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Sex Workers and HIV/AIDS
Sex workers, along with other marginalised groups such as men who have sex with men (MSM) and people who inject drugs (PWID), are often considered at risk of HIV. However, although sex workers are severely affected by HIV in many parts of the world, they are also one of the groups most likely to respond well to HIV prevention campaigns.
Prevention campaigns aimed at sex workers not only reduce HIV transmissions that result from paid sex; they can also play a vital role in restricting the overall spread of HIV in a country. Proof of this can be seen in countries such as Cambodia, the Dominican Republic, India and Thailand, where general reductions in the national HIV prevalence have been largely attributed to HIV prevention initiatives aimed at sex workers and their clients.
Why are sex workers at particular risk of HIV transmission?
It is difficult to talk about sex workers as a single ‘group’, because those involved in the sex industry come from a diverse range of backgrounds and cultures. As a result, the levels of risk that they face in terms of HIV infection varies greatly depending on the country that they live in, whether they work from a brothel or ‘on the street’, and whether they have access to condoms, among other factors. 1 A wealthy sex worker supplying services to businessmen in London, for instance, may face a very different level of risk to that of an impoverished girl who is being forced to sell sex in a red-light district in Thailand.
There can also be significant variance within countries. For example, in India, HIV prevalence is 4.6 percent among sex workers in Mumbai compared with 24 percent among street-based, and 29 percent among brothel-based, sex workers in Maharashtra. 2
Despite this diversity, sex workers often share several common factors in their lives, regardless of their background. Some of these factors can increase their exposure to HIV. 3
Multiple partners and inconsistent condom use
In general, sex workers have comparitively high numbers of sexual partners. This in itself does not necessarily increase their likelihood of becoming infected with HIV if they use condoms consistently and correctly.
The reality, however, is that sex workers and their clients do not always use condoms. The 2010 UNAIDS global report found only a third of the 86 countries surveyed reported 90 percent of sex workers using a condom with their last client, while more than half reported condom use by 78 percent of sex workers. 4 In 2012, 44 countries reported higher median condom use; 85 percent, up from 78 percent in 2009. 5
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. They may also offer more money for unprotected sex – a proposal that can be hard to refuse if the sex worker in question is in desperate need of an income.
“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) 6
The clients of sex workers are fuelling HIV transmission, because they act as a link between sex workers 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 extended periods of time away from home. High HIV prevalence among the male clients of sex workers has been detected in studies globally. 7 8 9 10
Social and legal factors
Sex workers are generally stigmatised, marginalised and criminalised by the societies in which they live, and in various ways, these factors can contribute to their vulnerability to HIV.
Even though sex work is at least partially legal in many countries, the law rarely protects sex workers. 11 Around the world, there is a severe lack of legislation and policies protecting sex workers from the actions of clients that can put them at risk. For example, a sex worker who is raped will generally have little hope of bringing charges against their attacker. The lack of protection in such cases leaves sex workers open to abuse, violence and rape, creating an environment, which facilitates HIV transmission. 12
Non-governmental organisations report that almost two thirds of the countries they work in have laws that make it difficult for them to provide services to sex workers. 13 In some countries, police use the possession of condoms as evidence that somebody is involved in 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 14
“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. 15
In addition, the stigma that sex workers face can make it hard for them to access health, legal, and social services. They may either be afraid to seek out these services for fear of discrimination, or physically blocked 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
Without access to these services, sex workers may face a higher risk of HIV infection, and be more likely to transmit HIV if they do become infected.
Injecting drug use
In some countries, large numbers of sex workers are also people who inject drugs. Some become involved in sex work as a means of financing their drug use, while others are involved in sex work first, and then turn to drug use. Since needle sharing is one of the most efficient routes of HIV transmission between people, sex workers who inject drugs and share needles face a particularly high risk of becoming infected with HIV.
Researchers investigating HIV prevalence among female sex workers (FSWs) 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 FSWs in Europe concluded that their HIV vulnerability was linked primarily to unsafe injecting. 18 A study in Manipur, India, found that HIV prevalence among female sex workers who injected drugs was 9.4 times higher than among FSWs 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 people trafficking
Migration and sex work are often linked as poor migrants sometimes turn to sex work because 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 loneliness that often accompanies migration.
In addition to voluntary migration, people trafficking – whereby people, usually women and children, are forcibly moved between areas – has also been linked to the spread of HIV. Large numbers of trafficked women and children are forced into sex work every year. Even in countries where HIV prevalence is low, trafficked women are still vulnerable to HIV infection because they struggle to negotiate condom use, are forced to endure multiple sex partners, and may be subjected to violence. 21
One study conducted among trafficked sex workers rescued from brothels in Mumbai, India, found that almost a quarter of trafficked girls and women were HIV-positive. 22 Sex trafficking also relates to a high risk of HIV infection for girls trafficked in Southeast Asia. 23
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 with underage girls or boys. 24 25
HIV and sex work around the world
Globally, HIV prevalence among sex workers differs greatly as sex workers come from a variety of backgrounds and cultures, and operate in a range of settings.
