Journal of Urban Health

, Volume 88, Issue 2, pp 329–341 | Cite as

Patterns of Exchange Sex and HIV Infection in High-Risk Heterosexual Men and Women

  • Samuel M. JennessEmail author
  • Paul Kobrak
  • Travis Wendel
  • Alan Neaigus
  • Christopher S. Murrill
  • Holly Hagan


Heterosexual partnerships involving the trade of money or goods for sex are a well-described HIV risk factor in Africa and Southeast Asia, but less research has been conducted on exchange partnerships and their impact on HIV infection in the United States. In our study, men and women were recruited from high-risk risk neighborhoods in New York City through respondent-driven sampling in 2006–2007. We examined the factors associated with having an exchange partner in the past year, the relationship between exchange partnerships and HIV infection, and the risk characteristics of those with exchange partners by the directionality of payment. Overall, 28% of men and 41% of women had a past-year exchange partner. For men, factors independently associated with exchange partnerships were older age, more total sexual partners, male partners, and frequent non-injection drug use. For women, factors were homelessness, more total sexual partners, more unprotected sex partners, and frequent non-injection drug use. Exchange partnerships were associated with HIV infection for both men and women, although the relationships were substantially confounded by other behavioral risks. Those who both bought and sold sex exhibited the highest levels of risk with their exchange and non-exchange partners. Exchange partnerships may be an HIV risk both directly and indirectly, given the overlap of this phenomenon with other risk factors that occur with both exchange and non-exchange partners.


HIV Heterosexual Behavioral risk Exchange sex Prostitution 



The authors would like to acknowledge Elizabeth DiNenno, Amy Drake, Amy Lansky, and Isa Miles of the Centers for Disease Control and Prevention for their contributions to the NHBS study design; Blayne Cutler, James Hadler, and Colin Shepard for reviewing earlier drafts of this paper; and all the efforts of the NYC NHBS field staff. This work was funded by a cooperative agreement between the New York City Department of Health and Mental Hygiene and the Centers for Disease Control and Prevention (grant no. U62/CCU223595-03-1).


