Transactional sex among adults accessing sexual health services in Alabama, 2008-2022: Prevalence, associated risk factors, and associations with HIV, HCV, and STI diagnosis

Abstract

Background: 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.

Keywords: Alabama; HIV; Sex Work; Sexually transmitted diseases/epidemiology.