Vol.:(0123456789) 1 3 AIDS and Behavior https://doi.org/10.1007/s10461-018-2039-z ORIGINAL PAPER Exchange Sex Among Persons Who Inject Drugs in the New York Metropolitan Area: The Importance of Local Context, Gender and Sexual Identity Suzan M. Walters 1  · Alexis V. Rivera 4  · Kathleen H. Reilly 4  · Bridget J. Anderson 2  · Barbara Bolden 3  · Afework Wogayehu 3  · Alan Neaigus 5  · Sarah Braunstein 4 © Springer Science+Business Media, LLC, part of Springer Nature 2018 Abstract Exchanging sex for money or drugs is known to increase risk for HIV among persons who inject drugs (PWID). To better understand determinants of exchange sex among PWID we examined factors associated with exchange sex in the New York metropolitan area—defned as New York City (NYC), NY; Newark, NJ; and Long Island, NY—using data from the 2012 National HIV Behavioral Surveillance system cycle on injection drug use. Of the 1160 PWID in this analysis, 24% reported exchange sex, with diferences in gender and sexual identity by location. In multivariable analysis gay/bisexual men, het- erosexual women, and lesbian, gay, or bisexual (LGB) women were more likely to exchange sex compared to heterosexual men. Exchange sex was also associated with race/ethnicity, homelessness, incarceration, location, and non-injection crack and cocaine use. We fnd that heterosexual women and LGB women who injected drugs residing in Newark were more likely to report exchange sex compared to NYC. This study highlights how local conditions impact exchange sex. Keywords Exchange sex · Injection drug use · Sexualities · Inequalities · LGB Introduction People who inject drugs (PWID) face dual risk for HIV infection from sharing contaminated syringes and equip- ment as well as through sexual transmission [1, 2]. Although many PWID engage in both types of risk behaviors [1, 3], a 2011 study conducted among drug detoxifcation patients at Beth Israel Medical Center in New York City (NYC), suggested that most recent HIV infections among PWID occurred through sexual transmission rather than injection drug use [4]. Since the study was conducted among PWID in treatment the results likely cannot be generalizable to all PWID. However, Walters et al. documented higher rates of condomless sex (64%) than injection sharing (32%) among women who injected drugs in NYC, which supports the claim that sexual transmission is a high risk for PWID [5]. HIV risk is further complicated because PWID may transmit HIV to their partners (who may not inject drugs) through condomless sex [6]. A sexual risk behavior linked to higher risk for HIV among PWID is exchange sex (the act of selling sex in exchange for money or goods) [7–10]. Exchange sex is an act that is part of the broader category of sex work and has been noted to fall in between commercial sex work and exchange for gifts from romantic partners [11]. Studies have shown that among women who inject drugs, those who exchange sex are at higher risk for HIV [12, 13]. Exchange sex has also been associated with higher prevalence and risk for HIV among men, but less data exists on this association specif- cally among men who inject drugs [14–18]. Furthermore, * Suzan M. Walters suzanmwalters@gmail.com 1 Department of Sociology, State University of New York at Stony Brook, 152-11 Union Turnpike Apt 3A, Flushing, Stony Brook, NY 11367, USA 2 New York State Department of Health, Ofce of Public Health, Albany, NY, USA 3 Division of HIV, STD and TB Services, New Jersey Department of Health, Trenton, NJ, USA 4 New York City Department of Health and Mental Hygiene, Bureau of HIV/AIDS Prevention and Control, New York, NY, USA 5 Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA