Female Sex Workers

A 2002 cross-sectional study randomly selected 1,512 female sex workers from two regions in southern and northern Karnataka, India and evaluated the impact of sex worker collectives on condom use and HIV/STI knowledge. NGO-operated female sex worker collective programs are often managed by older sex workers and not only provide members with condoms and STIs/HIV education, but also offer literacy training, medical care, and legal support for sex workers. The study found that the collectivization of female sex workers was correlated with better HIV knowledge and increased condom use. Female sex workers who were either members of collectives or had been in touch with peer educators “have knowledge that condom use can prevent [infections] and HIV,” (Halli et al., 2006: 742). Multiple logistic regression analysis found that collectivized sex workers had almost 16 times the odds of regularly using condoms with clients, reporting using condoms with clients 97% of the time. The study also found that condom usage and HIV/STI increased incrementally, in proportion to greater involvement with collectives, suggesting “in the southern Indian context, collectivization does add incrementally to the effect of peer education in reducing STI/HIV/AIDS-related risk behavior” (Halli et al., 2006: 747).

The Sonagachi project in India which provided free access to STI treatment, condoms and peer education was successfully replicated, including community organizing and advocacy; peer education; condom social marketing and establishment of a small clinic. Sex workers were randomly selected in 2 small urban communities in northeastern India. One hundred sex workers participated in each community, with an 85% retention rate. Overall condom use increased significantly in the intervention community to 39% as compared to 11% in the control community. The proportion of consistent condom users increased 25% in the intervention community compared with a 16% decrease in the control community (Basu et al., 2004). Providers initiated awareness and an offer of services at sex work sites through sex worker peer education, mobile VCT camps and community level task forces. Services include VCT; initiating antiretroviral therapy with escorting to follow-up at government clinics; treatment for opportunistic infections and TB; nutritional support; and support for a network of positive women. VCT rates between 2004 and 2005 increased almost nine times to a total of 2,578 with all who received counseling taking the HIV test. Barriers to HIV prevention and treatment were a belief that testing positive was a death sentence; lack of treatment literacy; and stigma by health provider (Saha, 2008) (Gray IIIa). A recent study of Sonagachi found that services are provided to 20,000 sex workers, along with a savings and bank cooperative and schools for children of sex workers. HIV risk reduction was also accomplished by training madams in brothels concerning the utility of condom promotion to promote the sustainability of sex work and their business; by creating a sense of empowerment among sex workers to refuse condomless sex; and creating a sense of community among sex workers, along with stable housing (Ghose et al., 2011). By providing housing for children of sex workers, sex workers were less easily coerced into unsafe sex. Peer discussions and problem solving increased condom use (Basu and Dutta, 2011). A recent review of Sonagachi has found that social support and addressing workplace autonomy, among other factors, were critical to the success of Sonagachi (Swendeman et al., 2009).

A study of two communities in China using data from behavioral surveillance in 2003, 2004 and 2005 found that while baseline data in 2003 of the two communities was not significantly different, the county which had comprehensive HIV prevention interventions for female sex workers had significantly higher prevalence of condom use with clients and regular sex partners, higher HIV related knowledge and increased uptake of VCT and HIV services by 2005. The HIV prevention intervention consisted of a prevention committee with high government support, an outreach team, VCT sites, a needle exchange center, a methadone maintenance clinic, STI clinics, support groups, trained peer educators and social marketing of condoms. More than 150 sex workers were interviewed in each community in 2003, 2004, and 2005. By 2005, sex workers in the intervention community were seven times more likely to have appropriate responses for questions on HIV, more sex workers in the intervention community perceived themselves at risk for acquiring HIV and at least twice as likely to report condom use with clients and sex worker partners. HIV knowledge was significantly associated with condom use. While over 75% sex workers in the intervention community reported accessing VCT, less than 10% of sex workers from the community with no intervention reported accessing VCT.

