**7. Sample**

A purposive sample (4 men and 31 women: n=35) of drug-using sex workers was selected. They were located for the research by key service providers and by an agency which offers specialist support to drug using sex workers. In order for sex workers to be eligible for inclusion in the study they had to self identify as a problematic drug user as defined by the Irish National Drug Strategy – i.e. their drug use caused them social, psychological, physical or legal difficulties, and they were involved in sex work or had recently given up sex work after a prolonged period of sex working.

#### **8. Research instruments**

Two research instruments were utilised to register these sex workers' accounts. A topic guide was designed for use in in-depth face-to-face interviews, and a short survey was used to gather biographic and demographic information and to record current drug use frequency and any associated criminal activity over the previous 90 days. The interviews were conducted in a number of different venues: some in rooms provided by an agency, some in cars, some in prison and some in cafés. In keeping with NACD policy all participants were recompensed for their time with a voucher for a local chain store.

In order to comply with ethical guidelines, prior to conducting the interview, the research was explained to the participant, who signed a consent form and was assured that they could withdraw from the study at any time and that all information was confidential and anonymous. Their permission to audio record the interview was also sought; all agreed to be recorded.

The interviews lasted 45 minutes to an hour and the data quality was good. Generally speaking, the sex workers were very open and viewed the interview as a way of helping out, or doing the researcher a favor. Ethical guidelines were complied with in relation to storage of the data on a password protected computer; all personal identifiers were removed from the data. The data were anonymized, each sex worker was given a pseudo-name (in alphabetical order). Hard copies of the data were stored in a locked filing cabinet. Data was only used for the purpose of the research.

#### **9. Data analysis**

The researchers fully immersed themselves in the data by listening repeatedly to the recordings. All interviews were fully transcribed. Emerging themes and trends were identified in the data as were comparative data. Inductive analysis of the qualitative data was facilitated by the use of QSR NVivo software, and quantitative data were analysed using the statistical package for the social sciences (SPSS). In the following accounts, I denotes 'Interviewer' and R denotes 'Respondent'.

What I Knew was What I Learnt on the Street!

Irish Drug Using Sex Workers Accounts of How They Contracted HIV and Hepatitis C 281

cent said that they had received information about the virus, 36.7 per cent reported having received an onward referral; however, only 13.3 per cent (n=4) reported having ever received treatment for HCV. Less than half the sample (43.8 per cent) reported having received the hepatitis B vaccine, and 17.2 per cent had received it in the last three months; 19.4 per cent had received confirmation that the vaccine had worked. Only one of the study participants reported receiving the combination interferon and ribavirin HCV treatment and three of the women were receiving HIV triple therapy treatment; all three commenced

While all participants reported using needle exchanges to access sterile injecting equipment, most admitted to engaging in unsafe injecting practices in the past. Because they had commenced illicit drug use at a young age, many were unaware of the attendant risks of contracting HIV/HCV at the time and in any case were unable to access sterile injecting equipment, because there were limited harm reduction interventions in Dublin

Some spoke about recent occasions where they put themselves at risk by sharing injecting

Despite having access to sterile needles, Úna explained how she unwittingly used a friend's equipment because she was in the throes of withdrawal. This account highlights the struggle to maintain safe practices in a very risky, unsafe environment with an irresponsible drug using friend who was HIV positive. This detailed narrative has been tabulated to facilitate reading. Úna's account is presented in the left hand column where it is broken into numbered blocks to highlight the main topic focus in each. In the right hand column the

In the above account Úna describes how she always accessed sterile needles (1), and would always put an identifier on them (6), dispose of them carefully (14) and would not inject in a public space (15). She expresses her horror (9) and disappointment at discovering that she had used another's works and had thus contracted HIV (13). This narrative also emphasizes other risks such as homelessness (4), sex working (3) to fund a cocaine habit (13) and the dangers of social drug (3) use with a treacherous drug buddy who did not alert her to his HIV positive status. She received her HIV diagnosis in prison (12), given her marginalized

*R: I have shared works and that's how I got the hepatitis. And then one day last year I was with a girl and she has the HIV. We were actually out one night and we got cocaine off somebody. And I actually brought her home back to the hostel. And we went to IV cocaine, and she was after putting her needle, her works into me and she only realised, or so she said, she only realised that she put the wrong needle in, that it was hers. And it was after being used already because she had HIV. So my head was wrecked, for the whole three months I had to wait for the* 

equipment or accidentally using another's equipment, for example, Eileen explained:

**12. Risk and risk management in participants' accounts** 

author's accompanying analysis and interpretation is presented.

position she may never had had a blood test for in a treatment service.

treatment while in prison [1].

