Diverse contexts and social factors among young cisgender men and transgender women who sell or trade sex in Bangkok and Pattaya, Thailand: formative research for a PrEP program implementation study

ABSTRACT

HIV incidence is high and persistent among cisgender men who have sex with men (MSM) and transgender women (TGW) who have sex with men, particularly among those who sell or trade sex. In preparation for an open-label combination HIV pre-exposure prophylaxis (PrEP) program for these groups, we conducted formative research to explore the context of sex work/trade and factors that affect implementation of PrEP interventions. This study analyzed interviews with 20 young (aged 18–26 years) MSM and TGW who sell/trade sex and three sex work venue managers in Bangkok and Pattaya, Thailand. Participants described diverse contexts of sex work/trade, including in multiple informal and formal sex venues. Several participants reported mobility across provinces and out of the country, which led to intermittent sex work/trade. TGW sex workers reported challenges with access and cost of femininizing hormones and limited employment opportunities. Factors that could facilitate or challenge PrEP program implementation included HIV stigma, the role of venue management in sexual health practice, lack of PrEP knowledge, lower perceived HIV risk, and interest in personal health and wellbeing. Program implementers must consider myriad factors to successfully implement PrEP among young MSM and TGW engaged in sex work or trade in Thailand.

KEYWORDS:

• HIV
• pre-exposure prophylaxis (PrEP)
• men who have sex with men
• transgender women
• sex work
• Thailand

Introduction

HIV incidence among cisgender men who have sex with men (MSM) and transgender women (TGW) remains high despite significant advances in HIV prevention and treatment (Beyrer et al., 2010, 2012). Young MSM have some of the highest rates of HIV acquisition globally, including in Southeast Asia (Beyrer et al., 2012; Van Griensven et al., 2013). In Thailand, HIV incidence is high among young MSM; HIV incidence was 11.1 per 100 person-years (PY; 95% confidence interval [CI] 6.7–17.4) among young MSM engaged in sex work in the Bangkok MSM Cohort Study (Dunne et al., 2019). Transgender women (TGW) also experience a disproportionate burden of HIV (Baral, Poteat et al., 2013). In Thailand, 12.5% of TGW are estimated to be living with HIV (CI 5.1–19.9) and are 9.9 times (CI 7.8–12.6) more likely to be infected with HIV when compared to all adults of reproductive age (Baral, Poteat et al., 2013).

MSM and TGW who engage in sex work are less frequently considered separately in HIV research but are critical groups for HIV prevention research engagement given heightened acquisition risk (Poteat et al., 2015). Previous research has described the risk environment associated with sex work, including intersectional stigma and discrimination in HIV prevention services, criminalization, and individual barriers to condom use, pre-exposure prophylaxis (PrEP), and HIV testing and counseling (Chemnasiri et al., 2019; Guadamuz et al., 2011). Increased frequency of unprotected anal sex within a non-dense sexual network and unequal power dynamics with clients and sex venue management also challenge HIV prevention (Beyrer et al., 2012; Poteat et al., 2015). In Thailand, sex work settings range from large well-known venues including agogo bars, massage parlors, and saunas; street-based sex work; longer-term sexual partnerships to trade for rent, school, or other financial obligations (so-called “sugar daddy” relationships); and more recently mobile dating applications and online platforms. These settings constitute unique risk environments as it relates to HIV acquisition but also present critical considerations for HIV prevention.

PrEP is one prevention strategy that is often a core component of multi-level, combination HIV prevention services (Bekker et al., 2015). As part of a larger combination prevention trial with daily, oral PrEP (Wirtz et al., 2020), this formative, qualitative study aimed to explore the diverse contexts of sex work among young MSM and TGW and understand the factors that may affect PrEP implementation among MSM and TGW sex worker communities in Thailand.

Methods

The Combination Prevention Effectiveness (COPE) study was a mixed-methods study that aimed to assess the effectiveness and cost-effectiveness of a combination intervention among HIV-uninfected young (aged 18–26 years) MSM and TGW engaged in sex work in Thailand (Wirtz et al., 2020). This analysis is drawn from the formative phase of COPE. The study protocol for this phase has been previously published (Wirtz et al., 2020).

