about HIV/AIDS risk factors (40 percent) than to rarely or never ask patients under 30 (7

percent). Older persons may not be comfortable disclosing their sexual behaviors or substance

abuse to others, since their generation or culture may not encourage such disclosures. This can

make finding treatment programs and support programs especially difficult.

Certainly, there is a need to educate service providers about the sex- and substance-related

behaviors of older persons. At the very least, service providers should conduct thorough sex and

substance abuse risk assessments with their patients over 50, and challenge all assumptions that

older people do not engage in these activities or will not discuss them.

Sex industry workers

Among sex workers, street prostitutes are the most vulnerable to HIV infection, given the

coexisting features of poverty, homelessness, history of childhood sexual abuse, and alcohol and

drug dependence. Comparatively, male and female sex workers who work in massage parlors,

escort services, their own apartments, or brothels rather than on the street are far less likely to be

at risk for infection, less likely to depend on substances, and more likely to control sexual

transactions and insist on condom use.

Seroprevalence rates among sex workers vary dramatically. A 1990 study of nearly 1,400 sex

workers in six U.S. cities yielded a seroprevalence rate of 12 percent, ranging from 0 to 47

percent as a function of the city and the level of injection substance abuse. Most alarming was

the high association of injection substance abuse and HIV infection rate.

Among female sex workers, IDU continues to be the major cause of HIV infection. Female

injection drug users who trade sex for money or drugs are more likely to share syringes than

injection drug users who do not exchange sex for money or drugs. Drug use also increases the

likelihood of sex work and risky sex. Studies of crack cocaine abusers in three urban

neighborhoods found that 68 percent of the women who were regular crack smokers exchanged

sex for drugs or money. Of those, 30 percent had not used a condom in 30 days. Recent research

has also demonstrated an association between HIV infection, heavy crack use, and unprotected

fellatio. This is likely due to the combination of poor dental hygiene, damage to the mouth from

hot crack stems or pipes, high frequency of fellatio, and inconsistent or marginal condom use.

Street-based sex workers may agree to unprotected sex if clients offer more money, if workers

themselves are desperate for money to buy drugs, or if activity has been slow.

HIV treatment challenges may occur given the sex workers' more immediate needs for drugs,

food, and housing. These needs overshadow future concerns about living with HIV/AIDS.

Beyond this, sex workers with HIV/AIDS may continue to work routinely for the purpose of

exchanging sex for drugs or money. Sex workers thus run risks of spreading HIV/AIDS as well

as reinfection of HIV and the acquisition and transmission of other diseases such as hepatitis and

STDs.

There are many examples of effective treatment programs for sex workers with substance abuse

disorders, including the California Prostitutes Education Project (CAL-PEP); Sisters Helping

Each Other in Chicago, Illinois; Second Chance in Toledo, Ohio; the Threshold Project in