*antibodies and all to come back.* 

at the time.

#### **10. Findings**

The women and men interviewed were white indigenous Irish people; the vast majority were from Dublin, and all, but one, were living in Dublin at the time of interview. In addition many respondents reported other vulnerabilities such as being homeless, two had spent many years in residential care systems, four were in prison at the time of the interview either serving a sentence or on remand; four women had recently been released from prison and were living in transitional accommodation (specifically for women released from prison). Nine were living in emergency accommodation, most in city centre hostels and nine were living in the private rented sector. Four were living in the parental home or were staying with friends. In many cases, their marginality was compounded by the loss of their children, many were parents (24 women and one man) but the majority had put their children into care which substantially added to their distress and to their drug use. A brief outline of participants' reported drug use sets the context for reading their accounts of managing risk in their daily lives and work.

#### **11. Illicit drug use and treatment experience**

Research participants [were asked about their use of a range of substances in the 90 days prior to interview. Although 88 per cent of participants were on prescribed methadone, 65 per cent also reported recent heroin use, 29 per cent reported cocaine use, and 15 per cent reported crack cocaine use. Participants who were actively involved in sex work at the time of interview were more likely to report the use of all substances [1].

All 35 participants had a history of injecting drug use: 53 per cent reported injecting in the 90 days preceding interview, and seven were high frequency injectors (they reported daily injecting in the preceding 90 days, with five of them injecting more than four times per day in that period). Four of these high frequency injectors were injecting cocaine daily [1].

Participants reported a high level of contact with healthcare services: 64.7 per cent reported having had a health check in the 90 days prior to interview. Almost all also reported having been tested for HIV (figures for reported infection have been given above). Over threequarters of the study participants (78.1 per cent) had had a positive HCV diagnosis; 26.7 per cent said that they had received information about the virus, 36.7 per cent reported having received an onward referral; however, only 13.3 per cent (n=4) reported having ever received treatment for HCV. Less than half the sample (43.8 per cent) reported having received the hepatitis B vaccine, and 17.2 per cent had received it in the last three months; 19.4 per cent had received confirmation that the vaccine had worked. Only one of the study participants reported receiving the combination interferon and ribavirin HCV treatment and three of the women were receiving HIV triple therapy treatment; all three commenced treatment while in prison [1].

#### **12. Risk and risk management in participants' accounts**

280 Immunodeficiency

**9. Data analysis** 

**10. Findings** 

[1].

denotes 'Interviewer' and R denotes 'Respondent'.

managing risk in their daily lives and work.

**11. Illicit drug use and treatment experience** 

of interview were more likely to report the use of all substances [1].

The researchers fully immersed themselves in the data by listening repeatedly to the recordings. All interviews were fully transcribed. Emerging themes and trends were identified in the data as were comparative data. Inductive analysis of the qualitative data was facilitated by the use of QSR NVivo software, and quantitative data were analysed using the statistical package for the social sciences (SPSS). In the following accounts, I

The women and men interviewed were white indigenous Irish people; the vast majority were from Dublin, and all, but one, were living in Dublin at the time of interview. In addition many respondents reported other vulnerabilities such as being homeless, two had spent many years in residential care systems, four were in prison at the time of the interview either serving a sentence or on remand; four women had recently been released from prison and were living in transitional accommodation (specifically for women released from prison). Nine were living in emergency accommodation, most in city centre hostels and nine were living in the private rented sector. Four were living in the parental home or were staying with friends. In many cases, their marginality was compounded by the loss of their children, many were parents (24 women and one man) but the majority had put their children into care which substantially added to their distress and to their drug use. A brief outline of participants' reported drug use sets the context for reading their accounts of