In Sub-Saharan Africa, male and transgender sex workers (MTSW) are often engaged in sex work for financial reasons and are at a high risk of HIV transmission. Criminalisation of homosexuality drives male sex work underground, making it extremely difficult for MTSWs to access HIV prevention initiatives. 28
In Central America, there is a strong correlation between injecting drug use and sex work along major drug trafficking routes, particularly where female sex workers are concerned. 30 Likewise, injecting drug use and sex work play a significant role in the spread of HIV in Russia and Eastern Europe, where many have turned to sex work as a means of income. 31
Data on HIV prevalence among sex workers in Western Europe is limited. However, the research available shows that HIV prevalence among male and transgender sex workers typically exceeds that of female sex workers. 32 Similarly, statistics on HIV prevalence among sex workers in the United States are few in number, but HIV cases among those who inject drugs tend to be significantly higher than among those who do not. 33
Research on HIV prevalence among female sex workers is more widely available than research on HIV prevalence among male and transgender sex workers. This is due mainly to the fact that male and transgender sex workers are often included in men who have sex with men (MSM) statistics. 34 Combining these populations presents challenges to understanding the trends within these two groups, which have very different profiles and vulnerabilities to HIV transmission. 35 Below is a table showing HIV prevalence among sex workers around the world in selected countries. 36
HIV prevalence (%) among sex workers in selected countries worldwide
|Russia, Eastern Europe and Central Asia:|
|Western and Central Europe:|
|Bosnia and Herzegovina||0||0.5|
Preventing HIV among sex workers
Experts recommend that campaigns aiming to prevent HIV amongst sex workers should initially focus on achieving three main outcomes:
- An increased level of condom use and safer sex amongst 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 occurring amongst sex workers 37
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.
Others have suggested a combination prevention approach. For example, 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 percent. Providing these services in tandem with prevention initiatives which support safe workplaces and tackle stigma and discrimination in society as part of a community-driven approach has the potential to work in settings worldwide. 38
Examples of successful HIV prevention programmes
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 percent in 1989 to over 90 percent since 1992, with Thailand’s overall HIV prevalence reflecting this decline. 39 Between 1998 and 2003, a similar programme in Cambodia reduced HIV prevalence among sex workers over the age of 20 from 44 percent to 8 percent. 40
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 (e.g. cooking, dance, beauty and information technology) that provide alternatives to sex work. 41 To date, eight commerical sex worker clinics have been set up, with plans to extend the network to more cities throughout the country.
In Guatemala, a sexual health clinic which 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. 42
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 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 percent to 86 percent. 43
Law enforcement practices, human rights and legal education
The Service Workers in Group, or (SWING), in Thailand 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. 44
In 2001, the Blue Diamond Society (BDS) was established in Nepal in response to the appalling social, economic and health conditions faced by LGBT in the country. Though not 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, 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. 45
As as well as providing both healthcare and education services to sex workers, EMPOWER in Thailand, promotes the recognition of sex work as work and equal access to protection and benefits. One of their biggest achievements is the National Social Security Scheme, which provides social insurance and benefits for sex workers working in entertainment venues. 46
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. 47
Barriers to accessing HIV prevention services
In many cases, laws and policies are actively stopping HIV prevention campaigns for sex workers. The number of countries reporting such laws, policies and regulations increased from 41 percent in 2006 to 67 percent in 2010, 48 and prominsingly dipped to 60 percent in 2012. 49
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 percent of countries had laws protecting vulnerable groups from stigma and discrimination. However, the enforcement of these protection laws remains an area of concern. 50
Until June 2013, the US government had a policy of refusing overseas aid to any HIV prevention programme that does not ‘explicitly oppose’ the practice of sex work. 51 As a result, many sex workers missed out on financial support that could otherwise have saved lives. 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 U.S. government to fight AIDS in 2005, because it would have required them to agree with the American sex worker policy. 52
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 amongst sex workers. As a result of the demolition, it became near impossible to continue these campaigns, condom distribution fell, and the newly homeless and destitute sex workers became even more vulnerable to HIV. 53
Since the introduction of an 'anti-human trafficking' law in Cambodia in 2008, violent crackdowns against sex workers in Cambodian brothels have increased. 54 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. 55 By 2006, the programme had been credited with reducing HIV prevalence among brothel based sex workers from 44 percent in 1998 to 12.7 percent. 56
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. 57
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" 58
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’. 59
These types of laws and the conditions that sex workers have to work and live in, dramatically increases their vulnerability to HIV. 60
Removing barriers to HIV prevention for sex workers
Involving sex workers
Involving sex workers directly in HIV prevention campaigns can raise their self-esteem and empower them, encouraging them to look after their health and to access services that could help them.
“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 61
The Sonagachi Project in India is a prime example of this. 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. 62 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. 63
New technologies such as mobile phones mean that sex workers no longer need to work on the street or in brothels, and are therefore harder to reach without the involvement of people who have real insight into their networks, work and lives. 64
“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, sex worker, 27, Papua New Guinea 65
Should sex work be legalised?
In some countries, sex work is illegal, meaning that it is fully prohibited by the law. 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 give them protection 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 campaigns could arguably be carried out much more effectively. 66
On the other hand, some claim that legalisation increases the number of individuals who enter sex work, and the demand for sex work. Another problem is that even in countries where sex work is legal, such as the Netherlands and Australia, there are still sex workers who do not register with authorities, and operate ‘on the street’, where they cannot be reached by HIV prevention campaigns.
The way forward
When it comes to responding to the HIV epidemic, certain methods have had positive results – reaching out to sex workers, empowering them, and involving them in HIV prevention.
By addressing the underlying social and economic 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. 67 Governments and organisations need to create an environment where sex workers are able to protect themselves against HIV, and have widespread access to 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. 68 In 2009, less than one percent of global funding for HIV prevention was spent on HIV and sex work. 69 As well as a means of helping sex workers, HIV prevention among sex workers in many places should be viewed as a way of stemming the wider HIV epidemic.
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