Sex workers are among the highest risk groups for HIV. UNAIDS defines sex workers as:
"Female, male and transgender adults and young people who receive money or goods in exchange for sexual services, either regularly or occasionally. Sex work varies between and within countries and communities. Sex work may vary in the degree to which it is more or less “formal” or organized, and in the degree to which it is distinct from other social and sexual relationships and types of sexual economic exchange." 1
In low- and middle-income countries, HIV prevalence among sex workers is an estimated 12%. However, there are significant variations between regions and countries.2
In four countries, HIV prevalence is 50 times higher than in the general population.3 One study of 16 countries in sub-Saharan Africa found an average HIV prevalence of 37% among sex workers. In Nigeria and Ghana, HIV prevalence among sex workers is eight times higher than for the rest of the population.4
Although sex workers are one of the groups most affected by HIV, they are also one of the groups most likely to respond well to HIV prevention programmes. Proof of this can be seen in countries such as Cambodia, the Dominican Republic, India and Thailand, where reductions in national HIV prevalence have been helped by initiatives targeting sex workers and their clients.
Why are sex workers at particular risk of HIV transmission?
Sex workers often share common factors, regardless of their background, that can make them vulnerable to HIV transmission.5
Multiple partners and inconsistent condom use
In general, sex workers have comparatively high numbers of sexual partners compared with the general population. However, this does not necessarily increase their likelihood of becoming infected with HIV if they use condoms consistently and correctly.6 In 2012, 44 countries reported a median condom use of 85%, up from 78% in 2009.7
In some cases, sex workers have no access to condoms, or are not aware of their importance. In other cases, sex workers are simply powerless to negotiate safer sex. Clients may refuse to pay for sex if they have to use a condom, and use intimidation or violence to force unprotected sex.8 They may also offer more money for unprotected sex – a proposal that can be hard to refuse:
"Sex workers have told us that when they ask a client to use a condom, he offers double the price to have sex without the condom. These women are trying to provide for their children and families, so they take the offer." - Ndeye Astou Diop, Aboya (an organisation that works with HIV positive women in Senegal) 9
The clients of sex workers also act as a 'bridge population', transmitting HIV between sex workers and the general population. High HIV prevalence among the male clients of sex workers has been detected in studies globally.10 11 12
Social and legal factors
Sex workers are often stigmatised, marginalised and criminalised by the societies in which they live, and in various ways, these factors that contribute to their vulnerability to HIV.
Even though sex work is at least partially legal in some countries, the law rarely protects sex workers. Around the world, there is a severe lack of legislation and policies protecting sex workers who may be at risk of violence from both state and non-state actors such as law enforcement, partners, family members and their clients.13
For example, a sex worker who is raped will generally have little hope of bringing charges against their attacker. This lack of protection leaves sex workers open to abuse, violence and rape, creating an environment which can facilitate HIV transmission.14 In some countries, police use the possession of condoms as evidence of sex work, further impeding sex workers’ efforts to protect themselves.
"Why is the city giving me condoms when I can’t carry them without going to jail?" - Maria, sex worker in Los Angeles, USA 15
"To avoid arrest that can involve violence, rape and other trauma, many sex workers try to avoid things that may identify them as sex workers—like carrying condoms or visiting health clinics for check-ups." - Kay Thi Win, Programme Manager of the Targeted Outreach Programme initiative in Myanmar, which provides peer-to-peer HIV prevention and support for sex workers 16
In addition, the stigma that sex workers face can make it hard for them to access healthcare, legal, and social services. They may either be afraid to seek out these services for fear of discrimination, or prevented from accessing them – for instance, if a nurse refuses to treat them after finding out about their occupation.
"When I visited a VCT [voluntary counseling and testing] clinic, health personnel were not polite and immediately asked me if I was a sex worker. A doctor asked me outright, “Are you HIV‑positive?” This discouraged me from going to the clinics." - Payal, 18, Nepal 16
Injecting drug use
In some countries, sex workers also inject drugs. Sex workers who inject drugs and share needles are at a particularly high risk of HIV infection.