Data collection

Data collection occurred in two phases: July – November 2016, and June – August 2018. In-depth interviews (IDIs) among young MSM and TGW who self-reported selling or trading sex (n = 62) and sex work venue managers (n = 24) were conducted in Thai by two trained qualitative researchers. Interviews were conducted in a private meeting room and spanned 90–120 minutes. Interviews were semi-structured to allow in-depth discussion of the domains outlined by the field guide (Table 1). Interview guides for both young MSM and TGW who sell or trade sex and sex venue management were created with reference to the modified SEM framework and further customized to each respondent population (Baral, Logie et al., 2013). The domains of both interview guides are outlined in Table 1.

Table 1. Interview domains included in semi-structured guides for young MSM and TGW who sell or trade sex and venue management.

		Domains
Young MSM and TGW who sell or trade sex	Individual Level	Experiences and contexts of TGW in sex work/trade
		Experiences and contexts of MSM in sex work/trade
		Knowledge and attitudes toward existing HIV preventive services (e.g., condoms, PrEP, etc.), perceived accessibility of these services, barriers to use of these services (including stigma)
		Knowledge and local practice regarding issues concerning sex and sex with substance use
	Network Level	HIV prevention methods utilized when engaging in sex with diverse sexual partners (e.g., long-term partners, primary partners, clients, etc.)
		Appropriate messaging or logos for HIV prevention-related educational materials
		Localized mechanisms for recruitment into a subsequent HIV combination preventive intervention effectiveness evaluation
		Perceived feasibility and acceptability of PrEP program implementation within the MSM and TGW sex worker community
	Structural Level	Perceived structural-level factors that influence sexual decision making
Venue management	Individual Level	Attitudes and perceptions of HIV status of employees, HIV testing, and worker autonomy, privacy, and choice of HIV status disclosure
	Network Level	Knowledge regarding the contexts and populations of local young MSM and TGW who sell or trade sex
	Structural Level	Perceived ability and barriers to providing HIV-preventive-related health care services to young MSM and TGW in venues or off-site
		Acceptability and perceived barriers to community mobilization

Data management

A subset of 23 out of 86 IDIs conducted in Thai were selected for professional translation into English for further analysis. Available interview transcripts, predominantly from the first round of collection, were selected based on the following: depth of participant responses regarding PrEP knowledge and PrEP uptake experiences, analysis of a maximum variation sample of sexual and gender identities and experiences across work modalities, and a response distribution of a socio-demographic survey that was comparable to and representative of transcripts not selected for translation. Transcripts were identified for translation by the lead qualitative researcher (TC).

Data analysis

The 23 selected interview transcripts were deductively coded and analyzed using a codebook derived from the interview guide domains (Table 1) and stored in ATLAS.ti (Cleverbridge, Inc, Chicago, IL). The qualitative research team (JMT and BJ) coded through two interviews to preliminarily assess the consistency of the codebook. Once coder consensus was established, each team member coded individual interviews and engaged in regular cross-validation to refine the codebook. Emergent themes from the interviews were identified using grounded theory methodology by one research team member (JMT) (Charmaz & Belgrave, 2012). Given that this formative study was exploratory, themes were identified by their relevance to the key research domains or relevance across multiple participants. Constant comparative method (Glaser, 1965) was used to ensure that emergent themes were salient across the interviews. Emergent themes were iteratively evaluated by the research team (JMT, TC, AV) and assigned through inductive coding until thematic saturation was achieved.

Ethical review

The COPE qualitative study protocol received ethical review and approval from the presiding ethics committees and institutional review boards at the Thailand Ministry of Public Health; the Faculty of Tropical Medicine, Mahidol University; the United States Centers for Disease Control and Prevention; and the Johns Hopkins Bloomberg School of Public Health.

Results

Study population

Of the 23 participants included in this analysis, nine participants were young MSM and 11 were young TGW; all sold or traded sex across a range of diverse sex work contexts. Eighteen participants predominately lived in the Bangkok metropolitan area, though relatively high proportions also reported regular mobility across provinces (Table 2).

Table 2. Characteristics of evaluated qualitative participants in Bangkok and Pattaya, Thailand.