Research participants [were asked about their use of a range of substances in the 90 days prior to interview. Although 88 per cent of participants were on prescribed methadone, 65 per cent also reported recent heroin use, 29 per cent reported cocaine use, and 15 per cent reported crack cocaine use. Participants who were actively involved in sex work at the time

All 35 participants had a history of injecting drug use: 53 per cent reported injecting in the 90 days preceding interview, and seven were high frequency injectors (they reported daily injecting in the preceding 90 days, with five of them injecting more than four times per day in that period). Four of these high frequency injectors were injecting cocaine daily

Participants reported a high level of contact with healthcare services: 64.7 per cent reported having had a health check in the 90 days prior to interview. Almost all also reported having been tested for HIV (figures for reported infection have been given above). Over threequarters of the study participants (78.1 per cent) had had a positive HCV diagnosis; 26.7 per While all participants reported using needle exchanges to access sterile injecting equipment, most admitted to engaging in unsafe injecting practices in the past. Because they had commenced illicit drug use at a young age, many were unaware of the attendant risks of contracting HIV/HCV at the time and in any case were unable to access sterile injecting equipment, because there were limited harm reduction interventions in Dublin at the time.

Some spoke about recent occasions where they put themselves at risk by sharing injecting equipment or accidentally using another's equipment, for example, Eileen explained:

*R: I have shared works and that's how I got the hepatitis. And then one day last year I was with a girl and she has the HIV. We were actually out one night and we got cocaine off somebody. And I actually brought her home back to the hostel. And we went to IV cocaine, and she was after putting her needle, her works into me and she only realised, or so she said, she only realised that she put the wrong needle in, that it was hers. And it was after being used already because she had HIV. So my head was wrecked, for the whole three months I had to wait for the antibodies and all to come back.* 

Despite having access to sterile needles, Úna explained how she unwittingly used a friend's equipment because she was in the throes of withdrawal. This account highlights the struggle to maintain safe practices in a very risky, unsafe environment with an irresponsible drug using friend who was HIV positive. This detailed narrative has been tabulated to facilitate reading. Úna's account is presented in the left hand column where it is broken into numbered blocks to highlight the main topic focus in each. In the right hand column the author's accompanying analysis and interpretation is presented.

In the above account Úna describes how she always accessed sterile needles (1), and would always put an identifier on them (6), dispose of them carefully (14) and would not inject in a public space (15). She expresses her horror (9) and disappointment at discovering that she had used another's works and had thus contracted HIV (13). This narrative also emphasizes other risks such as homelessness (4), sex working (3) to fund a cocaine habit (13) and the dangers of social drug (3) use with a treacherous drug buddy who did not alert her to his HIV positive status. She received her HIV diagnosis in prison (12), given her marginalized position she may never had had a blood test for in a treatment service.


What I Knew was What I Learnt on the Street!

Pride in strict hygiene

apartment blocks

Rejects reckless practices of those who inject in public spaces such as the stairs in

sex working

practices

Links between cocaine use and

Irish Drug Using Sex Workers Accounts of How They Contracted HIV and Hepatitis C 283

Úna's account Analysis

12. I knew that I was after catching it from him. I was after being stopped [cocaine] for a while and I was after getting back on the coke then and he was the only one then I was hanging around with and that I was going and getting drugs with. He was the only one that I knew I was after

13. I was always careful about my needles and all. And I'd always clean up after myself and I'd wrap them up well and I'd throw them out, you know like. I'd never leave them

14. I'd never, like, up in X Apartment Block they'd all sit round the stairs and you'd come up, they'd have their trousers

Yolanda has also contracted HIV and Hep C from sharing needles.

