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Public Health Issues in the Adult Film Industry

Public Health Issues in the Adult Film Industry

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Public Health Issues in the Adult Film Industry

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  1. Public Health Issues in the Adult Film Industry Peter R. Kerndt, MD, MPH Director, STD Program Los Angeles County DHS Policy Implications of an Outbreak

  2. Background • In April, 2004, four cases of HIV were found in the adult film industry (AFI) in Los Angeles County • Workplace transmission of HIV suggested by sexual contact histories and subsequent gene sequencing • How can AFI workers be protected from HIV and other STDs? How can the next outbreak be prevented?

  3. Overview of Presentation • The HIV Outbreak of April 2004 • The Adult Film Industry today: avoidable risks in worker health and safety? • AFI health and safety issues • AFI health and safety solutions • Where do we go from here?

  4. Why LAC DHS is Concerned about the Adult Film Industry • Public health: • DHS obligated to stop spread of communicable diseases, including to sex industry workers • Workers can help spread STDs in the general population through their private sex partners • Worker health: • STDs can have severe health consequences • STDs are preventable • Appropriate health safeguards for AFI workers can prevent spread of HIV and other STDs

  5. Before April, 2004 • The LAC DHS Sexually Transmitted Disease Program (STDP) was already working on AFI issues: • Collaborated with Adult Industry Medical Health Care Foundation (AIM) to pilot routine syphilis, chlamydia and gonorrhea screening for AFI performers • Convened an interagency working group to address AFI work practices and then…

  6. The HIV Outbreak of 2004

  7. The 2004 HIV Outbreak The Index Case • April 9, 2004: a male performer tests positive for HIV by PCR DNA test (Roche Amplicor HIV-1) at AIM • Positive test confirmed April 12, 2004 • Reported in Adult Video News (AVN) April 13 • STDP notified verbally April 14 • Index Case was AFI veteran: • 40 years old male • Described as “mild mannered”, an “Old Pro” • Working in AFI since 1998 • Performed in 250 films

  8. The 2004 HIV Outbreak The Index Case (continued) • Tested regularly for HIV: according to AIM, had been tested every 3 weeks for 7 years, always negative, including: • negative HIV test Feb. 12, 2004 • negative HIV test March 17, 2004 • Went to Brazil in late February: • Engaged in unprotected insertive vaginal, anal, and double-anal penetration • Experienced flu-like illness that self-resolved

  9. The 2004 HIV Outbreak The Index Case (continued) • Returned to California March 10 • Over the next month, continued performing in adult films • had direct sexual contact with 13 female performers • engaged in unprotected oral, vaginal, and/or anal sex • engaged in unprotected double-anal sex with 3 of the female performers • by self report, had no private sexual partners since Feb 12 • Positive HIV test April 9

  10. The Index Case (continued) • The Film “Split That Booty 2” is suspected as the film that documents the at-risk work practices for the Index patient

  11. The 2004 HIV Outbreak The Three Female Cases • Within three weeks, 3 of the 13 females who worked with Index Case after his return from Brazil test HIV-positive = 23% attack rate • 1st female case tested HIV+ on April 13 • Sexual contact with Index Case: March 24 • Last negative HIV test: March 20 • Age 21 • 2nd female case tested HIV+ on April 25 • Sexual contact with Index Case: March 24 • Last negative HIV test: April 13 • Age 26 • 3rd female case tested HIV+ on May 5 • Sexual contact with Index Case: March 30 • Last negative HIV test: April 12 • Age 25

  12. The 2004 HIV Outbreak The Three Female Cases (continued) • All three HIV+ females had unprotected double-anal intercourse with Index Case • Increased potential for mucosal tears • Index Case said he did NOT have double-anal intercourse with any other occupational sex partners during this period

  13. F #1 Last Neg 3/20 F #1 Sexual Contact with Index 3/24 F #2 Sexual Contact with Index 3/24 F #3 Sexual Contact with Index 3/30 F #1 Pos 4/13 F #2 Last Neg 4/13 F #3 Last Neg 4/17 F #5 Pos 4/25 F #3 Pos 5/5