  1. 1.
    Cowan FM, Langhaug LF, Hargrove JW, et al. Is sexual contact with sex workers important in driving the HIV epidemic among men in rural Zimbabwe? J Acquir Immune Defic Syndr. 2005; 40(3): 371–376.PubMedCrossRefGoogle Scholar
  2. 2.
    Hor LB, Detels R, Heng S, Mun P. The role of sex worker clients in transmission of HIV in Cambodia. Int J STD AIDS. 2005; 16(2): 170–174.PubMedCrossRefGoogle Scholar
  3. 3.
    Morison L, Weiss HA, Buve A, et al. Commercial sex and the spread of HIV in four cities in sub-Saharan Africa. AIDS. 2001; 15(Suppl 4): S61–69.PubMedCrossRefGoogle Scholar
  4. 4.
    Ankomah A. Condom use in sexual exchange relationships among young single adults in Ghana. AIDS Educ Prev. 1998; 10(4): 303–316.PubMedGoogle Scholar
  5. 5.
    Maganja RK, Maman S, Groves A, Mbwambo JK. Skinning the goat and pulling the load: transactional sex among youth in Dar es Salaam, Tanzania. AIDS Care. 2007; 19(8): 974–981.PubMedCrossRefGoogle Scholar
  6. 6.
    El-Bassel N, Schilling RF, Gilbert L, Faruque S, Irwin KL, Edlin BR. Sex trading and psychological distress in a street-based sample of low-income urban men. J Psychoact Drugs. 2000; 32(3): 259–267.Google Scholar
  7. 7.
    Newman PA, Rhodes F, Weiss RE. Correlates of sex trading among drug-using men who have sex with men. Am J Public Health. 2004; 94(11): 1998–2003.PubMedCrossRefGoogle Scholar
  8. 8.
    Operario D, Soma T, Underhill K. Sex work and HIV status among transgender women: systematic review and meta-analysis. J Acquir Immune Defic Syndr. 2008; 48(1): 97–103.PubMedCrossRefGoogle Scholar
  9. 9.
    Edwards JM, Iritani BJ, Hallfors DD. Prevalence and correlates of exchanging sex for drugs or money among adolescents in the United States. Sex Transm Infect. 2006; 82(5): 354–358.PubMedCrossRefGoogle Scholar
  10. 10.
    Cohan DL, Kim A, Ruiz J, et al. Health indicators among low income women who report a history of sex work: the population based Northern California Young Women’s Survey. Sex Transm Infect. 2005; 81(5): 428–433.PubMedCrossRefGoogle Scholar
  11. 11.
    Dunkle KL, Wingood GM, Camp CM, DiClemente RJ. Economically motivated relationships and transactional sex among unmarried African American and white women: results from a U.S. national telephone survey. Public Health Rep. 2010; 125(Suppl 4): 90–100.PubMedGoogle Scholar
  12. 12.
    Edlin BR, Irwin KL, Faruque S, et al. Intersecting epidemics—crack cocaine use and HIV infection among inner-city young adults. Multicenter crack cocaine and HIV infection study team. N Engl J Med. 1994; 331(21): 1422–1427.PubMedCrossRefGoogle Scholar
  13. 13.
    Astemborski J, Vlahov D, Warren D, Solomon L, Nelson KE. The trading of sex for drugs or money and HIV seropositivity among female intravenous drug users. Am J Public Health. 1994; 84(3): 382–387.PubMedCrossRefGoogle Scholar
  14. 14.
    Latkin CA, Hua W, Forman VL. The relationship between social network characteristics and exchanging sex for drugs or money among drug users in Baltimore, MD, USA. Int J STD AIDS. 2003; 14(11): 770–775.PubMedCrossRefGoogle Scholar
  15. 15.
    Windle M. The trading of sex for money or drugs, sexually transmitted diseases (STDs), and HIV-related risk behaviors among multisubstance using alcoholic inpatients. Drug Alcohol Depend. 1997; 49(1): 33–38.PubMedCrossRefGoogle Scholar
  16. 16.
    Decker MR, Raj A, Gupta J, Silverman JG. Sex purchasing and associations with HIV/STI among a clinic-based sample of US men. J Acquir Immune Defic Syndr. 2008; 48(3): 355–359.PubMedCrossRefGoogle Scholar
  17. 17.
    Bobashev GV, Zule WA, Osilla KC, Kline TL, Wechsberg WM. Transactional sex among men and women in the south at high risk for HIV and other STIs. J Urban Health. 2009; 86(Suppl 1): 32–47.PubMedCrossRefGoogle Scholar
  18. 18.
    Dworkin SL, Ehrhardt AA. Going beyond “ABC” to include “GEM”: critical reflections on progress in the HIV/AIDS epidemic. Am J Public Health. 2007; 97(1): 13–18.PubMedCrossRefGoogle Scholar
  19. 19.
    Higgins JA, Hoffman S, Dworkin SL. Rethinking gender, heterosexual men, and women’s vulnerability to HIV/AIDS. Am J Public Health. 2010; 100(3): 435–445.PubMedCrossRefGoogle Scholar
  20. 20.
    Campsmith ML, Rhodes P, Hall HI, Green T. HIV prevalence estimates—United States, 2006. MMWR Morb Mortal Wkly Rep. 2008; 57(39): 1073–1076.Google Scholar
  21. 21.
    Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA. 2008; 300(5): 520–529.PubMedCrossRefGoogle Scholar
  22. 22.
    Gallagher KM, Sullivan PS, Lansky A, Onorato IM. Behavioral surveillance among people at risk for HIV infection in the U.S.: the National HIV Behavioral Surveillance System. Public Health Rep. 2007; 122(Suppl 1): 32–38.PubMedGoogle Scholar
  23. 23.
    Jenness SM, Murrill CS, Liu KL, Wendel T, Begier E, Hagan H. Missed opportunities for HIV testing among high-risk heterosexuals. Sex Transm Dis. 2009; 36(11): 704–710.PubMedCrossRefGoogle Scholar
  24. 24.