*I: Do you think that you might have accidentally used other peoples?* 

*R: I don't know, I just think I shared with other people.* 

*of the way it runs; so many behind you. It's ridiculous.* 

*I: So thinking back to that period, would you have shared needles?* 

*I'll never do this again. I'd rather go sick. I'd never try prostitution again.* 

15. I'd never do anything like that. Asserts own carefulness

Carol talked about her lack of knowledge and ignorance of how blood borne viral infections

*I: But at that time, because you were very young did you know anything about needles?* 

*R: I knew nothing about nothing. What I knew was what I learnt on the street. That's where I learned how to inject from someone else showing me. I knew nothing at the time. I didn't know anything really about hepatitis till I went in for clinics to get off methadone, to get clean completely and that was seven years ago. Other than that I knew nothing about nothing. I knew nothing. Nobody tells you anything. You have Hep C and that's the end of it. There's no one telling you what hepatitis is, or anything like and to get to the doctor, now you ring the doctor and you have to wait three months to see the doctor. When you go into the doctor you're only in there and you could have a list of questions and they only want you in and out real quick because* 

*R: Yes. But I was very fussy, a fussy junkie, people say, but I was. I'd only share with X [my sister] and Y [my child's father] father at the time. Anybody else, no I wouldn't. I was fussy. Even with the prostitution when I had had enough. The last time I had a right cry was when I came home and I was on my knees crying. I never had to score drugs for a few days. I was actually asked to work three or four days non-stop at that time. I was more crying, you know that kind of way. I said* 

down banging [injecting] their groins and all.

*R: I don't know. I knew some of the times.* 

using after because

around or

were transmitted

**Table 1.**


#### **Table 1.**

282 Immunodeficiency

every day. And

he never told me and

but he was sleeping in it as well.

I'd know that was MY works.

looked and I had his works and

me I thought it was my works,

weeks later that I was HIV positive.

Úna's account Analysis

Commitment to safe drug use

Drug buddy enabling and

Enabled to do sex work to fund shared drug use

Buddy enabling shared marginalisation, sleeping in a

Concern for safe injecting by putting identifier on own

Awful horror at discovering that her drug buddy was HIV

Reemphasizes that she would not knowingly use another's

Treacherous, reckless buddy

HIV diagnosis done in prison

Hunger and hurry and impaired judgement due to being in the throes of

Risky relationship

stolen car

syringe

withdrawal

positive

works

Using the other's contaminated syringe

sharing in use

1. I used to go up to [Drugs Treatment Service] and get them

2. I ended up meeting a fella [boy]. He was only a friend ... like, he wasn't a boyfriend or that. He was more like a drug buddy. We used to just go off and get drugs together and

a. he'd give me a lift up to [...] Street every night and he would wait in the car for me and I'd go off, do whatever and come back and he would give me a lift back up to get the drugs. But I was buying drugs for the two of us. He would go up to the park and have a turn-on and then we'd go back out and make more money and that's the way it was going then,

3. I was living on the streets, and we were sleeping in the car, like he was letting me sleep in the car. It was a robbed car

4. So I didn't know that he had HIV. He had it for 14 years, but

5. we ended up going up to the Park one night to have a turnon [inject drugs] and I used to burn the end of me works so

6. And I was dying sick that day and we were just basically rushing to get the drugs into us like, 'cause I was dying sick.

7. And he ended up anyway taking my works and giving me his works. And I didn't know. I didn't cop it until I had my turn-on and then until he was having his turn-on and I copped that the works that he had was my works and I

8. I nearly died. I went mad over it like and a few days later his ex-girlfriend called me, and she was saying to me "I hope you're not using after him, 'cause did he not tell you that he has HIV?". And I said, "No". She said "He has it for

9. I was getting real agitated because I knew that I was after using his works. I didn't use his works knowing that it was his works. I didn't know that it was his works. Like, he gave

10. and he thought – well, I don't know if he knew that he was using my works and I think he did know that I was using

11. I came in here [prison] then and I found out then a few

his works but he didn't open his fuckin' mouth

the last 14 years". She said, "Don't use after him".

[sterile needles]. I always did yea, but then

Yolanda has also contracted HIV and Hep C from sharing needles.