  14. The 2004 HIV Outbreak Industry Responses:The Quarantine List • Within days of Index Case test result, AIM establishes a “Quarantine List” of exposed performers • Voluntary effort, no legal authority, self-enforced • List maintained on publicly accessible AIM website, using performer stage names (not legal names) • AIM attempts to identify, contact, and provide HIV testing to all potentially exposed performers • The quarantine list ultimately includes: • 25 first generation partners (had sex with one of the 4 cases) • 36 second generation partners (had sex with first generation)

  15. Index HIV + Case HIV + ♀ Secondary ♂sex contact Primary ♀ sex contact Secondary♀ Sex contact 2004 AFI Outbreak: Sexual Contacts

  16. The 2004 HIV Outbreak Industry Responses:Quarantine List Testing • At first: stop until June 8 (2 mos after Index Case positive) • May 11: AIM begins “clearing” performers who tested negative at least 30 days after exposure • According to AIM, PCR-DNA, other tests, would detect any infection within 30 days • AIM maintains list on website until June 30. By then: • 24 of 25 known first generation partners tested negative at least once since exposure, cleared to work • 35 of 36 known second generation partners tested negative at least once since exposure, cleared to work (or else their first-generation partner cleared)

  17. The 2004 HIV Outbreak Industry Responses: The Moratorium • After Index Case positive, AIM, AVN, others in industry call for 60-day moratorium on all filming • Voluntary effort, no legal authority, self-enforced • At least 18 production companies reportedly halt production, probably more participate, though many apparently do not • Duration of actual work stoppage for various producers not known

  18. The 2004 HIV Outbreak Public Health Responses: LAC DHS • 4-20: LAC DHS Field staff obtain test results for many performers on AIM website • 4-21: LAC DHS Health Officer Dr. Jonathan E. Fielding instructs AIM to work with DHS as needed to address industry outbreak; more test results obtained • STD Program staff subsequently interview and provide assistance to all 4 AFI HIV cases

  19. The 2004 HIV Outbreak Public Health Responses: LAC DHScontinued • 8-04: Health Officer letter to AIM: • testing is not adequate protection • recommending condoms for all sex acts • 9-04: Health Officer letter to 760 AFI production company custodians of records, recommending: • condom use for all sex acts • routine periodic HIV/STD screening • HAV/HBV vaccination • worker education

  20. The 2004 HIV Outbreak Public Health Responses: Cal/OSHA • 6-4: Cal/OSHA initiates investigation, per LAC DHS request • 9-15: Cal/OSHA issues citations to 2 production companies • Both companies involved in film production during which HIV transmission occurred • Total of 4 citations each • Failure to comply with bloodborne pathogens (BP) standard • Failure to report serious work-related illness • Failure to record injuries and illnesses • Failure to prepare and follow and written illness and injury prevention program, or IIPP • Total fines = $30,560 per company

  21. The 2004 HIV Outbreak Public Health Responses: Cal/OSHAcontinued • September 2004: CA Department of Industrial Relations creates webpage for AFI • www.dir.ca.gov/dosh/AdultFilmIndustry.html • Provides information for industry workers and employers on compliance and assistance resources • Through citations and the webpage, Cal/OSHA has asserted that existing occupational regulations apply to AFI, specifically including: • Bloodborne Pathogens standard (CCR T8 §5193) • Illness and Injury Prevention Program (CCR T8 §3203)

  22. The 2004 HIV Outbreak Public Health Responses: Cal/OSHAcontinued • Basic requirements of the Bloodborne Pathogens (BP) standard: • Protect employees from hazards from blood and other potentially infectious materials (OPIM, e.g., semen) • Use personal protective equipment (e.g., condoms), work practice controls, and engineering controls to prevent exposure • Create Exposure Control Plan (ECP) • Provide HBV vaccination • Provide worker training • Provide medical (confidential) monitoring

  23. The 2004 HIV Outbreak Public Health Responses: CDC • 5-18/19: CDC NIOSH and CDC NCHSTP conduct LA site visit, per LAC DHS request for Technical Assistance • CDC NIOSH and CDC NCHSTP establish convincing evidence of occupational HIV transmission among AFI performers, through gene-sequencing…

  24. The 2004 HIV Outbreak Public Health Responses: Using Gene-Sequencing to Establish Occupational Transmission • The Index Case and 2 Female Cases provided whole blood specimens • Gene sequencing was performed on the p17 region of gag and the gp-41 region of env using standard techniques • Sequencing was performed by two different CDC scientists on separate days • The sequences of the 3 HIV samples were identical: meaning this was the same exact strain of HIV….very rare!