Researchers investigating HIV prevalence among female sex workers (FSW) have raised particular concerns about epidemics in Eastern Europe and Central Asia, where there is a significant overlap between sex work and injecting drug use.17 A 2013 review of FSW in Europe concluded that their HIV vulnerability was linked primarily to unsafe injecting, rather than sex work itself.18 A study in Manipur, India, found that HIV prevalence among female sex workers who injected drugs was 9.4 times higher than among FSW who did not inject.19
In 2010, out of 113 countries reporting the existence of HIV programmes aimed at sex workers, the least commonly reported interventions were those that targeted the needs of sex workers who also injected drugs.20
Migration, mobility and sex work
Migration and sex work are often linked as some migrants may turn to sex work if they cannot find an alternative means of making money. As well as selling sex themselves, migrants may also become the clients of sex workers as a means of escaping the solitude that often accompanies migration.21
Another way in which HIV, sex work and mobility are linked is through ‘sex tourism’, whereby clients travel between countries seeking paid sex. Sex tourism is fuelling the demand for sex workers in many countries, particularly in Asia and the Caribbean. In some cases, men travel to another country in order to take advantage of lenient age of consent laws, or because they know that it will be easy to find paid sex.22 23
The relationship between human trafficking and sex work
Human trafficking is defined as:
"The recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation." 24
Large numbers of trafficked people are forced into selling sex every year. This is different from sex work, in that trafficked people are forced into selling sex. Even in countries where HIV prevalence is low, trafficked people who are forced to sell sex are still vulnerable to HIV infection because they struggle to access condoms, cannot negotiate condom use and are often subjected to violence.25
However, many emphasise that the relationship between sex work and human trafficking should not be overplayed as it can lead to false or exaggerated anti-sex work arguments and harmful action by the authorities, ultimately undermining HIV prevention for sex workers.27
Young sex workers and HIV
Young people who also belong to key affected populations such as sex workers, are largely being missed in the current HIV response.
Although the number of young sex workers worldwide is unknown, there are a number of studies that show a large percentage of sex workers are under 18 years old.
For example, a study from Ukraine found that 20% of female sex workers were 10-19 years old. In parts of sub-Saharan Africa, median HIV prevalence among under 25s is reportedly 11%.28
Young sex workers face many of the same barriers to HIV prevention as their older counterparts including the inability to negotiate condom use and legal barriers to HIV and sexual health services. Young sex workers also lack access to youth-friendly HIV services.29
Preventing HIV among sex workers
Experts recommend that HIV prevention programmes for sex workers should initially focus on achieving three main outcomes:
- consistent and correct condom use and safer sex among sex workers and their clients
- increased sex worker involvement and control over their working and social conditions
- a reduction in the number of sexually transmitted infections (STIs) occurring among sex workers.30
There are several means of achieving these goals. Effective measures include the provision of condoms; educating sex workers and their clients about HIV; encouraging peer education (where sex workers inform one another about HIV); bringing sex workers together; reducing the stigma that communities attach to sex work; and ensuring that laws and policies respect sex workers’ human and citizen rights.
One study from South Africa reported that combining pre-exposure prophylaxis (PrEP) with HIV testing and treatment could reduce HIV transmission between sex workers and their clients by up to 40%. Providing these services in tandem with prevention initiatives that support safe workplaces and tackle stigma and discrimination in society have the potential to work in settings worldwide.31
Successful HIV prevention programmes for sex workers
In 2013, the WHO, UNFPA, UNAIDS, NSWP, World Bank and UNDP released a new tool offering advice on building HIV programmes for sex workers that are led by the sex worker community.32
The tool, Implementing comprehensive HIV/STI programmes with sex workers: practical approaches from collaborative interventions also contains examples of best practice from around the world to support efforts in planning programmes and services.32
A number of successful HIV programmes targeting sex workers are given below.