Carol talked about her lack of knowledge and ignorance of how blood borne viral infections were transmitted

*I: But at that time, because you were very young did you know anything about needles?* 

*R: I knew nothing about nothing. What I knew was what I learnt on the street. That's where I learned how to inject from someone else showing me. I knew nothing at the time. I didn't know anything really about hepatitis till I went in for clinics to get off methadone, to get clean completely and that was seven years ago. Other than that I knew nothing about nothing. I knew nothing. Nobody tells you anything. You have Hep C and that's the end of it. There's no one telling you what hepatitis is, or anything like and to get to the doctor, now you ring the doctor and you have to wait three months to see the doctor. When you go into the doctor you're only in there and you could have a list of questions and they only want you in and out real quick because of the way it runs; so many behind you. It's ridiculous.* 

*I: So thinking back to that period, would you have shared needles?* 

*R: Yes. But I was very fussy, a fussy junkie, people say, but I was. I'd only share with X [my sister] and Y [my child's father] father at the time. Anybody else, no I wouldn't. I was fussy. Even with the prostitution when I had had enough. The last time I had a right cry was when I came home and I was on my knees crying. I never had to score drugs for a few days. I was actually asked to work three or four days non-stop at that time. I was more crying, you know that kind of way. I said I'll never do this again. I'd rather go sick. I'd never try prostitution again.* 

Having a baby was a turning point in Yseult's life in that she decided to discontinue the use of illicit substances and stopped engaging in sex work.

What I Knew was What I Learnt on the Street!

Irish Drug Using Sex Workers Accounts of How They Contracted HIV and Hepatitis C 285

*R: I still got HIV from the time I was raped down there. You know like. Every time like I came in here and they asked me: 'Did I have hepatitis C test? And they asked me, "Did I want a HIV test? I don't need a HIV test! The only person I used after was me partner". Other than that I never had unsafe sex apart from three times, I was raped. And it comes back and they told me that I had HIV, I couldn't believe it. I asked for another test just to make sure. And then I accused my partner, they wanted to know what I had done. But I asked him for his results, his* 

*results came back negative. So the only other person I could lead it to was that ... creep...* 

increased their risks of unhygienic injecting practices. For example:

*it on a stairs or just anywhere. (Úna)* 

aware that other sex workers did. For example, Iseult said:

enticement was always the prospect of getting more money.

**13. Condom use** 

*going to.* 

*it … (Carmel)* 

*into the discretion of a toilet where no one sees what you are doing. (Laura)* 

Twelve of the research participants lived in city centre hostels, refuges or emergency accommodation and had experienced homelessness in the past. Due to the lack of a private space, they used semi-public or public environments to administer their injections which

*R: … sometimes I have to take them [drugs] in the toilets of – [drug service]. You're not meant to, you're not allowed to, but people do it, you know what I mean, but I'd use, most of the time I'd use in public toilets. I'd do it on my own … most of the people that I know are on the streets and you're not going to be going with a group of people somewhere to have a turn on. So you go* 

 *… With me like, I'd have to go to a restaurant toilet or sometimes and do it [inject], or like if I was in a car and drive somewhere to the Park or somewhere and do it, but I wouldn't dare do* 

All the men and women interviewed were aware of the risk of contracting and transmitting a range of sexually transmitted infections, including HIV and HCV infection if they did not use condoms. The vast majority reported always using condoms while working. However, most said that although they did not have sex with a customer without a condom, they were

*R: … like you'd get a fella that would come up to you: 'Will you have sex without a condom?' and I'd say, 'No way!' and next of all, say a girl that was standing down there, a couple of yards away, she would jump into the car, but I know what he is after asking, and I do be thinking: 'Jesus Christ, she is going to bring that home' and he is bringing that [HIV] home, and then he is going to come back out here next week. And the next stupid girl that gets in the car with him is* 

Among the few who reported having unprotected sex with a paying customer, the

*R: But I never ended up catching anything else 'cause I used to say, if they wanted to do it without a johnnie [condom], I used to put up the price. But they'd have to be sorta clean, or if there was someone who sorta that has a bird [girl friend] or something. … I even let some young fellas use without a condom, but I used to put the price up, sure, they used to think it was worth* 