Characteristics	MSM	TGW	Venue staff
	(N = 9)	(N = 11)	(N = 3)
Mean age (range)	21 (18–23)	23 (18–26)	33 (27–39)
Modality of sex work or trade^a
Internet-Based	6 (67%)	8 (73%)	1 (33%)
Venue-Based^b	7 (78%)	8 (73%)	3 (100%)
Massage Parlor	4 (44%)	3 (27%)	3 (100%)
Bar	3 (33%)	8 (73%)	1 (33%)
Agogo	1 (11%)	2 (18%)	0 (0%)
Coyote	1 (11%)	0 (0%)	0 (0%)
Street-Based	2 (22%)	6 (55%)	0 (0%)
Individual Financial Support (“Sugar Daddy”)	2 (22%)	3 (27%)	0 (0%)
Multiple Modalities	7 (78%)	9 (82%)	2 (67%)
Sex work or trade city
Bangkok	8 (89%)	10 (91%)	3 (100%)
Pattaya	1 (11%)	1 (9%)	0 (0%)
Migration^c	5 (56%)	9 (82%)	0 (0%)

^a These values represent the different types of sex work modalities participants reported; participants can report working with multiple sex work modalities.

^b Venue-based sex work locations include sex entertainment venues and bars, agogo bars, coyote bars, and massage parlors.

^c Migration refers to participants who report moving between cities or provinces or abroad at least twice, independent of their parents or family.

Contexts of sex work or trade among young MSM and TGW in Thailand

Sex work across multiple modalities

Young MSM and TGW who sell or trade sex reported engaging in sex work at various locations, including bars, massage parlors, and online through websites and apps (Table 2). Some participants also contextualized the changing modalities of work by describing periods of time in which they would pause selling sex at other locations because they had an individual financial supporter, or “sugar daddy.” Most participants described engaging in at least two sex work modalities during a given period. For example, one participant discussed work at a sex work venue, but also sold or traded sex via social media platforms.

The majority of participants reported engaging in internet-based sex work, describing the autonomy afforded by online venues to select clients and negotiate favorable rates, as compared to venue-based sex work. Other participants reported that they had transitioned to internet-based sex work due to the competitive nature of working through other modalities (Table 3).

Table 3. Contexts of sex work or trade among young MSM and TGW in Thailand and supporting quotations.

Topic	Relevant quotations
Sex work across multiple modalities	[Massage parlor-based sex work] is not like taking the job myself (internet-based sex work). Not like posting [online] by myself. See, one day I got almost ten people, about 10,000 [Baht]. Staying at the [massage] parlor, they (venue management) can choose, you know. [The client] must also pay the parlor too. [Participant #20, TGW, Bangkok] “It is competitive [to get a client], like a beauty contest. Everybody is a friend but at last they all want the customer for themselves.” [Participant #5, TGW, Bangkok]
Fluidity of sex work	Interviewer: Why do you go back and forth [between Pattaya and your hometown]? Why don't you stay [in Pattaya] for long? Participant: I had to face a lot of problems, for example, [paying] room rent. I had to go back [home] for a break. I went back to work in a factory. When I have enough money to rent a room, I would come back again  …  It [rent] is expensive. You have to pay five thousand Baht for deposit. When you didn't have a customer for some time, you had to go back home first and came back afterwards. [Participant #12, TGW, Pattaya] I was a monk for a while, and I stopped [selling sex] for years. Not long after I was in monkhood, my grandfather died. No one lived with my grandmother, so I left everything in Bangkok to stay with her, even though I wanted to find a rich supporter (sugar daddy) and could earn at least 1000 Baht if I stayed and worked [at a sex work venue] in Bangkok. [Participant #5, TGW, Bangkok] I worked at the massage parlor for around one month [to pay for university tuition]  …  I went every day because it was already the end of [the university] semester  …  when I had worked for about one month, it was before I went back home  …  I quit [to move back home]. [Participant #17, MSM, Bangkok] I started sex work because [a senior TGW or kathoey] recommended, “hey, if you want money quickly, you [should] work this, this, this (street-based sex work)”  …  she recommended to go to Nana (nightlife hotspot in Bangkok) for the first time [selling sex]. [Participant #23, TGW, Bangkok]
Migration	Interviewer: Do you go to Pattaya often? Participant: Mostly I stay in Bangkok. I haven't gone to Pattaya for a long time. I came to live in Bangkok for three to four months now  …  I will go back home and go there (Pattaya) again. I will go [to Pattaya] at the end of the month  …  end of next month  …  [Selling sex in Pattaya] gets a good rate. [Participant #22, TGW, Bangkok] Interviewer: If you go to Phuket, will it be a long time? Participant: I may be there for a long time. I might not work as a dancer as I used to be. I may work as a clown at Patong. You could get more than 10,000 or 5,000 [Baht] for only a short period of work. These performers shop around and get good tips from foreigners. But next month is not a high season period, I don't know if there will be many people there. [Participant #2, MSM, Bangkok]. Interviewer: About what you said that you went to Korea for a while. Was it last month? Participant: During [last month], I went to Korea. My roommate went first. She asked me to go, so I did  …  Thais can stay [in Korea] for 90 days, three months, so we went to work (sell sex) there [Participant #8, TGW, Bangkok].
Challenges faced by TGW who sell or trade sex	Participant: I’ve taken contraceptives since I was in Grade Three, nine years old. Interviewer: Oh, really? Since Grade Three. See, who recommended so? Participant: There was a senior near my place, she is a kathoey. See, she had everything already, like this (sexual reassignment surgery). She had the sexually reassignment surgery. [Participant #23, TGW, Bangkok] Participant: I used to take hormonal pills in the past  …  I have stopped  …  I had money at that time (laugh). But lately I’ve got no money to buy it. [Participant #12, TGW, Bangkok] “It is hard to earn a living being a transgender woman. It is hard to earn a living. Being gay, it is easy to earn a living” [Participant #20, TGW, Bangkok]. Interviewer: Do you have any problem entering an MSM shop (massage parlor)? Participant: Yes, because some shops wouldn't allow me to get in. Interviewer: Aren't there massage shops for transgender women? Participant: I don't think it's possible. There would be no men who dare to go into a kathoey shop. That's not possible. It must be a woman shop where kathoeys work there. [Participant #11, TGW, Bangkok] Actually, it is easy to be gay. We could go over here over there (different sex work venues and opportunities), easier than being transgender women. It is more difficult to move around when you are transgender woman. If you apply for a job and you have long hair, it is more difficult for transgender women to get it. Gay men will get the job easier than transgender women because gays have a male look  …  Yes, it is hard to socialize. [Participant #6, MSM, Pattaya]