    Karpati AM, Bassett MT, McCord C. Neighbourhood mortality inequalities in New York City, 1989–1991 and 1999–2001. J Epidemiol Community Health. 2006; 60(12): 1060–1064.PubMedCrossRefGoogle Scholar
  25. 25.
    Heckathorn D. Extensions of respondent-driven sampling: analyzing continuous variables and controlling for differential recruitment. Sociol Methodol. 2007; 37(1): 151–207.CrossRefGoogle Scholar
  26. 26.
    Risser JM, Padgett P, Wolverton M, Risser WL. Relationship between heterosexual anal sex, injection drug use and HIV infection among black men and women. Int J STD AIDS. 2009; 20(5): 310–314.PubMedCrossRefGoogle Scholar
  27. 27.
    Johnston L, O’Bra H, Chopra M, et al. The Associations of Voluntary Counseling and Testing Acceptance and the Perceived Likelihood of Being HIV-Infected Among Men with Multiple Sex Partners in a South African Township. AIDS Behav. 2010; 14(4): 922–931.PubMedCrossRefGoogle Scholar
  28. 28.
    Mercer CH, Copas AJ, Sonnenberg P, et al. Who has sex with whom? Characteristics of heterosexual partnerships reported in a national probability survey and implications for STI risk. Int J Epidemiol. 2009; 38(1): 206–214.PubMedCrossRefGoogle Scholar
  29. 29.
    Chatterji M, Murray N, London D, Anglewicz P. The factors influencing transactional sex among young men and women in 12 sub-Saharan African countries. Soc Biol Spring Summer. 2005; 52(1–2): 56–72.Google Scholar
  30. 30.
    Edwards JM, Halpern CT, Wechsberg WM. Correlates of exchanging sex for drugs or money among women who use crack cocaine. AIDS Educ Prev. 2006; 18(5): 420–429.PubMedCrossRefGoogle Scholar
  31. 31.
    Adimora AA, Schoenbach VJ. Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. J Infect Dis. 2005; 191(Suppl 1): S115–122.PubMedCrossRefGoogle Scholar
  32. 32.
    Lane SD, Keefe RH, Rubinstein RA, et al. Marriage promotion and missing men: African American women in a demographic double bind. Med Anthropol Q. 2004; 18(4): 405–428.PubMedCrossRefGoogle Scholar
  33. 33.
    Thomas JC, Torrone E. Incarceration as forced migration: effects on selected community health outcomes. Am J Public Health. 2006; 96(10): 1762–1765.PubMedCrossRefGoogle Scholar
  34. 34.
    Lowndes CM, Alary M, Meda H, et al. Role of core and bridging groups in the transmission dynamics of HIV and STIs in Cotonou, Benin, West Africa. Sex Transm Infect. 2002; 78(Suppl 1): i69–77.PubMedCrossRefGoogle Scholar
  35. 35.
    Lowndes CM, Renton A, Alary M, Rhodes T, Garnett G, Stimson G. Conditions for widespread heterosexual spread of HIV in the russian Federation: implications for research, monitoring and prevention. Int J Drug Policy. 2003; 14: 45–62.CrossRefGoogle Scholar
  36. 36.
    Hallfors DD, Iritani BJ, Miller WC, Bauer DJ. Sexual and drug behavior patterns and HIV and STD racial disparities: the need for new directions. Am J Public Health. 2007; 97(1): 125–132.PubMedCrossRefGoogle Scholar
  37. 37.
    el-Bassel N, Schilling RF, Irwin KL, et al. Sex trading and psychological distress among women recruited from the streets of Harlem. Am J Public Health. 1997; 87(1): 66–70.PubMedCrossRefGoogle Scholar
  38. 38.
    Koblin BA, Husnik MJ, Colfax G, et al. Risk factors for HIV infection among men who have sex with men. AIDS. 2006; 20(5): 731–739.PubMedCrossRefGoogle Scholar
  39. 39.
    The NIMH Multisite HIV/STD Prevention Trial for African American Couples Group. The contribution of male and female partners’ substance use to sexual risks and STDs among African American HIV serodiscordant couples. AIDS Behav. 2010; 14: 1045–1054.CrossRefGoogle Scholar
  40. 40.
    Wee S, Barrett ME, Lian WM, Jayabaskar T, Chan KW. Determinants of inconsistent condom use with female sex workers among men attending the STD clinic in Singapore. Sex Transm Infect. 2004; 80(4): 310–314.PubMedCrossRefGoogle Scholar
  41. 41.
    Crepaz N, Lyles CM, Wolitski RJ, et al. Do prevention interventions reduce HIV risk behaviours among people living with HIV? A meta-analytic review of controlled trials. AIDS. 2006; 20(2): 143–157.PubMedCrossRefGoogle Scholar
  42. 42.
    Lyles CM, Kay LS, Crepaz N, et al. Best-evidence interventions: findings from a systematic review of HIV behavioral interventions for US populations at high risk, 2000–2004. Am J Public Health. 2007; 97(1): 133–143.PubMedCrossRefGoogle Scholar
  43. 43.
    Noar SM. Behavioral interventions to reduce HIV-related sexual risk behavior: review and synthesis of meta-analytic evidence. AIDS Behav. 2008; 12(3): 335–353.PubMedCrossRefGoogle Scholar

Copyright information

© The New York Academy of Medicine 2011

Authors and Affiliations

  • Samuel M. Jenness
    • 1
    Email author
  • Paul Kobrak
    • 1
  • Travis Wendel
    • 2
  • Alan Neaigus
    • 1
  • Christopher S. Murrill
    • 1
  • Holly Hagan
    • 3
  1. 1.New York City Department of Health and Mental HygieneHIV Epidemiology ProgramNew YorkUSA
  2. 2.National Development and Research Institutes, Inc.New YorkUSA
  3. 3.New York University College of NursingNew YorkUSA

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