  25. The 2004 HIV Outbreak Public Health Responses: Establishing Occupational Transmission continued • Epidemiology also supports occupational transmission • All 3 female cases tested HIV-negative shortly before or within 3 weeks after unprotected sexual contact with the Index Case • All 3 female cases tested HIV-positive within one month of exposure to the Index Case

  26. The 2004 HIV Outbreak Public Health Responses: Ongoing • Collaboration to draft model Exposure Control Plan (ECP) for AFI • LAC DHS • Cal/OSHA • CA DHS • NIOSH • Other agencies (e.g., Los Angeles City Attorney’s AIDS/HIV Discrimination Unit)

  27. The 2004 HIV Outbreak Industry Responses…One Year Later • Mostly business as usual • Some changes at AIM. Reportedly: • Creation of a sex-scene contacts database, to facilitate future partner identification and notification • Some increases in education and testing services • No widespread changes in industry norms regarding: • Condoms • Employer financing of testing • Work practices • Training and education of workers

  28. The 2004 HIV Outbreak Policy One Year Later • Cal/OSHA has established that BP applies to AFI: it is the “law of the land” • But: no subsequent enforcement, and no apparent compliance by industry

  29. The Adult Film IndustryToday:AvoidableRisksinWorker Health and Safety?

  30. The Industry: Avoidable Risks? The Industry: Background

  31. The Industry: Avoidable Risks? Large and Legal • Legal in CA: People v. Freeman, 1988 • CA State Supreme Court decision (250 Cal.Rptr. 598) • Court ruled pornography is not pandering if content protected by 1st amendment • Economic value: • Estimated gross revenue from up to 11,000 films annually: as high as $13 billion • Estimated retail value of product produced in LA County in 2002: $3 billion (LA Economic Development Corp.)

  32. The Industry: Avoidable Risks? Other Characteristics that Impact Health and Safety • Movement across borders not uncommon: non-US performers shoot in US, and US companies shoot overseas • 2 Female Cases were non-US nationals • Index Case presumably became infected while filming in Brazil • Workers not organized • Typically transient in industry • “Rebel” and “outcast” social status impedes organizing • Males (In straight industry) more long-term, would likely need to push organizing effort

  33. The Industry: Avoidable Risks? In LA County • ~ 200 AFI production companies • An estimated 5-10 large companies produce half of films, or more* • Approximately 5 major film distributors* • More than 700 legal custodians of records • 6,000 workers (total) • 1,200 sex performers • An estimated 75% of performers are female* • Only 30-100 regular male performers* • Most women make only one film* * anecdotal information from industry sources

  34. The Industry: Avoidable Risks? Making an Adult Film* • Films shot in private homes or film studios • Performers paid $400 to $1,000 per scene (men paid less than women) • Production costs: • Approximately $10,000 equipment costs • Typical production cost: $13,000 - $16,000 / film • as low as $5,000 / film • as high as $50,000 / film for larger companies • “Successful” films typically sell 1,500 -2,000 units • Wholesale price: • approx. $8-$10 per unit for “vanilla” films • Approx. $10-$13 per unit for “gonzo” films * anecdotal information from industry sources

  35. The Industry: Avoidable Risks? Beyond Home DVD / Video • Cable TV • Comcast: $50 million from “adult “ films in 2002 • DirecTV: $200 to $500 million from adult films in 2002 • Hotels: • Hilton, Marriot, Hyatt, Sheraton and Holiday Inn, all offer adult films on in-room pay-per-view television systems. • Estimated 50% of hotel guests watch adult film, accounting for nearly 70 % of in-room profits.

  36. The Industry: Avoidable Risks? The Industry Revealed:Work Practices and Prevention Gaps

  37. The Industry: Avoidable Risks? General AFI Work Practices that can Increase HIV/STD Risks to Performers • Multiple partners over short time periods • Increases risk of STD/HIV infection • Increases potential for rapid spread • Prolonged episodes of sexual contact • Can increase transmission risk • Prolonged contact and friction can also increase abrasion, in turn increasing transmission risk • Lack of protective equipment (condoms, gloves, dental dams)