Fluidity of sex work

Participants also reported inconsistent engagement in sex work or trade. Participants described patterns wherein they would work part time at sex work venues for a few months, but then abstain from sex work for a period. Participants cited different reasons for these fluctuations in sex work, including monastic ordination (a common rite of passage in Thailand), moving back home for familial or financial reasons, returning to university, or securing regular income.

Participants reported that compared to other jobs, sex work or trade provided greater income, which supported the cost of living in Bangkok or Pattaya, and in some cases subsidized university tuition (Table 3).

Migration

Participants described frequent migration within the last 12 months, which was often tied to transitions in and out of sex work. Mobility across Thai provinces was qualitatively associated with current income, housing status, or ability to find work (both in sex work and other jobs) and occurred at least once or twice a year. Some migration was seasonal, as participants cited moving to tourist destinations during peak seasons. Some participants also temporarily migrated to sell or trade sex in other countries (Table 3).

Challenges faced by TGW who sell or trade sex

Notable challenges for young TGW sex workers were reported. Many TGW participants disclosed using birth control pills and other forms of hormone therapy but often intermittently due to the additional cost of medication. Some TGW participants reported difficulties in getting hired at sex work venues or massage parlors and having interested clientele – a finding that was corroborated by reports from MSM participants who commented that TGW often could not find sex work. Overall, participants felt that TGW faced more challenges in finding sex work opportunities, but also faced broader societal challenges than other populations (Table 3).

Factors that may affect PrEP implementation among young MSM and TGW who sell or trade sex

Participants reported structural-, network-, and individual-level factors that may affect their engagement in HIV-related services and their willingness to use PrEP.

Structural-level stigmatization of HIV and HIV-related services

HIV stigma was a commonly reported deterrent for HIV-related service engagement, including HIV testing and PrEP uptake. For many, stigma was exacerbated by prevalent local notions of HIV fatalism. Participants expressed that many Thais hold the belief that people living with HIV “deserve” to have HIV. Participants stated that they and many of their peers were reluctant to seek HIV-related services due to fear of knowing their HIV status, stigma of being seen obtaining HIV-related services, or lack of confidence in the care provided. One participant also reported hesitancy in taking PrEP because of fear that PrEP would be mistaken for HIV treatment, which resulted in inconsistent PrEP use while on an extended trip with a client (Table 4).