*I: And what about blood test for HIV or Hepatitis C?* 

*R: Yes I have Hepatitis C. And the last blood test I had was after I had him. But I haven't turned on [injected] or used or anything like that since then, so I don't think I have HIV and I didn't go for any other blood tests. But when he was born I was HIV negative and Hep C positive.* 

*I: When was that last test?* 

*R: Well he is two now, so it was about two years ago. I don't go into all the risks that I would have taken when I was using.* 

Florence felt that using cocaine was the factor which precipitated her throwing caution to the wind and asked her friend to inject her with equipment that turned out to be contaminated.

*R: … the time I got the hepatitis C, 'cause when I was on the coke, I, it's like, with gear you have a conscience, but with coke you don't and this young fella, now, I wasn't going out with him, we were just friends, but I couldn't get meself, so I needed him to get me, and that's how, I got hepatitis from him. I knew he had hepatitis and I still used, we just threw the works on the table and whichever …* 

Mary was unsure as to whether or not she was HIV positive, one doctor had said she was and another had said she wasn't.

*R: ... when he told me, I nearly collapsed, because at the time I wasn't sleeping around. When I was working I wore condoms. I never shared a needle in my life. I was always scrupulous clean, spotless like. If I had a turn on, I'd have everything ready down to tissue, water, and you know the way if you're injecting with a few friends, and they say do you want me to clean that out, I say oh Jesus, no. I don't know whether I'm sick or not. What do you mean, sick or not? I say I don't know if I have the virus or not I'd say. I'd have a tissue, I'd have a bag. I'd have a tissue in the bag for squirting the watery blood into. I don't know if I have or not. I'm not in denial.... they just told me that they were sorry, because I was after giving 3 signatures for Hepatitis A, B and C. And then it came back with like a print, except it was writ in pen, but photocopied and HIV. But I didn't sign for any HIVs to be done. They told me, "Sorry you haven't any hepatitis (s) but it's very unusual for you to be HIV" because when I went to the hospital they told me they couldn't detect any virus in my body. So that's why I was to get it re-checked because I am still convinced that I haven't got it. And that's why I don't like answering questions about because I'm not sure if I have it or not. One place told me I had it and the other place told me I hadn't. And that's why I went up to James's Hospital* 

Angels contracted HIV as a result of being raped.

*R: I still got HIV from the time I was raped down there. You know like. Every time like I came in here and they asked me: 'Did I have hepatitis C test? And they asked me, "Did I want a HIV test? I don't need a HIV test! The only person I used after was me partner". Other than that I never had unsafe sex apart from three times, I was raped. And it comes back and they told me that I had HIV, I couldn't believe it. I asked for another test just to make sure. And then I accused my partner, they wanted to know what I had done. But I asked him for his results, his results came back negative. So the only other person I could lead it to was that ... creep...* 

Twelve of the research participants lived in city centre hostels, refuges or emergency accommodation and had experienced homelessness in the past. Due to the lack of a private space, they used semi-public or public environments to administer their injections which increased their risks of unhygienic injecting practices. For example:

*R: … sometimes I have to take them [drugs] in the toilets of – [drug service]. You're not meant to, you're not allowed to, but people do it, you know what I mean, but I'd use, most of the time I'd use in public toilets. I'd do it on my own … most of the people that I know are on the streets and you're not going to be going with a group of people somewhere to have a turn on. So you go into the discretion of a toilet where no one sees what you are doing. (Laura)* 

 *… With me like, I'd have to go to a restaurant toilet or sometimes and do it [inject], or like if I was in a car and drive somewhere to the Park or somewhere and do it, but I wouldn't dare do it on a stairs or just anywhere. (Úna)* 

#### **13. Condom use**

284 Immunodeficiency

*positive.* 

contaminated.

*Hospital* 

Angels contracted HIV as a result of being raped.

*I: When was that last test?* 

*have taken when I was using.* 

*table and whichever …* 

and another had said she wasn't.