The Avahan project study with a representative sample of 400 sex workers in India found that increased exposure to sex worker peer educators, visiting the program clinic for services concerning sexually transmitted infections and receiving condoms from a peer educator or outreach worker was associated with consistent condom use with occasional clients and regular clients and treatment seeking behavior for sexually transmitted infections. Female sex workers exposed to any of the three core services of Avahan were using condoms consistently with 75% of occasional clients and 72% with regular clients. Those who had received any of the three core services in districts where only Avahan operated were 3.17 times more likely to have consistent condom use with occasional clients and 2.46 times more likely to use condoms consistently with regular clients (Ramakrishnan et al., 2010: i67). In another evaluation of the Avahan project, 2,312 female sex workers were surveyed at baseline and 2,400 were surveyed 28 to 37 months later and found that compared with baseline, there was a reduction in the prevalence of HIV from 2019.6% to 16.4%. Reported condom use at last sex increased significantly for repeat clients from 66.1% to 84.1%. by follow up, 95.3% of sex workers had been visited by a peer educator, 76.6% had visited the drop-in center and 85.1% had visited the project sexual health clinic. Other sex worker populations in India without these interventions have reported sharp increases in HIV prevalence over time. However, the cross-sectional surveys were unlinked and anonymous, making it impossible to ascertain what the rate of new HIV infection acquisition was during the intervention (Ramesh et al., 2010). Additional surveys conducted on Avahan’s impact demonstrated significant increases in condom use among sex workers (Verma et al., 2010; Lowndes et al., 2010) with modeling studies suggesting reductions in HIV incidence and prevalence (Ng et al., 2011; Pickles et al., 2010).

In a prospective, community-based, pre/post-intervention trial of thirty establishments in Chengjiang, thirty-four in Ruili and twenty-three in Longchuan, China, outreach workers visited the establishments to conduct intervention activities over six weeks. The study participants were female sex workers. Intervention activities included lectures, discussion, video and audiocassettes, and distribution of educational folders and condoms. Pre- and post-intervention cross-sectional surveys assessed changes in STI/AIDS knowledge and condom use. After the intervention, knowledge of the three HIV transmission routes increased from 25 to 88%, knowledge that condoms can reduce the risk of STI/HIV infection increased from 56 to 94%. Condom use at last sex and in the last three sexual encounters increased from 61 to 85% and from 41 to 70%, respectively. Multivariate analyses indicated that the intervention was an independent factor for these changes. The intervention program was effective at increasing HIV/AIDS knowledge and condom use rates among sex workers in the community.

A study of 924 female sex workers from 2004 to 2008 in Mexico’s border cities found that one 30-minute intervention based on principles of behavior change led to an increase in protected sex acts and a 40% decrease in STIs over a six month period when compared to a group that received standard presentation of prevention messages for VCT. Local health workers in the intervention group discussed with women how to negotiate safer sex, barriers to using protection, negotiation of condom use and ways to improve social support.

A prospective, community-based, pre/post, intervention trial set in entertainment establishments (karaoke bars, massage parlors, dance halls, beauty parlors) where sex workers operate at sites in five provinces of China (Anhui, Beijing, Fujian, Guangxi and Xinjiang) showed increased condom use and decreased STI prevalence after setting up a Women's Health Clinic near participants' places of work at each site. The participants were all sex workers working in targeted entertainment establishments. Clinic-based outreach activities, including awareness-raising, condom promotion, and sexual health care, were developed and delivered to sex workers. Cross-sectional surveys at baseline and post-intervention were used to evaluate changes in condom use with the last three clients, and the prevalence of chlamydia and gonorrhea. In total, 907 sex workers were surveyed at baseline and 782 at 12 months post-intervention. Outreach teams made 2552 visits to the target entertainment establishments, approached 13,785 female sex workers, and distributed 33,575 copies of education material and 5102 packets of condoms. The rate of condom use with the most recent three clients increased from 55.2% at baseline to 67.5% at 12 months evaluation. The prevalence of gonorrhea fell from 26% at baseline to 4% after intervention, and that of chlamydia fell from about 41 to 26%.

A study evaluated the impact of clinics for 1,554 sex workers in Guatemala and found that HIV incidence significantly declined from 1.85 per 100 person years in 2005 to .42 per 100 person years in 2008. Sex workers were offered HIV screening, condom promotion and education every six months. There was a significant increase in the proportion of consistent condom use from the baseline visit, except with regular partners.

