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Sex Workers and HIV/AIDS
For years, ‘prostitution’ has been a major theme in discussions about the global HIV and AIDS epidemic. The media often run stories about HIV that focus on sex workers, individuals who sell sex, and both governments and HIV-related organisations frequently talk about prostitutes and prostitution in the context of HIV and AIDS.
Why is ‘HIV/AIDS and prostitution’ an issue?
This topic is significant for several reasons:
- High rates of HIV have been found amongst individuals who sell sex in many different and diverse countries. Even where HIV prevalence is low amongst this group, it is usually higher than the rate found amongst the general adult population.
- Sex workers usually have a high number of sexual partners. This means that if they do become infected with HIV, they can potentially pass it on to multiple clients.
- Preventing HIV infections amongst those involved in the sex trade has been proven to be an instrumental part of many countries’ fight against AIDS.
‘Prostitutes’ or ‘sex workers’?
Although the word ‘prostitution’ can be used to describe the act of selling sex, it can also mean ‘using a skill or ability in a way that is considered shameful’. It seems to include a moral judgement, by implying that individuals who sell sex are involved in a practice that is corrupt and so are themselves unworthy. A far more neutral and respectful alternative is the term ‘sex work’.
This issue may not matter so much in the context of everyday conversations or casual debates, but in serious discussions on the topic it is important that words are chosen carefully. Since this article seeks to discuss the issue of HIV and sex work in an open and non-judgemental way, we refer to sex workers rather than prostitutes.
The term 'sex worker' refers to a wide array of people who sell sex, and who work in a variety of environments. They include women, men and transgender people and people who may work either full time or part time, in brothels, or bars, on the street or from home for example.
What role do sex workers play in the global HIV and AIDS epidemic?
Sex workers, along with other marginalised groups such as men who have sex with men and injecting drug users, are often labelled a 'high risk group' in the context of HIV and AIDS. But the debate about sex workers’ wider role in the global AIDS epidemic often polarises opinion. Some argue that sex workers are being wrongly portrayed as 'spreaders' of HIV, while others claim that HIV transmission through paid sex is ‘driving’ the epidemic.
In truth, the situation differs vastly between different countries and regions. While HIV prevalence is high amongst sex workers in some areas, in others it is relatively low, and they seem to play a fairly minor role in the spread of HIV. For instance, in most parts of Western Europe and North America, HIV transmission through paid sex is not considered to be a major issue. In other regions, however, notably parts of Asia, large numbers of sex workers are living with HIV, and this is influencing the overall pattern of the AIDS epidemic.
The factors that put sex workers at risk vary between countries. In some places, sex workers commonly use drugs and share needles. The overlap between sex work and injecting drug use is linked to growing HIV epidemics in a number of countries throughout Eastern Europe and Asia.1
As well as regional differences between sex workers, the picture is further blurred by a general lack of information on this group. Sex workers are a marginalised and often criminalised population, and are therefore very difficult to track and monitor.2 They can therefore be hard to reach with HIV prevention programmes.
Many sex workers are playing a positive role in HIV prevention efforts, through supporting others to be better protected from HIV and speaking up about their rights.3 Some people argue that labelling sex workers as a ‘high risk group’ is used as an excuse to further stigmatise sex workers by those who are morally opposed to their profession:
“Apart from the stigma already attached to [sex workers], society has further marginalised them as core transmitters of the HIV infection. It fails to understand and recognise that they are but links in the broad networks of heterosexual transmission of HIV. And that they constitute a community that bears and will continue to bear the greatest impact of the HIV epidemic.” Meena Seshu, SANGRAM (a project working with sex workers in India)4
The clients of sex workers are often referred to as a 'bridge' population for the transmission of HIV, meaning that they act as a link between high risk groups and the general population. Many women do not report using condoms with their husbands and may therefore be at risk of HIV infection if their partners frequent sex workers. This is particularly true for wives of migrant workers who travel long distances and spend an extended period of time away from home. High HIV prevalence amongst the male clients of sex workers have been detected in studies across the world.5 6 7 8
HIV and sex work around the world
According to the Commission on AIDS in Asia 'men who buy sex are the single-most powerful driving force in Asia's HIV epidemics'.9 There are an estimated 10 million sex workers in Asia, and 75 million male clients.10
Historically, the AIDS epidemic in India was first identified amongst sex workers and their clients, before other sections of society became affected.11 HIV infection rates among sex workers continue to be detected in India, at 2.7% of sex workers nationally.12 What is more, sex workers in some areas have a much higher HIV prevalence, such as 6.9% in the states of Maharashtra and Andhra Pradesh.13
