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Public Health Issues in the Adult Film Industry

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. Background. In April, 2004, four cases of HIV were found in the adult film industry (AFI) in Los Angeles County

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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.

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