A clinic in Mozambique for sex workers and long distance truckers established in 2001, with evaluation data from 2004 to 2009, found that the service was highly utilized by both sex workers and long distance truckers, with steep increases for HIV testing, contraceptive services and STIs, with high client satisfaction. The average clinic running cost is $1,408 per month for guards and peer educators funded by the Flemish International Cooperation Agency, with 475 clients visiting the clinic every month. The Mozambican government covers the costs of the salaries of the three clinic nurses, drugs and medical supplies. Of the clinic visits, 43% were for contraception; 24% for HIV testing and 23% for STI care. HIV testing was introduced in 2006 and the average number of tests increased to 115 in 2009. Condoms distributed increased from 3,151 in 2004 to 9,200 in 2009. In order to provide quality care, it was concluded that the numbers of clients could not be increased without additional staff, hours and resources. A mapping and enumeration conducted in 2008 estimated 4,415 sex workers in the area near the clinic. In addition to clinic data, two focus group discussions with sex workers and six focus group discussions were held in 2008, along with interviews with clinic staff and peer educators. One sex worker noted: “Nothing compares to this clinic. The information given is clear and simple while in the hospital where I went… you are not adequately treated” (Lafort et al., 2010: 146).

A study of sex workers in Brazil from 2003 to 2005 that provided clinic-based health care with destigmatization of sex work and activities for dialogue among sex workers concerning discrimination, human rights and sex work resulted in fewer reported unprotected sex acts, particularly among those who perceived increased mutual aid and trust.

A meta-analysis of 34 articles, 16 from Sub-Saharan Africa, 16 from East and Central Asia and 2 from Latin America, of which 12 studies focused on sex workers, found that peer education was significantly associated with increased condom use.

A randomized controlled trial from 2007 to 2008 of 98 female sex workers in Armenia found that a two hour intervention with a three-month follow-up increased consistent condom use and increased applying condoms to clients. The two hour face to face intervention by a health educator emphasized gender empowerment, self-efficacy to persuade clients to use condoms, condom application skills and eroticizing safe sex. Participants randomized to the wait-list control were offered participation in the intervention following the completion of all follow-up assessments. The intervention was pilot-tested and revised based on sex worker feedback. During the two-hour intervention, sex workers could practice on a penile model; think about risky situations and strategies to reduce HIV risk-related behaviors, how to initiate safe sex conversations, how to negotiate condom use, and how to refuse sex without condoms. A fifteen-minute session was provided after three months to address any new barriers and to provide support. Women in the intervention group at six months were 2.8 times more likely to report using condoms consistently with clients, 2.8 times more likely to report using condoms consistently with their clients in the last seven days and 4.2 times more likely to apply condoms to their male clients.

A study starting from 1980 until 2005 in Kenya with 3,000 sex workers found that community engagement which led to leveraging existing social capital to form a cohort community resulted in improved health and empowerment. Prior to the project, sex workers were highly stigmatized and disenfranchised. The study brought a clinic which provided nonjudgmental quality healthcare services, including STI treatment, contraception, no-cost condoms and one-on-one counseling. As one sex worker put it: “They teach us how to keep our bodies healthy….The doctors are good and keep your secrets…if they find you (HIV) positive.” The study helped to create a sense of community and support. Community meetings taught about antiretroviral therapy, and the importance of adherence. Sex workers decided to unite the women into a ‘no condom, no sex’ services campaign that “has likely averted thousands of infections over the years.” Peer educators were elected by other members who attended the clinic and conduct most of the outreach work. The study was conducted with 48 in-depth interviews; 28 peer leaders; 6 researchers; and women’s groups. Four meetings were observed. However, women’s denial of their own identities as sex worker due to stigma presents a challenge for effective community engagement.

