Available online 13 February 2024

Author links open overlay panel, , , , , ABSTRACTBackground

The U.S. Deep South bears a disproportionate burden of HIV and other STIs. Transactional sex may influence these epidemics, but few studies have estimated its prevalence or correlates in the Deep South.

Methods

We estimated the history of transactional sex among adults accessing an Alabama AIDS Service Organization from 2008-2022, using chi-square tests to examine its sociodemographic and behavioral correlates. We used modified Poisson regression with cluster-robust standard errors to estimate adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) for the associations between transactional sex and new HIV, hepatitis C (HCV), and STI diagnoses.

Results

Transactional sex was reported at 944/20,013 visits (4.7%) and associated with older age, being a cisgender woman or gender minority, identifying as white, diverse drug use, and sharing of drug equipment. Compared to others, clients reporting transactional sex had increased prevalence of syphilis (apR 3.60, 95% CI 1.16-11.19) and HCV (aPR 1.53, 95% CI 1.24-1.88).

Conclusion

Using 14 years of community-based data, this study is the first to estimate the relationship between transactional sex and HIV, HCV, and STIs in Alabama and highlights the need address STI burden and diverse drug use among people who transact sex in the Deep South.

Section snippetsBACKGROUND

The U.S. South represents 38% of the U.S. population, but as of 2020 more than 50% of new U.S. HIV diagnoses occurred in the region [1]. HIV and other health-related outcomes are poorer in states comprising the “Deep South,” including Alabama [2]. In Alabama, 16% of people with HIV (PWH) are unaware of their status, and as of 2020 only 49% of Alabamans newly diagnosed with HIV are retained in HIV care [3]. In 2019, more than 20% of new HIV infections occurred in Jefferson County, home to the

Data Collection

These data were collected as part of routine service provision among clients accessing services at a Birmingham, Alabama-based AIDS Service Organization (ASO) between May 2008 and June 2022. Established in 1985, the ASO was the first non-profit, community-based organization dedicated to providing HIV prevention education and support services for at-risk communities and people with HIV in Alabama. While the ASO is based in Birmingham, many of its clients travel from other areas of Alabama to

Prevalence of transactional sex and outcomes

The prevalence of historical transactional sex over the entire study period was 4.7% (ranging from a low of 0% in 2008 to a high of 7.3% in 2014). The most prevalent diagnoses during the study period were HCV (19.4%), chlamydia (9.2%), and gonorrhea (7.4%). Prevalence of syphilis was 2.1%, of trichomoniasis was 3.0%, and of HIV was 0.7%.

STI diagnoses were minimal from 2008-2015 (Fig. 1). Diagnoses of chalmydia peaked at 11.9% in 2020; gonorrhea at 8.8% in 2018; trichomoniasis at 4.6% in 2022;

DISCUSSION

This is among the first analyses to examine transactional sex and its relationships with other behavioral characteristics and STI outcomes in a Deep South context. Among clients accessing an ASO in Alabama, transactional sex was associated with identifying as a gender minority adult, identifying as non-Hispanic White, and with higher rates of diverse (injection and non-injection) drug use. In this sample, a history of transactional sex was associated with increased HCV prevalence.

Although our

Conclusion

Our study addresses a near total dearth of data regarding transactional sex in the Deep South, a region disproportionately impacted by HIV and other STIs. Using 14 years of data, our findings highlight the need for continued high-quality data that is attentive to risk and resilience among individuals who transact sex in Deep South communities and explores transactional sex’s relationship with intersectional identities and risk behaviors. We suggest that to best address the health concerns of

FUNDING

This work was partially supported by the National Institute of Mental Health (R25MH083620).

CRediT authorship contribution statement

Musgrove Karen: Data curation, Funding acquisition, Project administration, Writing – review & editing. MacCarthy Sarah: Conceptualization, Supervision, Writing – review & editing. Kellar Polly: Data curation, Project administration, Writing – review & editing. Atkins Kaitlyn: Conceptualization, Formal analysis, Writing – original draft, Writing – review & editing. Kay Emma Sophia: Project administration, Writing – review & editing, Conceptualization. Bruce Josh: Data curation, Project

Declaration of Competing Interest

The authors have no competing interests to declare.

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