Encouraging condom use
The 100% Condom Use Programme, established in Thailand in the early 1990s, enforced condom use in all of Thailand’s brothels and massage parlours, distributing free condoms and making it a legal requirement for establishments to make clients use them. The programme saw condom use among sex workers rise from 14% in 1989 to over 90% since 1992, with Thailand’s overall HIV prevalence reflecting this.33 Between 1998 and 2003, a similar programme in Cambodia reduced HIV prevalence among sex workers over the age of 20 from 44% to 8%.34
However, concerns have been raised about the absence of sex workers from participation in the design and implementation of the programme. With police, local authorities and brothel owners charged with enforcing the policy, sex workers remain vulnerable to abuse and exploitation.35
Education provision and HIV-specific prevention services
In Haiti, a non-governmental organisation called FOSREF offers sex workers HIV testing and counselling services, treatment for sexually transmitted infections and vocational training (cooking, dance, beauty and information technology) that provide alternatives to sex work. To date, eight commercial sex worker clinics have been set up, with plans to extend the network to more cities throughout the country.36
In Guatemala, a sexual health clinic that offered counselling, testing and follow-up services over a six-month period witnessed a four-fold decrease in HIV among sex workers. HIV prevalence among sex workers in Chile and El Salvador has also fallen significantly following the targeting of sex workers with similar prevention programmes.13
Between 1992 and 2001, the Sonagachi Project in Calcutta, India, employed sex workers as peer educators to disseminate information promoting behavioural change, distribute condoms, and to refer sex workers to clinics. Sex workers participated in every aspect of the project, empowering participants to demand better working conditions and human rights protections. Between 1992 and 2001, condom use among sex workers rose dramatically from 27% to 86%.37
Law enforcement practices, human rights and legal education
In Thailand, the Service Workers in Group (SWING), is a partnership between sex workers and the police formed in 2004, which aims to foster law enforcement practices that protect rights, and supports effective HIV programming. In Thailand, sex workers are picked up by the police for carrying condoms, which are used as evidence of sex work. SWING sensitises young police cadets by giving them the opportunity to interact with sex workers in a neutral setting. Positive changes have already been noted in Bangkok constabularies, with fewer reported arrests and incidents of harassment.38
In 2001, the Blue Diamond Society (BDS) was established in Nepal in response to the appalling social, economic and health conditions faced by the LGBT community. Though it is not strictly a sex worker organisation, it adopts an integrated approach to meet the community’s needs and advocate for the rights of male and transgender sex workers, ensuring access to HIV prevention services. A key component of this approach has been the forming of alliances with legal institutions and legal services, with BDS also having two in-house lawyers. Between 2010 and 2011, over 10,000 community members participated in human rights and legal training across the country, increasing community knowledge of human rights and building skills about how to claim these rights.38
Addressing stigma and discrimination
The Survival Advocacy Network (SAN) is a transgender and female sex worker network founded by, and for, sex workers in Fiji. In 2010, SAN launched a project to train healthcare providers to enable sex workers to access healthcare without fear of stigma or discrimination. It developed training materials, trained health service providers in understanding human rights, and established referral linkages with a pool of sensitised healthcare staff who provide diagnosis and treatment for HIV and STIs. This initiative has proved highly successful with the Ministry of Health planning to establish additional clinics across the country.38
Barriers to accessing HIV prevention services
In many cases, laws and policies are actively stopping HIV prevention campaigns for sex workers. 60% of all countries reported such laws, policies and regulations in 2012.7
Sex work is viewed as morally corrupt or criminal in many places, and those involved are often neglected and marginalised by wider society. In 2012, 61% of countries had laws protecting key affected populations from stigma and discrimination. However, the enforcement of these laws remains an area of concern.7
Until June 2013, the USA government had a policy of refusing overseas aid to any HIV prevention programme that does not ‘explicitly oppose’ the practice of sex work.39 As a result, many organisations missed out on financial support that could have aided sex workers. It also increased tensions with authorities seeking to reach out to sex workers. In Brazil, the National AIDS Council refused $40 million in aid from the USA government to fight HIV in 2005, because it would have required them to agree with the American sex worker policy.40
In Goa, India, the state government chose to demolish the red-light district of Baina in 2004, in an attempt to ‘rehabilitate’ sex workers. They did so despite pleas from NGOs that had worked in the area for over a decade to prevent HIV among sex workers. As a result of the demolition, it became near impossible to continue these programmes, condom distribution fell, and the newly homeless and destitute sex workers became even more vulnerable to HIV.41
