well, like Roache, and Dalmaine, Zimovane and all that'. He had not contracted HIV but was HCV positive. He accessed needles in his local needle exchange and had devised a strategy for when he ran out of needles: 'If I run out, I would end up using one of the old ones that I had, or else I would try and buy a new one off someone else, like you know'.

He was currently sex working in well known places in Dublin city centre:

*R: I'd be going to the Park from about four up to till half nine, ten. After that then you head into town like and you meet people coming out of the [X Pub]. Then you go into the [X city centre] buildings, find a little spot and do what you have to do, like.* 

*I: And how many times would you go to the Park?* 

*R: Most nights* 

288 Immunodeficiency

but now always does so.

*like I didn't know.* 

prescribed benzodiazepines.

*would you know their status?* 

*R: There was times when I didn't.* 

*months later, then I came back positive then.* 

*don't even wanna be here", you know, you just have no value like, 'cause when I was diagnosed, before I was diagnosed HIV, I was diagnosed negative, and they told me, they said "You're clean", like, it's the tip of the iceberg with you, like you are going to come back positive". Three* 

Colm was also sexually abused as a young boy of 12 by a twenty year old male neighbour; he started using heroin at the age of 15 and started sex working at 16 to make money to buy

*I: Can I ask you now about safer sex? Were there times when you didn't use condoms?* 

*I: And what were the circumstances around that? Did the punter ask you not to?* 

*R: No, I always bally [use a prophylaxis] up, I always use condoms, always.* 

*R: He gives you plenty of, gives you more money if you don't. But then, then, it's not my fault* 

*I: You know you said you still occasionally would do people? Would they know your status or* 

In addition to receiving opiate substitution treatment (90 mg methadone) he was also injecting a quarter gram of heroin twice a week and taking both prescribed and un-

Darragh commenced drug use at the age of 12: 'I started off smoking hash, and then taking a few tablets like Upjohns, Roache 5, and things like that and napps then, and start banging up napps'. Unlike the three other men who were gay he was heterosexual and was the father of two children. He was currently in opiate substitute treatment and was prescribed 190 milligrams of methadone, but in addition he was also buying tablets on the street: 'But I do buy tablets as well, like Roache, and Dalmaine, Zimovane and all that'. He had not contracted HIV but was HCV positive. He accessed needles in his local needle exchange and had devised a strategy for when he ran out of needles: 'If I run out, I would end up using one of the old

ones that I had, or else I would try and buy a new one off someone else, like you know'.

*R: I tell you, the needle exchanges have really, really been fantastic, because they have changed. I'm telling you a lot of people would be infected with HIV or Hepatitis C only for them. Whoever got that brought in may God bless them, I'm telling you, because I'm Hepatitis C, 'cause I was unlucky because I was using well before they allowed that, pass that agreement, you know.*  He was unsure of his HIV status: 'One time they told me I had it and one time they told me I hadn't got it, I don't know'. There were occasions in the past when he didn't use condoms,

drugs. He had contracted HCV before the introduction of needle exchanges.

*I: And do you think that was just at the beginning, years ago?* 

*R: That was years ago and a couple of times I didn't and I escaped.* 

*I: And how many clients would you see, how many clients would you see a night?* 

*R: In a night? It all depends, sometimes I would meet one client and he would give me €500, just for being with him for half an hour. And then sometimes I would meet a client and I would only get €70 or €80 off him. That's the way it goes, like.* 

*I: Would you have regular people?* 

*R: Ah yea, yea I have at the moment regular people that ring me. These are all barristers, and cops, top people, you know what I mean?* 

If offered more money for sex without a condom, Darragh had a pragmatic and practical reason for agreeing to do so.

*I: In terms of sexual health, do you bring condoms with you or would you bring condoms with you when you go to the Park?* 

*R: Mmm, no. They would say: "Ah no, I'm not into using them condoms", this, that and all, they make up an excuse like, they are not interested.* 

*I: Have you fucked anybody without a condom?* 

*R: I have, yea.* 

*I: And you can't charge more though for that, can you?* 

*R: You can, yea, they say I'll give you x amount if you do it without the condom, you do be saying to yourself, that extra few quid will save me coming up tomorrow like, you know what I mean?* 

#### **15. Discussion**

The three categories of high risk behaviour (sex working, injecting drug use, men having sex with men) identified by the UNAIDS *Report on the Global AIDS Epidemic 2010* associated with the transmission of HIV are also the risk behaviours which emerged from the analysis of our data. These risks are similar in low, middle-income and higher income countries. Engaging in unsafe injecting (and sexual) practices facilitates the spread of the HIV and HCV viruses [25, 26]. For the participants in this study, blood borne viral infections (HIV, HCV) were transmitted as a result of accidents (sharing works, having a friend administer the injection, unwittingly using another's works, re-using old syringes), and of ignorance of the consequences of injecting drug use. Although some respondents were aware of the dangers of using another's injecting equipment, their judgement was impaired due to: being 'strung out' (suffering withdrawal symptoms), to administering the injection in a rushed unsterile environment, and to the distractions and confusion that can occur when injecting in the company of friends/drug buddies and allowing friends to administer the injection to them.