High HIV rates were also first identified amongst sex workers in Thailand, although the Thai government were faster to act on this problem. In the early 1990s, they implemented the now famous ‘100% condom programme’, enforcing mandatory condom use in commercial sex establishments throughout Thailand, which helped to significantly reduce the spread of HIV. A similar programme has also significantly reduced HIV prevalence in Cambodia since it began in 2001 (from 44% in 1998 to 8% in 2003 among sex workers older than 20 years).14 However, it is vital that the ‘100% condom programmes’ are implemented in a way that put the rights and needs of sex workers first. Reports suggest that police in some countries have used commercial sex clients as ‘informants’ to identify non-complying sex workers.15 The same programme would then become a source of abuse by the police, adding to the harassment that sex workers often already face:
“I am fed up with the police and I hate the clients’ misbehaviour and violence. Governments and agencies should really try to address this. We have self respect and don’t want others to hurt us.” Ms Fulmaya, 16, Nepal, works in a guest-house16
Although HIV prevalence among female sex workers in Thailand has dropped to 1.8%, male sex workers are a traditionally overlooked group with a much higher HIV prevalence (17.7%).17 Sex workers who work outside of formal commercial sex establishments like brothels or karaoke bars in Thailand are not reached by the '100%' condom programme and there are concerns that HIV prevalence among this group is rising.18
The overlap between sex work and injecting drug use is of increasing concern in Asia, in particular in southern India, Pakistan, Indonesia and Vietnam.19 In Vietnam, more than a third of injecting drug users surveyed said they had bought sex in the previous 12 months, but only about a fifth said they consistently used condoms with their sexual partners.
HIV prevalence among female sex workers in sub-Saharan Africa varies widely but on average it is high at 37 percent across the region.20 In West Africa HIV prevalence is much lower among the general population than in Eastern and Southern Africa, but more than a third of sex workers are reported to be living with HIV.21 As many as a fifth of men in West Africa had visited sex workers in 2007 which means that they can act as a potential 'bridge' for HIV transmission to the rest of the population, either through their wives or other sexual partners.22
Although the impact of sex work on rate of new HIV infections varies widely in sub-Saharan Africa, it impacts significantly on the HIV/AIDS epidemics of a number of countries in this region. In Ghana, for example, female sex workers, their clients and the sexual partners of clients made up a third of all new HIV infections in 2009, 10% of all new HIV infections in Uganda, and 14% of HIV infections in Kenya in the same year.23
Male and transgender sex workers (MTSW) in the region often engage in sex work for financial reasons and are at high risk of HIV infection. Criminalisation of homosexuality and marginalisation drive male sex work underground and make it extremely difficult to access MTSW with HIV/AIDS prevention initiatives. A study of male sex workers in Mombasa, Kenya found that less than half of male sex workers surveyed consistently used condoms with their male clients.24 Low condom use among MTSW is particularly worrisome because of the increased risk of HIV transmission associated with anal sex. Male sex workers are also found to have low condom use rates with their female clients.25 26
“Twenty-three of my friends died of AIDS. Nineteen trans women and 4 women, all sex workers. None of them got ARVs. It was the fear of discrimination and abuse from the doctors that kept them from getting medication.” A transsexual sex worker from Windhoek, South Africa27
The Caribbean's thriving sex industry serves both local clients and tourists and features prominently in the AIDS epidemics of certain countries such as Guyana, Haiti, Jamaica, where HIV prevalence among sex workers is 17 percent, 8 percent and 5 percent respectively.28 Male sex workers in the Dominican Republic have been identified as particularly high risk, because of the secret nature of their work and lack of prevention programmes aimed at this group. The epidemic among male sex workers in the country is being driven by both high unemployment rates in rural areas, which has encouraged migration to urban areas, and the profitable sex tourism industry.29
A handful of countries in the region have established HIV prevention campaigns aimed at sex workers; in Haiti, for example, a non-governmental organisation called FOSREF offer sex workers HIV testing and counselling services, treatment for sexually transmitted infections and vocational training (for example in cooking, dance, beauty or information technology) that provide alternatives to sex work. In general, though, organisations that work with sex workers are being overlooked in the Caribbean, and this is holding back the region’s fight against AIDS.30
Information about the role of sex workers in Latin America’s AIDS epidemic is sparse, and shows a varied picture. A study released in 2006, which analysed sex workers in nine South American countries over a thirteen-year period, concluded that “consistently low HIV seroprevalences were detected among female commercial sex workers in South America, particularly in the Andean region”.31
