Condom use and prevalence of sexually transmitted infection among performers in the adult entertainment industry

Sir: In their recent report, Coyne et al. ¹ reported low rates of consistent condom use and high prevalence of sexually transmitted infections (STI) among patients attending their clinic who work in the adult entertainment industry (AEI). This mirrors our own experience, with some notable differences. We present data on AEI performers attending our clinic, including some additional information, which we hope will be of interest.

We performed a retrospective case note review of AEI performers attending our designated sex worker clinics. Thirty-seven performers were identified; median age 32.6 years. Fifteen were women, 14 were heterosexual men and eight were men who have sex with men (MSM). Most were either British (78%) or Eastern European (16%). Although a small number of patients, collectively they had attended for over 400 sexual health screens.

In keeping with the data presented by Coyne et al., condom use on set was uncommon, although interestingly, MSM reported higher rates of consistent use than either women or heterosexual men (25% versus 0% versus 7%, respectively). However, this was not the case with regular partners (25% versus 30% versus 33%). All MSM reported anal intercourse on set, while a lower, but significant nonetheless, proportion of heterosexuals reported this (34%).

We also observed high rates of STIs (see Table 1). Chlamydia was the most frequent diagnosis, but this may be due to the higher proportion of MSM in our cohort, who exhibited higher rates of Chlamydia than the other two groups. The other notable difference is the lower rate of non-specific infections observed, although this may be because urethral smears are no longer performed on asymptomatic men attending our centre.

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Table 1

STIs diagnosed among AEI performers attending the Jefferiss Wing

	MSM (n = 8)	Heterosexual men (n = 14)	Women (n = 15)
Chlamydia	9	2	7
Non-specific infection*	12	3	2
Gonorrhoea
Pharyngeal only	1	1	0
Rectal only	2	0	3
Urethral only	1	0	0
2+ sites	2	1	3
Genital warts	5	2	4
Molluscum contagiosum	2	1	1
Genital HSV	0	1	1
Infectious syphilis	1	0	0
Pubic lice	1	0	0
Total number of STI diagnoses	36	11	22
Total number of STI screens performed	123	135	172
Number of STIs diagnosed per 100 STI screens	29.3	8.1	12.2

*Non-specific infection defined as chlamydia-negative non-specific urethritis, proctitis, epididymo-orchitis, cervicitis or pelvic inflammatory disease

AEI = adult entertainment industry; STI = sexually transmitted infection; MSM = men who have sex with men; HSV = herpes simplex

A minority of women and heterosexual men were involved with conventional sex work (33% and 7% respectively), compared with 75% of MSM. Likewise, a smaller proportion of the former groups admitted non-injecting recreational drug use (20% and 14%, respectively), compared with MSM (38%). No patients in the study reported injecting drug use.

Despite marginally higher on set condom use, STIs were significantly more common in MSM compared with both women and heterosexual men. There may be numerous other factors predisposing to STI transmission in MSM performers, such as higher rates of anal intercourse, multiple on set sexual partners, increased frequency of film-making and lower requirement for certification. Also, it is very likely that behaviours exhibited outside of the AEI are impacting rates of STI acquisition among MSM performers, such as low condom usage (especially for oral intercourse), recreational drug use and commercial sex work.

Although there were no cases of HIV transmission among our cohort, these data clearly identify the high-risks associated with working in the AEI, particularly for MSM. Indeed, we found that three out of eight MSM had taken HIV postexposure prophylaxis, two following potential exposures at work. Even if monthly certification became a legal requirement, this would not ensure the safety of AEI performers as it would be impossible to enforce safe sex outside the constraints of the industry. Although the obvious solution would be widespread condom use, this is clearly an unrealistic goal. As health providers, perhaps we need to consider alternative strategies to reduce the risk of HIV transmission, such as the use of combined HIV antibody/antigen assays that shorten the window period. Future microbicide and pre-exposure prophylaxis trials should target AEI performers as they are a well-defined population who already attend genitourinary services on a frequent basis, and are likely to be amenable to non-barrier methods of reducing the risk of HIV transmission.