Empowerment for sex workers in India through Sonagachi has evolved from 1992 when staff of an NGO approached sex workers to currently, where sex workers have formed their own autonomous organization, Durbar, with 65,000 sex workers in the state of West Bengal. Review of Durbar’s work as based on 22 focus group discussions with sex workers, with 5 to 25 sex workers in each focus group. In depth interviews were conducted with 10 key sex worker leaders and eight non sex worker staff of Durbar. Feedback was provided by Durbar following a dissemination workshop.  A focus group discussion was held with brothel keepers and police and government officials were interviewed as well. Interviews were also held with non-Durbar sex workers. Sex workers and non-sex workers staff were given an equal status within the organization, with each having different expertise, with sex workers assuming key responsibilities within Durbar and in representing Durbar. Literacy classes which questioned social norms and used critical thinking were added to health projects, providing skills in discussion and debate. Durbar has assumed direct responsibility for running the health projects for sex workers as of 1999. Durbar was formed in 1993 by a group of sex workers who came together as peer educators through the NGO. Members of Durbar have successfully organized against maltreatment from brothels and pimps, against violence by the police and others, against forcible AIDS surveillance and against eviction of sex workers from brothels and red light areas, achieving greater power for sex workers in the sex trade. Durbar has a savings and credit cooperative. Prior to the formation of Durbar, sex workers reported a lack of control over their own lives and a sense of powerlessness. Durbar claimed prostitution as legitimate work, viewing it as “a legitimate and necessary occupation within the context of a wider economy, which offers the poor very few viable livelihood options,” (Gooptu and Bandyopadhyay, 2007: 256) harming no one. Now that Durbar is a collective, police, government official and politicians “behave civilly with them now and meet with them…to discuss and solve problems…” (Gooptu and Bandyopadhyay, 2007: 257). Durbar has given sex workers a sense of their rights, so that Durbar now claims legal recognition and enforcement of their rights by the Indian government. In addition to establishing health services to meet sex worker needs for HIV/AIDS prevention, treatment and care, Durbar has set up services for counseling and treatment for the general population, particularly the poor. Durbar has also intervened on behalf of underage girls and those brought forcibly to the sex trade. Durbar has raised funds for flood victims, presenting themselves as “socially responsible citizens with a conscience and a sense of duty toward the vulnerable” rather than “weak needing rescue” (Gooptu and Bandyopadhyay, 2007: 265).

SANGRAM in India began in 1992 with peer education and condom distribution, but evolved to create a sense of collective solidarity. SANGRAM has been incorporated into the policy process of the state of Mahararashtra. Through SANGRAM, a collective of women sex workers was formed - VAMP. VAMP has grown from 150 women in 1995 to 5,000 members as of 2008. VAMP by exercising civil rights, ended police raids and has also gained the right of no cost condoms from the state government. Condom distribution by peer sex workers has increased from 6,000 to 8,000. VAMP member support members who are HIV-positive.

A systematic review of 28 interventions (Shahmanesh et al., 2008) “showed that policy-level support and empowerment strategies for sex workers can improve acceptability, adherence and coverage of HIV preventions programmes” (Padian et al., 2011b: 273).

A study of a community-led HIV prevention program by sex workers in India (Ashoyada) led members to report that violence from police had been reduced.

A pre- and post-test study that compared condom use and policies in 68 sex establishments in the Dominican Republic from 1999 to 2000 with 200 female sex workers age 18 or older found that a combination strategy of a community-based approach combined with government policy and enforcement was most effective in increasing condom use rates. The study was approved by and involved the sex worker union of the Dominican Republic, MODEMU. The two environmental-structural interventions compared in the study included a community-based approach implemented in sex establishments in one city, and a combined community-based approach with government policy and regulations at another. All sex establishments that participated in the study implemented a 100% condom use policy, and owners were informed that ultimate responsibility for usage was their own, not their employees, and penalties in the form of warnings and fines were administered in cases where owners were found to not be compliant. All personnel, including sex workers, managers, owners, deejays, security, etc. attended activities in the form of workshops and meetings in order to strengthen relationships and collective commitment for condom use. Key elements to ensure condom usage and measure compliance included use of posters, condom availability, monthly confidential STI checkups, and a lack of a positive STI diagnosis (Kerrigan et al., 2004: 2). Quarterly meetings were held with sex workers and managers. In one site (Puerta Plata), owners were subject to graduated sanctions, such as notifications, fines, and closing. Data collected showed that consistent condom use with new clients significantly increased in Santo Domingo, from 75% to 94%. In Puerta Plata, the rate increased from 96% to 98%. Significant overall declines in the STI rates of both approach sites were observed. Furthermore, an association was found between higher rates of consistent condom use and higher levels of exposure to the workshops. Lastly, levels of compliance with the policies was found to be significantly higher in the Puerta Plata site which implemented government sanctions for non-compliance in addition to the community approach. In Puerta Plata, the rate of consistent condom use by regular and nonpaying partners rose significantly, from 13% to over 28%.  Sex workers in Puerta Plata reported a significantly increased ability to reject unsafe sex, from 50% to 79%. In Puerta Plata, there was a significant decrease from over 28% to less than 17% of one or more STIs (Kerrigan et al., 2006; Kerrigan et al., 2004).* 