What I Knew was What I Learnt on the Street!

Irish Drug Using Sex Workers Accounts of How They Contracted HIV and Hepatitis C 291

incidents of violence, which in turn can enable information about dangerous individuals to be disseminated to other sex workers or be used to report a crime to the police for investigation.

In this study, the male interviewees, because they were men who have paid sex with other men, constitute a high risk group for transmitting blood borne viral infections, particularly if

Despite the existence of harm reduction interventions such as opiate substitution treatment, needle exchanges for drug users who engage in sex working, this population remain a highrisk group for contracting blood borne viral infections and death. In Ireland, some injecting drug users and other young people are still taking risks as exemplified in the recent surveillance statistics[11]. The introduction of safe injecting spaces and places might enable intravenous drug users to inject in more hygienic and safer settings thereby reducing the risk of transmission. Health messages displayed in public places might inform the intravenous drug users of the harmful consequences of unhygienic injecting practices and sharing equipment and may therefore increase their awareness of the inherent risks. Marginalized, vulnerable young people such as those leaving residential care in the justice or social welfare systems need to be targeted and informed of the dangers of illicit drug use and sex work. Health messages should also target customers and potential customers of sex workers, their insistence on not wearing a condom during sexual intercourse is putting them

A change in how drug use and addiction is perceived could result in a change in the risk environment in Ireland. For example, in Portugal [33], since heroin use has been decriminalised, public perceptions have changed from viewing opiate users as criminals and addicts to viewing then as sick people in need of treatment. In Switzerland and the Netherlands successful harm reduction interventions have reduced the rates of new

Changes to the risk environment in Ireland in terms of policy, perception and policing could lead to the creation of an enabling environment for injecting drug using sex workers so that changes in individual behaviour could be brought about by enhanced structural interventions [34]. This approach advocates all forms of social interventions (improved education, greater needle exchange coverage, enhanced condom provision) which are extraindividual – in other words interventions that change the context within which risks are

\*\* The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

they are using used syringes, and are not practicing safe sex.

and whoever else they are having sex with at risk.

infections among people who inject drugs

produced and reproduced [12].

*Hallows College, Dublin, Ireland* 

**Author details** 

Teresa Whitaker\*, \*\*

Corresponding Author

 \*

**16. Conclusion** 

In a systematic review and meta-analysis of interventions to prevent Hepatitis C virus infection in injecting drug users, it was found that a complex of interventions worked best to reduce the incidence. For example combining counselling with strategies such as -- enabling the injector to maintain control over the injection process by not injecting in chaotic and rushed settings; maintenance in opiate substitution treatment of ≥ than 60 mg a day; and using sterile syringes obtained from a syringe exchange program [27]. In our study, most of the participants were accessing some of the elements in such a treatment complex. However, their attempts to reduce their risks were exacerbated by the fact that many were homeless and spent much time on the streets and were likely to inject in public places and spaces which lacked the necessary hygiene. Only three of the seven who reported being HIV positive were receiving anti retroviral treatment; two others were unsure of their HIV status. They are a high risk group in terms of passing on the virus to others. Other research has found that sex workers who are injecting drug users are associated with poorer engagement with Opioid Agonist Treatment and retention in treatment[28]. Other jurisdictions[24] in Europe have been successful in reducing the rates of new infections among people who inject drugs: for example in Switzerland and in the Netherlands, HIV infections have almost been eliminated (at most 5% of new infections in 2007 and 2008 respectively) amongst those who engage in 'social' drug use, involving several people using the same contaminated injecting equipment. Whereas in Ireland, the rate of new infections for intravenous drug users accounted for 7.9% of all newly diagnosed cases in 2009. And in this small study the rate of HIV infection among the 35 people interviewed was 21 per cent.

For sex workers and their clients, unprotected sex increases the risk of contracting and transmitting a range of sexually transmitted infections (STIs), including HIV [29] and HCV infection [30]. In this study, sex workers were aware of the importance of protected sex and were generally proactive in the use of condoms with clients. Offers of increased money for sex without a condom weakened their resolve. This suggests that it is clients rather than sex workers who are more prepared to take the risk of contracting HIV. The power dynamics and the inequalities in physical strength between a sex worker and a customer can rob the sex worker of the opportunity to negotiate condom use [31].Gender violence against women and rape also led to the transmission of the HIV virus. Rape was a common experience for the sex working men and women. Enhanced policing practices could help to reduce the possibilities of sex workers being raped, and therefore of contracting HIV through rape. The latest Home Office Review of Effective Practice document and the new ACPO (Association of Chief Police Officers) Strategy & Operational Guidance for Policing Prostitution and Sexual Exploitation [32] mention's the partnership work in Merseyside of the UK Network of Sex Work Projects. It endorses taking a harm reduction approach to prostitution by introducing schemes such as the 'Ugly Mugs' scheme which can help to improve safety by allowing sex workers to report incidents of violence, which in turn can enable information about dangerous individuals to be disseminated to other sex workers or be used to report a crime to the police for investigation.

In this study, the male interviewees, because they were men who have paid sex with other men, constitute a high risk group for transmitting blood borne viral infections, particularly if they are using used syringes, and are not practicing safe sex.