However, HIV prevalence among sex workers is high in Uraguay (19%), Argentina (5%), and Brazil (5%).32 High rates of injecting drug use are common among sex workers in Central America, particularly on major drug trafficking routes. This is a major issue where HIV prevalence is high among female sex workers who inject drugs (12% in the Mexican border cities of Tijuana and Ciudad Juarez) as there is a significant risk of HIV infection being passed to male clients of sex workers and then into the wider population.33 This is particularly true because female sex workers who are injecting drug users in this area have been found to be more likely to engage in unprotected sex (often for more money used for buying drugs).34
Male sex workers in Latin America are at particularly high risk of HIV infection. In Argentina, for example, the HIV prevalence among male sex workers is thought to be 22.8% compared to 1.8% among female sex workers.35
Where efforts have been made to target sex workers with information on sexual health, notable changes have been observed. For example, in Guatemala where a sexual health clinic offered counselling, testing and follow-up services over a six-month period, a four-fold decrease in HIV was noted among sex workers.36 HIV prevalence among sex workers in Chile and El Salvador is also said to have fallen significantly following the targeting of sex workers with prevention programmes.37
Eastern Europe/ Central Asia
The number of sex workers in Eastern European and Central Asian countries has risen in recent years due to social, economic and political changes that have led many to turn to sex work as a means of income.38 The defining characteristic of this region's HIV/AIDS epidemic has traditionally been a very high prevalence among injecting drug users. However, there is a clear overlap between injecting drug use and sex work in this region and this is playing a significant role in the spread of HIV as many sex workers are also injecting drug users.39 It is estimated that more than a third of sex workers in the Russian federation inject drugs.40 High levels of needle sharing also place them at high risk of contracting HIV. For example, in St Petersburg nearly half of all sex workers admit to sharing injecting equipment.41
“Nearly half of all sex workers in St Petersburg admit to sharing injecting equipment ”
Prevention initiatives aimed at sex workers in Russia where there is a high rate of injecting drug use among sex workers need to include services that reduce the risk of HIV infection through drug use. One initiative in Saint Petersburg uses 'mobile points' or vans to reach sex workers.42 Apart from condoms and voluntary counselling and testing for sexually transmitted diseases, the vans also provide needle exchange services so that sex workers can exchange used needles for sterilised injecting equipment.
Western Europe and North America
There is a lack of recent data available on HIV infections among sex workers in Western Europe, although Western Europe is one of the few parts of the world which includes countries where commercial sex is either legal or controlled (Switzerland, Finland, Germany, Ireland, Austria, Latvia, Hungary, Turkey, and the Netherlands). Overall, the HIV prevalence among sex workers is less than 5%.43 Levels of HIV infection seem to be low (less than 1%) amongst sex workers who do not inject drugs. However, for those who do inject drugs the risk is often significantly higher. According to a study carried out in three cities in the Netherlands, the HIV prevalence among female sex workers who injected drugs was 13.8%, while it was 1.5% amongst other female sex workers.44
In many areas, it also seems that male and transgender sex workers are more vulnerable to HIV than female sex workers. For example, male sex workers in Spain were found to have an overall HIV prevalence of 12% in a study conducted in 19 Spanish cities compared to 1% for female sex workers during the same time period.45 46 A study conducted in three cities in the Netherlands found that 18.8% of transgender sex workers surveyed were HIV positive, compared to 5.7% of sex workers in general.47
In the United States, the government takes a strong stance against sex work, as demonstrated by its refusal to grant overseas aid to any HIV/AIDS projects that do not ‘explicitly oppose’ the practice. Domestically, sex work is illegal in the U.S. (with the exception of a few counties in the state of Nevada), and very little information is gathered about workers and their clients. As with Western Europe, many of the HIV cases that do occur amongst sex workers in the region are amongst sex workers who also inject drugs.48
The way forward
It is clear that sex workers are not ‘universally’ at high risk of becoming infected with HIV, and that the situation varies widely between regions. However, it is also apparent that in many of the countries where AIDS is taking its heaviest toll, large number of sex workers are being affected by HIV, and this is a major issue.
Improving the situation will require greater efforts by governments, groups, and individual members of society to help sex workers. It is particularly important that sex workers gain access to HIV prevention and treatment programmes. Such programmes not only save sex workers’ lives; they can also help to stem the wider impact that HIV is having on societies around the world.
- 1. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
- 2. UNAIDS (2009, February), 'UNAIDS guidance note on HIV and sex work'.