Since the introduction of an 'anti-human trafficking' law in Cambodia in 2008, violent crackdowns against sex workers in Cambodian brothels have increased.42 Police violence has pushed sex workers into other settings such as karaoke bars, 'beer gardens' or onto the street where it is difficult to access them with HIV prevention education. As condom use is far lower among sex workers and their clients outside brothels, organisations working with sex workers have expressed concern that the crackdowns are a major setback to the government's successful '100% condom' enforcement programme.43 By 2006, the programme had been credited with reducing HIV prevalence among brothel based sex workers from 44% in 1998 to 12.7%.44
Sex workers and human rights
Some laws not only criminalise sex work but also deny sex workers fundamental civil rights. They may be unable to own property, access education, justice, healthcare, banking services or purchase utilities. The social exclusion and poverty that results leaves sex workers vulnerable to exploitation, abuse and HIV infection. 45
Under these circumstances, sex workers are not recognised by the law and cannot exercise human rights like other people can. For example, the Swaziland Girls’ and Women’s Protection Act offers no defence for girls under the age of 16 if they are forced to have sexual intercourse:
"[A]t the time of the commission of the offence the girl was a prostitute." 46
Under this law, a girl under 16 years cannot consent to sex regardless of whether she is a sex worker or not, and is therefore considered a ‘non-person’.47
These types of laws and the conditions that sex workers have to work and live in, dramatically increase their vulnerability to HIV and undermine HIV prevention efforts targeting this group.48
Respecting, protecting and meeting the human rights needs of sex workers is vital in order to maintain their health and wellbeing.49
Removing barriers to HIV prevention for sex workers
Involving sex workers
Involving sex workers directly in HIV prevention programmes can raise their self-esteem and empower them to look after their health and access services that could help them. Indeed, these community empowerment-based responses have been shown to be most effective in addressing underlying social and structural barriers to the health and human rights of sex workers.50 The Sonagachi Project in India is a prime example of this.
"Building the capacity of sex workers to take the lead in programmes that respect human and citizen rights has proven to be one of the most successful strategies in preventing the spread of HIV. It promotes solidarity, enables them to reach more of their peers and share their knowledge on health matters. They no longer need to rely on outsiders, thus giving them increased control over their own health." - Mahooba Mahmood, Director of the Bangladeshi women’s organisation Naripokkho 51
Additionally, a five-year study conducted in Kenya found that prevention initiatives that involved sex workers in educating their peers led to increased protected sex and reduced HIV prevalence.52 SWOP, a sex worker prevention initiative that began in Nairobi, Kenya in 2008 operates on the basis that sex workers are more likely to trust other sex workers. Sex workers are involved in reaching out to their peers with advice on safe sex, condoms and information on where they can get tested for HIV. As a result of these outreach efforts, 7,000 sex workers had visited the SWOP clinic to access HIV prevention services by July 2010.53
"We have lots of work to do. We need to be empowered and supported so that we can take ownership of AIDS. What I’m calling for is to work with us, sit with us, feel with us and we will be able to reduce HIV transmission." - Linda John, 27, sex worker, Papua New Guinea 16
Should sex work be legalised?
In some countries, sex work is illegal, meaning that the law prohibits it. In others, it is criminalised, meaning that the act of sex work itself is not illegal, but that associated activities such as soliciting sex or running a brothel are. In a few countries, sex work is legalised and regulated.
It is argued that legalising or decriminalising sex work is beneficial to curbing the HIV epidemic, because it allows governments to monitor and regulate the sex trade. In doing so, they can ensure that sex workers are empowered to negotiate condom use, improve their access to public services, and protect them from violence and abuse. Where sex workers are criminalised, they can be difficult to reach or unwilling to cooperate for fear of being arrested. By removing legal restrictions, HIV prevention programmes could be carried out much more effectively.
In February 2014, the global report for the International Conference on Population and Development Beyond 2014 called on countries to:
"decriminalise adult, voluntary sex work to recognise the right of sex workers to work without coercion, violence or risk of arrest." 54
The way forward
When responding to the HIV epidemic among sex workers, empowering them and involving them in HIV prevention has had positive results. By addressing the underlying social and structural problems that make sex workers vulnerable to HIV – by giving them greater legal protection against violence, and by reducing the discrimination they face – HIV prevalence could be cut dramatically.
Harassment and abuse of sex workers by the police is also a widespread issue that needs particular attention from authorities. Governments and organisations need to create an environment where sex workers are able to protect themselves against HIV, and easily access HIV prevention, testing and treatment services.
Although spending on the global HIV response has reached unprecedented levels, funds directed at programmes for sex workers remain far below the estimated need.55 In 2009, less than 1% percent of global funding for HIV prevention was spent on HIV initiatives for sex workers.56
Photo credit: ©iStock.com/annede. Photos are used for illustrative purposes. They do not imply any health status or behaviour on the part of the people in the photo.
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