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Type of Exchange Sex and Associated Behaviors and Outcomes Among Cisgender Men and Women at Increased Risk for HIV via Heterosexual Transmission in Six U.S. Metropolitan Areas


Exchange sex is associated with sexual risk behaviors and poor outcomes and different types may incur different levels of risk. We assessed risk profiles of different types of exchange sex among non-injecting cisgender men and women who participated in the 2019 National HIV Behavioral Surveillance project at six sites. Six percent of men and 19% of women reported exchange sex in the past year; most engaged in non-commercial exchange sex for drugs/money with smaller percentages reporting formal sex work or non-commercial exchange sex for goods or services other than drugs/money. Exchange sex was associated with sexual risk and prevention behaviors and psychosocial and sexual health outcomes and associations varied by type of exchange sex. Efforts to improve access to STI/HIV testing and PrEP may benefit from tailoring based on type of exchange sex. Findings indicate value in a broader definition of exchange sex with follow-up assessment of exchange sex typology.

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Data and Stata v.16 statistical software code are available upon reasonable request.


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The authors would like to acknowledge Jack Marr, Monica Tate, Iran Yarbrough, Bridgette Robinson, Jake Ketchum, Anthony Rivers, Amisha Bhattarai, Megan Redmond, Joseph Ramirez, Genetha Mustaafaa, and other NHBS site coordinators, field supervisors, data managers, and data collection teams without whom this work would not be possible. The authors would also like to acknowledge Ann Sawyer for their careful review of the manuscript. Finally, the authors would like to thank the NHBS participants for their invaluable contributions to research and public health.


This work was supported by the Centers for Disease Control and Prevention PS 16–1601. Baltimore NHBS was supported through a contract to Johns Hopkins University from the Maryland Department of Health.

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T.M., D.G., C.F. and S.G. are principal investigators at their respective sites and provided study leadership and oversight. L.L., C.M., N.B. and D.E. coordinated data collection and data management at their respective sites. L.L. analyzed and interpreted the data. L.L. and T.M. drafted the manuscript. J.G. and D.G. contributed to data interpretation and critical text review. All authors provided feedback on early drafts of the manuscript, and all authors reviewed and approved the final manuscript.

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Correspondence to Lauren E. Lipira.

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The authors have not disclosed any competing interests.

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All procedures were approved by institutional review boards or deemed exempt from review as determined by individual study sites.

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All participants included in this study provided informed consent to participate in the National HIV Behavioral Surveillance project.

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Lipira, L.E., Glick, J.L., German, D. et al. Type of Exchange Sex and Associated Behaviors and Outcomes Among Cisgender Men and Women at Increased Risk for HIV via Heterosexual Transmission in Six U.S. Metropolitan Areas. Arch Sex Behav (2023).

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