Table 4. Factors that may affect PrEP implementation among young MSM and TGW who sell or trade sex and supporting quotations.

Topic	Relevant quotations
Structural-level stigmatization of HIV and HIV-related services	“The good side of cancer is that it occurs inside. You die without being seen. It is like you are so unfortunate to die from cancer. But with AIDS, people say you die from AIDS because you deserve it, you sleep around.” [Participant #9, MSM, Bangkok]. “I am afraid [of knowing my HIV status]. Tell you frankly that I am afraid. Now I am afraid. If I know that I have [HIV], I’d better die  …  I don't have the heart  …  if I don't take care of myself, it is my own fault [for getting HIV]” [Participant #20, TGW, Bangkok]. Interviewer: What makes them (the participant's friends) not want to come [to the HIV clinic]? Participant: Everybody would say the same thing, that they are shy and embarrassed. They are afraid of being seen by other people. In fact, the Drop In Center is at the end of the soi (street), there are very few chances that people would see them. But they still feel awkward and afraid that other people would know [they are using HIV-related services]. [Participant #11, TGW, Bangkok] “I had been wanting to get tested [for HIV]  …  but I didn't dare to go to the hospital. It felt like there were too many people, and they don't take care of me either” [Participant #19, MSM, Bangkok]. “I took [PrEP] seven days before they (client) came [on vacation] and one every other day while they were there. I was afraid they would know  …  They would think that I have AIDS because I took the pills, so I had to hide” [Participant #5, TGW, Bangkok].
Network-level role of venue management in HIV prevention	Interviewer: How did you know you should use condom? Who taught you to use condom when having sex? Participant: Masseurs in the shop. They told me I would have to use condom if I had sex with customers. [Participant #11, TGW, Bangkok] “Interviewer: What about when you were freelance? Who do you consult [about your health]? Participant: None. I searched from the internet” [Participant #6, MSM, Pattaya]. We will distribute condoms  …  we could never know whether they would put it on while they are in the room. We will stress about safety because if you get infected, your life would never be the same as normal people. Even you can live long today but the feelings in your mind will be changed. [Participant #3, MSM Venue Manager, Bangkok] We have to care for our masseurs who work with us and make them happy. It’ll make them willing to stay with us. You can't force your masseurs much, by saying, for example, “You have to go for a blood test with me.” I’d rather tell them, “Would you like to go with me for a blood test because I am going to fetch some condoms. But it's okay if you are not free.” [Participant #10, MSM Venue Owner, Bangkok] “I tell them to check their blood (HIV test). ‘Go check with me, will you?’ It's a way of supporting my boys (employees) too” [Participant #10, MSM Venue Owner, Bangkok].
Individual-level knowledge regarding PrEP and perceived risk of HIV acquisition	Interviewer: Have you ever heard of a drug which can be taken before having sex? Participant: I have never heard of a drug to be taken before having sex. I only used to take PEP (post-exposure prophylaxis). [Participant #4, MSM Venue Manager, Bangkok]. “Interviewer: Have you ever talked to university students about PrEP? Participant: Yes, I have. They would ask ‘Really? Could it be preventable?’ They still wondered. They were not confident” [Participant #11, TGW, Bangkok]. Interviewer: But you wouldn't let your boyfriends use condoms with you [during sex]. Why? Participant: I don't know. It was like I loved them (sexual partner) so much and I trusted them [to not use a condom during sex]. [Participant #11, TGW, Bangkok].
Individual-level interest in health and wellbeing as an avenue for HIV prevention	“Interviewer: But you always use condoms [during sex], right? Participant: Usually for regular customers, I give oral sex without a condom” [Participant #8, TGW, Bangkok]. As sex workers, you could really take care of yourself because you have to look fit and eat good stuff and it will come out right. I was very careful with this job. You had to take it seriously. You are dead if you risk it. If you get HIV infected then you are just waiting to die. [Participant #5, TGW, Bangkok] Interviewer: But for (sexual) intercourse, [the client] has to put on condom, right? Participant: Yes, for intercourse [the client] must put on condom. Even those who propose 30,000 [Baht] for [sex with] no condom, [I say] no. Even if you give me 100,000 [Baht], I will not give (engage in sex). Yes, there were a lot [of clients who asked for sex without a condom]. [Participant #7, TGW, Bangkok]

Network-level role of venue management in HIV prevention

Participants reported learning about sexual health, especially HIV prevention, through different sources. Venue-based participants learned about HIV and/or preventive services through peers or venue management. One participant who primarily sold sex online reported learning about sexual health through their own web searches. For both sources, participants did not describe the accuracy or quality of the sexual health information but expressed confidence in the information communicated (Table 4).