Having a baby was a turning point in Yseult's life in that she decided to discontinue the use

*R: Yes I have Hepatitis C. And the last blood test I had was after I had him. But I haven't turned on [injected] or used or anything like that since then, so I don't think I have HIV and I didn't go for any other blood tests. But when he was born I was HIV negative and Hep C* 

*R: Well he is two now, so it was about two years ago. I don't go into all the risks that I would* 

*R: … the time I got the hepatitis C, 'cause when I was on the coke, I, it's like, with gear you have a conscience, but with coke you don't and this young fella, now, I wasn't going out with him, we were just friends, but I couldn't get meself, so I needed him to get me, and that's how, I got hepatitis from him. I knew he had hepatitis and I still used, we just threw the works on the* 

Florence felt that using cocaine was the factor which precipitated her throwing caution to the wind and asked her friend to inject her with equipment that turned out to be

Mary was unsure as to whether or not she was HIV positive, one doctor had said she was

*R: ... when he told me, I nearly collapsed, because at the time I wasn't sleeping around. When I was working I wore condoms. I never shared a needle in my life. I was always scrupulous clean, spotless like. If I had a turn on, I'd have everything ready down to tissue, water, and you know the way if you're injecting with a few friends, and they say do you want me to clean that out, I say oh Jesus, no. I don't know whether I'm sick or not. What do you mean, sick or not? I say I don't know if I have the virus or not I'd say. I'd have a tissue, I'd have a bag. I'd have a tissue in the bag for squirting the watery blood into. I don't know if I have or not. I'm not in denial.... they just told me that they were sorry, because I was after giving 3 signatures for Hepatitis A, B and C. And then it came back with like a print, except it was writ in pen, but photocopied and HIV. But I didn't sign for any HIVs to be done. They told me, "Sorry you haven't any hepatitis (s) but it's very unusual for you to be HIV" because when I went to the hospital they told me they couldn't detect any virus in my body. So that's why I was to get it re-checked because I am still convinced that I haven't got it. And that's why I don't like answering questions about because I'm not sure if I have it or not. One place told me I had it and the other place told me I hadn't. And that's why I went up to James's* 

of illicit substances and stopped engaging in sex work.

*I: And what about blood test for HIV or Hepatitis C?* 

All the men and women interviewed were aware of the risk of contracting and transmitting a range of sexually transmitted infections, including HIV and HCV infection if they did not use condoms. The vast majority reported always using condoms while working. However, most said that although they did not have sex with a customer without a condom, they were aware that other sex workers did. For example, Iseult said:

*R: … like you'd get a fella that would come up to you: 'Will you have sex without a condom?' and I'd say, 'No way!' and next of all, say a girl that was standing down there, a couple of yards away, she would jump into the car, but I know what he is after asking, and I do be thinking: 'Jesus Christ, she is going to bring that home' and he is bringing that [HIV] home, and then he is going to come back out here next week. And the next stupid girl that gets in the car with him is going to.* 

Among the few who reported having unprotected sex with a paying customer, the enticement was always the prospect of getting more money.

*R: But I never ended up catching anything else 'cause I used to say, if they wanted to do it without a johnnie [condom], I used to put up the price. But they'd have to be sorta clean, or if there was someone who sorta that has a bird [girl friend] or something. … I even let some young fellas use without a condom, but I used to put the price up, sure, they used to think it was worth it … (Carmel)* 

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 that.'

What I Knew was What I Learnt on the Street!

Irish Drug Using Sex Workers Accounts of How They Contracted HIV and Hepatitis C 287

*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* 

*I: Do you think in terms of starting that it was more to do with just the fact that you were* 

*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* 

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

*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* 

*I: But would you think it is separate between, you weren't doing the prostitution in terms of* 

*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,

*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* 

*insane like. I wasn't the only one. There were a good few of us around, you know.* 

*really using heroin intravenously.* 

*homeless and had nowhere to live.* 

*addicted at that time.* 

commenced alcohol and illicit drug use at the age of 12.

*the money for the drinking or the tablets? Were the two connected?* 

their addiction issues and the difficulties of negotiating condom use with clients.

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 HIV.


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