- 3. UNAIDS (2011) 'HIV in Asia and the Pacific: Getting to zero'
- 4. UNDP (2007, 7th February),Interview - Meena Seshu, director, Sangram
- 5. M E Gomes do Espirito Santo, G D Etheredge (2005) 'Male clients of brothel prostitutes as a bridge for HIV infection between high risk and low risk groups of women in Senegal' Sex Transm Infect 81(4) 342-344
- 6. University of California (2009, July 13th) 'Tijuana sex workers' male clients raise HIV risk'
- 7. Jin X et al., (2010, January) 'HIV prevalence and risk behaviors among male clients of female sex workers in Yunnan, China' J Acquir Immune Defic Syndr 53(1) 131-135
- 8. Vietnam News (2010, August 13th) 'HIV infections remain high for male clients of sex workers'
- 9. Commission on AIDS in Asia (2008) 'Redefining AIDS in Asia: Crafting an Effective Response'
- 10. Commission on AIDS in Asia (2008) 'Redefining AIDS in Asia: Crafting an Effective Response'
- 11. Kakar D.N. and Kakar S.N. (2001), 'Combating AIDS in the 21st century Issues and Challenges', Sterling Publishers Private Limited, p.31
- 12. NACO (2013) 'Annual Report 2012-13'
- 13. NACO (2012, December) 'HIV Sentinel Surveillance in India 2010-11: A technical brief'
- 14. UNAIDS/WHO (2008) 'Report on the Global AIDS Epidemic'
- 15. UNAIDS (2011) 'HIV in Asia and the Pacific: Getting to zero'
- 16. UNAIDS (2011) 'HIV in Asia and the Pacific: Getting to zero'
- 17. UNGASS (2012) 'Thailand: Global AIDS Response Country Progress Report'
- 18. National AIDS Prevention and Alleviation Committee Thailand (2010) 'UNGASS Country Progress Report'
- 19. UNAIDS/WHO (2008) 'Report on the Global AIDS Epidemic'
- 20. UNAIDS (2013) 'Update: How Africa Turned AIDS Around'
- 21. UNAIDS/WHO (2009) AIDS Epidemic Update
- 22. World Bank/GAMET (2008, November) 'West Africa HIV/AIDS Epidemiology and Response Synthesis'
- 23. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
- 24. Geibel, Scott/Horizons/Population Council (2008, March 20th) 'Addressing the HIV Needs of Sex Workers and Men Who Have Sex with Men'
- 25. Geibel, Scott/Horizons/Population Council (2008, March 20th) 'Addressing the HIV Needs of Sex Workers and Men Who Have Sex with Men'
- 26. PlusNews (2010, April 20th) 'KENYA: Bisexual male sex workers run big risks'
- 27. Open Society Institute (2008) 'Rights Not Rescue: A Report on Female, Trans, and Male Sex Workers’ Human Rights in Botswana, Namibia, and South Africa'
- 28. UNAIDS (2012) 'Global Report: UNAIDS Report on the Global AIDS Epidemic 2012'
- 29. Padilla, Mark (2007) 'Caribbean Pleasure Industry: Tourism, Sexuality and AIDS in the Dominican Republic', University of Chicago Press
- 30. International HIV/AIDS Alliance (2009, April) 'Report on access to Global Fund resources by HIV/AIDS Key Populations in Latin America and the Caribbean'
- 31. Bautista C T (2006) 'Seroprevalence of and risk factors for HIV-1 infection among female commercial sex workers in South America' Sexually Transmitted Infections (82)4 311-316
- 32. UNAIDS (2012) 'Global Report 2012: AIDSinfo'
- 33. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
- 34. Strathdee, Steffanie A. (2008) 'Correlates of Injection Drug Use among Female Sex Workers in Two Mexico-U.S. Border Cities' 92(1-3) 132-140
- 35. UNAIDS/WHO (2009) AIDS Epidemic Update
- 36. UNAIDS/WHO (2009) AIDS Epidemic Update
- 37. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
- 38. UNAIDS (2006) 'HIV and sexually transmitted infection prevention among sex workers in Eastern Europe and Central Asia'
- 39. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
- 40. UNFPA (2010, July 6th) 'Working with Sex workers to Stop the Spread of HIV in Russia'
- 41. UNFPA (2010, July 6th) 'Working with Sex workers to Stop the Spread of HIV in Russia'
- 42. UNFPA (2010, July 6th) 'Working with Sex workers to Stop the Spread of HIV in Russia'
- 43. European Centre for Disease Prevention and Control (2009) 'HIV/AIDS Surveillance in Europe'
- 44. van Veen MG, et.al (2010, June) 'HIV and sexual risk behavior among commercial sex workers in the Netherlands' Arch Sex Behav 39(3):714-23
- 45. Belza M (2005, February) 'Risk of HIV infection among male sex workers in Spain' 81(1): 85–88
- 46. EuroHIV (2006) 'HIV/AIDS Surveillance in Europe'
- 47. van Veen MG, et.al (2010, June) 'HIV and sexual risk behavior among commercial sex workers in the Netherlands' Arch Sex Behav 39(3):714-23
- 48. Centre for AIDS Prevention Studies (2008, April) 'What are sex workers' HIV prevention needs?'