Participants reported that venue management does not monitor HIV testing and condom use among their sex workers. Venue managers also reported reluctance to pressure employees to disclose their HIV statuses or to mandate HIV testing and/or condom use. However, venue managers expressed support and care for their employees, emphasizing their investment in the wellbeing of their staff, especially regarding sexual health. Staff wellbeing was considered mutually beneficial for the venue, such that employees who feel supported and healthy are more likely to continue selling sex at that venue. One manager also posited that his employees would be receptive to trying PrEP if the venue owners recommend PrEP to staff. As many have prior experience selling or trading sex themselves, venue managers and staff felt they could act as role models or peer navigators for young MSM and TGW who sell or trade sex, particularly regarding HIV preventive practices (Table 4).

Individual-level knowledge regarding PrEP and perceived risk of HIV acquisition

Most participants expressed little to no knowledge regarding PrEP. Several participants had misconceptions about PrEP and post-exposure prophylaxis (PEP), often confusing the two prevention approaches. Participants also revealed misunderstandings about the proper use of PrEP and the overall benefits of PrEP. Some participants reported that the lack of PrEP knowledge in the MSM and TGW communities has contributed to a general lack of confidence in the efficacy of the drug (Table 4).

Participants reported varying levels of perceived HIV acquisition risk. Most participants stated that they were aware of their increased risk of HIV and STI acquisition due to the frequency of sexual encounters and concurrent partnerships. Condom use varied and was attributed to different considerations in negotiating condom use with clients. Some participants reported lower perceived risk of HIV transmission with long-term sexual partners as compared to casual partners, especially when engaging in oral sex (Table 4).

Individual-level interest in health and wellbeing as an avenue for HIV prevention

Many young MSM and TGW participants were committed to maintaining good personal health and wellbeing. For some, this entailed maintaining a good physique and eating healthy foods, while others equated this with frequent HIV testing and condom use. Participants often credited the nature of their profession as a key motivator in taking care of their personal health (Table 4).

Though some participants cited non-condom use during oral sex, the majority of participants reported that they almost always engaged in condom use during anal sexual intercourse. Participants stated that they would often insist on condom use with clients, and refusal from the client could sometimes result in termination of the sexual transaction. Some participants even reported declining additional payment for condomless sex over concerns of HIV acquisition risk (Table 4).

Discussion

In this study, young MSM and TGW who sell or trade sex described the dynamic context in which sex work occurs among this population in Bangkok and Pattaya, Thailand. First, participants reported engaging in multiple modalities of sex work in the same period, with many participants utilizing internet-based platforms. This is consistent with expanding literature outlining a global shift of commercial sex work from traditional venue-based interactions to internet-based sex work (Argento et al., 2018). This has implications for the implementation and delivery of HIV interventions at the network level for populations engaged in sex work, as the shift in sex work typologies may lead to loss of community and network support for sex workers, and ultimately sources of HIV prevention information (Argento et al., 2018). Future research should better explore the different modalities of sex work and how they may affect future HIV prevention programming among young MSM and TGW sex workers.

Participants reported diverse sources of information regarding HIV and HIV prevention services at the network level, with venue-based sex workers relying on information and mentorship from coworkers and venue management. Peer-led interventions among the MSM and TGW communities have been shown to increase awareness and uptake of PrEP (Reback et al., 2019; Young et al., 2018). However, with the ubiquitous use of the internet for engaging in sex work, internet venues can also serve as equivalent platforms to reach and share accurate information about HIV prevention to those engaged in sex work or trade (Gómez et al., 2022). Several dating sites permit users to indicate their PrEP status; however, there is room for improvement in ensuring access to accurate HIV prevention information, particularly within social media where lawsuits targeting online PrEP marketing have negatively impacted PrEP uptake (Grov et al., 2021; Hoenigl et al., 2020; Serrano et al., 2021). Given low perceived risk but high interest in personal health among participants at the individual level, online demand-generation activities could promote PrEP use as a means of maintaining one's wellbeing.

