Place of Sex Moderates the Association Between Alcohol Use During Sex and Condom Use Among Male Clients of Female Sex Workers in Tijuana, Mexico

Introduction: Mexico has a relatively low HIV prevalence (0.37%) among adults, which masks the dynamic epidemic in Tijuana, where HIV prevalence is nearly double. San Diego, California abuts Tijuana along the extreme western end of the U.S.–Mexico. Because prostitution is illegal in San Diego, men from the US will travel to Tijuana for sex with female sex workers (FSWs), where it is quasi-legal in the zona roja. Whereas research has focused on the HIV risk behaviors among female sex workers in Tijuana, less is known about the risk behaviors of their male clients. Clients may serve as a bridge population between high-risk and low-risk populations. Alcohol and illicit drug use place male clients at risk for HIV and other sexually transmitted infections. However, support for the relationship between alcohol use and sexual risk behavior has been inconsistent, and shown to be moderated by psychological factors like sensation-seeking. Structural factors as moderators of the association between substance use and condom use have not been examined, including the contexts in which sex takes place. In Tijuana, clients often meet and have sex with FSWs in bars, where there are adjacent rooms designated for sex. We examined whether having sex with FSWs in a bar moderates the link between alcohol intoxication during sex and condom use. Methods: We recruited 375 male clients of FSWs in Tijuana, Mexico from San Diego, California and Tijuana. Using computer assisted interviewing, we surveyed participants on their alcohol use, condom use, and physical contexts of sex with FSWs in the past four months. Results: Results showed that more frequent intoxication during sex with FSWs is associated with more unprotected sex, but only among clients having sex with FSWs in a bar context. Whereas having sex in a bar moderated the relationship between alcohol intoxication and condom use, it did not moderate the association between being high on illicit drugs and condom use. Results point to potential reasons for inconsistent condom use with FSWs in bars, including lower risk perceptions of sex with FSWs in bars, and to the potential for these clients to serve as a bridge population between FSWs and the clients’ spouses. Conclusions: Results support theory arguing for primacy of the “risk environment” over individual-level factors in understanding HIV risk. Future research should examine structural factors that underlie clients’ risk behavior in bars in order to inform structural-level HIV prevention interventions.