  38. The Industry: Avoidable Risks? STD Risks to AFI Performers:“Genital Fluid-Based” STDs • Transmission: • Contact of semen, vaginal and cervical secretions, and/or discharge with mucous membrane • Vaginal, anal, oral sex and shared sex toys • STDs include: • Chlamydia • Gonorrhea • HIV • Hepatitis B • Hepatitis C • Bacterial vaginosis • Trichomoniasis

  39. The Industry: Avoidable Risks? STD Risks to AFI Performers:“Bloodborne” STDs • Transmission: • Intravenous drug use, needle sharing • Vaginal, anal bleeding during sex, menstrual blood • STDs include: • HIV • Hepatitis B • Hepatitis C

  40. The Industry: Avoidable Risks? STD Risks to AFI Performers:“Skin-to-Skin” STDs • Direct contact of skin to skin or mucous membranes: • Syphilis • Herpes (HSV) • HPV (warts) • Direct contact: skin to skin contact, also shared bedding or clothes • Pubic lice • Scabies

  41. The Industry: Avoidable Risks? STD Risks to AFI Performers:“Fecal-Oral” STDs • Usually transmitted through contaminated food or water; CAN be transmitted sexually through: • Analingus • Oral sex immediately after anal sex • Oral contact with sex toys immediately after anal contact • STDs include: • Hepatitis A • Campylobacter • Shigella • Salmonella • Giardia • Cryptosporidium • Entomoeba histolytica

  42. The Industry: Avoidable Risks? Straight vs. Gay Male Adult Film:a Tale of Two Industries with Different Work Practices and Risk Reduction Norms

  43. The Industry: Avoidable Risks? Straight AFI • Minimal condom use • Industry sources estimate condoms used in <20% of vaginal and anal sex scenes • Only a few production companies are “condom only” (though these are larger companies) • Performers can try to work “condom only,” but may not get work • No company (even “condom only”) uses condoms for oral sex

  44. The Industry: Avoidable Risks? Straight AFI,cont’d • Widespread use of routine HIV/STD testing • Industry standard, promoted by AIM, is to test monthly • Performers and producers have access to test results • Performers generally must pay for testing • HIV-positive performers excluded from work

  45. The Industry: Avoidable Risks? Straight AFI, cont’d • High-risk sex acts relatively common • Pervasive use of ejaculation into the mouth • Growing use of internal ejaculation with vaginal and anal sex • Pervasive use of unprotected anal sex • Some use of double-vaginal and double-anal sex • Other risks: • Sharing of sex toys • Oral-anal contact • Ejaculation into eye (typically accidental)

  46. The Industry: Avoidable Risks? Gay Male AFI • Extensive condom use • Estimated 80-90% of gay male films use condoms • Condoms NOT used for oral sex • No industry testing norm for HIV or other STDs • Many HIV-positive men work in the industry • Some “bareback” companies shoot exclusively without condoms

  47. The Industry: Avoidable Risks? Risks Come Home to Roost:Previous Incidents of AFI HIV Transmission • Straight AFI • 1998: one male performer transmits HIV to at least 5 female performers • Other reported incidents of HIV transmission in 1999, 1997, and 1995 • Gay Male AFI • Unknown, due to lack of testing • Extensive presence of HIV-positive men in Gay Male AFI makes transmission possible

  48. The Industry: Avoidable Risks? Other STD Transmission: Straight AFI • In 18 months of pilot STD testing of AFI performers in June 2000-Dec 2001: • For female performers (n=390) • Chlamydia prevalence 3-fold greater than similarly-aged LAC females: 7.7% vs. 2.6%* • Gonorrhea prevalence 5-fold greater than similarly-aged LAC females: 2.0% vs. 0.4%* • For male performers (n=435) • Chlamydia prevalence nearly 7-fold greater than similarly-aged LAC males: 5.5% vs. 0.8%* • Gonorrhea prevalence 6-fold greater than similarly-aged LAC males: 2.0% vs. 0.3%* * Using highest available age-group rates for 2001; rates in 2001 were higher than all comparable rates in 2000. Source: STDP Sexually Transmitted Disease Morbidity Report 1998-2002

  49. Other STD Transmission: Straight AFI, cont’d STDs Reported by AIM, 2002 (self-reported data)

  50. Other STD Transmission: Straight AFI, cont’d STDs Reported for AIM Clients (no denominator), 2003-2005* * Note: Based on STD case reports by AIM or laboratory. Total individuals tested not known (no denominator data). Not all individuals tested and reported by AIM are necessarily AFI performers.