Participants described inconsistent engagement in sex work and frequent migration, which may have implications on access and adherence to PrEP, as has been demonstrated in research among mobile populations (Van Der Elst et al., 2013). Frequent mobility may limit access to PrEP when individuals do not have consistent access to affirming PrEP providers in new settings. This is particularly critical for those who migrate explicitly for the purposes of transactional sex. Methods to support access to PrEP during these periods may include providing a larger supply of medication and options for telemedicine, linking patients to providers in new settings, or re-engaging PrEP users when or if they return and resume sex work. Finally, structural barriers including systemic social discrimination, financial instability, and added costs associated with gender-affirming care (for TGW) exacerbate HIV risk environments and highlight the importance of ensuring access to PrEP across vocational and geographic settings for those engaged in sex work or trade (Boles & Elifson, 1994).

At the structural level, HIV stigma was salient, highlighting the potential impact of stigma on PrEP participation and in other HIV-related health services such as testing and treatment. Previous research has shown that MSM and TGW who sell or trade sex are less likely to exhibit health-seeking behaviors and more likely to disconnect from healthcare because of perceived stigma regarding HIV and fear of negative treatment from healthcare staff (Galea et al., 2011; Okal et al., 2009). As PrEP continues to be scaled up and prioritized at the national level, with recent prevention guidelines outlining PrEP recommendations further tailored to engage key populations such as MSM (Thailand Ministry of Public Health, 2021), it is important for providers and organizations to proactively address HIV-related stigma to improve uptake and adherence to PrEP and mitigate any social harms associated with PrEP medication.

Limitations

Our findings are subject to several study limitations. First, only 23 interviews were available to be translated from Thai to English due to funding constraints; however, these interviews provide a formative depth of knowledge regarding the experiences of these populations. Three venue management interviews were included in the analysis and may not fully capture the diversity of experiences and attitudes among these key stakeholders. Nonetheless, the inclusion of sex work venue management provides unique insight into the role of management in supporting HIV prevention amongst staff. There may also be selection bias, given that participants were recruited through a network of health-related community-based organizations and may have greater exposure to HIV-related services. Finally, our findings provide contextual description of social factors that may impact PrEP uptake for MSM and TGW engaged in sex work and do not provide evidence of a causal relationship.

Conclusions

In this study, young MSM and TGW who sell or trade sex described the diverse contexts in which sex work occurs among young MSM and TGW in Bangkok and Pattaya, Thailand. Though participants broadly described several factors that may present as challenges to PrEP implementation within these dynamic contexts, participants also reported many factors at the network and individual levels that may facilitate PrEP implementation and engagement in HIV prevention services. PrEP implementation for MSM and TGW who engage in sex work or trade may be most effective if they accommodate different, individual circumstances, provide accurate information in the same physical and virtual spaces where prospective users meet clients, and proactively mitigate the effects of HIV stigma.

Acknowledgements

We are grateful to the men and women who participated in this study. Without their experiences, this research would not be possible. This study is a collaborative effort between Johns Hopkins Bloomberg School of Public Health, the CDC Division of HIV Prevention, the Thailand Ministry of Public Health, Mahidol University, APCOM, and the community-based organizations Rainbow Sky Association of Thailand (RSAT) and Service Workers in Group Foundation (SWING). This work would not have been possible without the hard work and contributions of the Combination Prevention Effectiveness (COPE) Study Team.

Disclosure statement

The study drug, Truvada®, was donated to the project by Gilead Sciences. Gilead Sciences had no role in the design of the study nor in the interpretation of study results. AW and CB also receive separate research funding support from Gilead Sciences and ViiV Healthcare. All other authors declare no conflicts of interest.

Additional information

Funding

Research reported in this publication is supported by the National Institute of Allergy and Infectious Diseases (NIAID) of the NIH under Award Number R01AI118505 (PI: CB) and the U.S. CDC Division of HIV Prevention. This research has been facilitated by the infrastructure and resources provided by the Johns Hopkins University Center for AIDS Research, an NIH funded program (P30AI094189), which is supported by the following NIH Co-Funding and Participating Institutes and Centers: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, National Institute of Aging (NIA), Fogarty International Center (FIC), NIGMS, NIDDK, and OAR.