*Implementation of policies varies in practice. Recent documentation with 100% condom use policies, for example in Cambodia (Lowe, 2002), suggest that some aspects of 100% condom use policies can be disempowering to sex workers and violate human rights. Some have suggested that the Kerrigan 2004 and 2006 studies, along with the Pisey, 2008 study and Morisky and Tiglao, 2010 should not be instituted for this reason.  The 100% condom campaign in Thailand “may have adversely impacted marginalized sex workers through increased corruption, police raids and mandatory HIV testing” (Shannon et al., 2009: 659). “It is critical that all programmes follow a sex worker led approach and enable sex workers to collectively determine what role brothel owners should play in HIV/AIDS intervention programmes” (UNAIDS, 2011f: 12). 

A study with 24,302 sex workers in 130 establishments from 1995 to 2001 an intervention in the Philippines found significantly lower rates of HIV and highly significant improvements in consistent condom use behavior among sex workers who received peer education and training by managers employing sex workers, or a combination of both peer education and training by managers, as compared to a control group that only received usual care by peers and managers. Where both manager and peer education were used with 299 sex workers, self-reported condom use increased from 35.2% to 50.8% but among the 206 sex workers in the control group, condom use decreased from 45.6% to 20.1%. At establishments where a condom use policy existed, female sex workers were 2.6 times more likely to use condoms consistently compared with establishments that did not have such a policy in place. Thirteen sex workers were HIV-positive in the usual care group compared five in the intervention group. A total of 2,346 heterosexual men were trained by male peer educators using fotonovelas and resulted in a significant effect on condom use behavior with sex workers, as well as significant differences between the intervention and control group between baseline and end line. Condom use was determined by a validated 6 item Likert-type scale and was negatively correlated with occurrence of STIs as diagnosed at the Social Hygiene Clinic. HIV testing increased from 86% from baseline to follow up among 903 sex workers at follow-up and was associated with increased condom use (Morisky and Tiglao, 2010; Morisky et al., 2010; Chiao et al., 2009; Ang and Morisky, 2011). [See footnote above]

A study of 310 sex workers in China found that among sex workers who perceived support for condom use from “my boss” was correlated with higher rates of condom use. Sex workers with access to condoms and who agreed with the statement, “If I refuse to serve a customer who does not want to use a condom, my boss will support me” and whose manager encourages health check-ups reported more condom use. Sex workers who reported this support were 1.7 times more likely to report overall consistent condom use and 1.5 times more likely to report consistent condom use in the last three sexual acts. [See footnote above]

A study in Guangxi, China evaluated the efficacy of cultural adaptation of a voluntary counseling and testing (VCT) intervention, in increasing condom use and decreasing rates of sexually transmitted infections (STIs) among a group of female sex workers. This intervention is modeled after the "state-of-the-science" VCT program that was developed and evaluated by the Center for Disease Control and Prevention's Project RESPECT. The Project RESPECT two–session VCT program was adapted with five major modifications by the investigation team in response to the social and cultural context of female sex workers in China. Four hundred female sex workers were assigned to either an intervention group receiving the VCT intervention or a control group receiving standard of care STI testing and treatment. Data were collected at baseline and 6 months post intervention. Outcome measures included HIV/STI related knowledge and perceptions, condom use, and history of STIs. Five common STIs were screened and tested through clinical examination and laboratory testing to serve as biomarkers. After controlling for potential confounders and baseline differences, the VCT intervention group was significantly higher than the control group in HIV/STI related knowledge and consistent condom use with clients at 6 months follow-up. In addition, the intervention group had a significantly lower infection rate of STIs than the control group at follow-up. This quasi-experimental trial provides evidence that the brief VCT intervention, through appropriate cultural adaptation, can be efficacious in increasing condom use and reducing STI infection rate among female sex workers in China.

A re-survey of 172 HIV-negative female sex workers one year after 2002 in Kenya found that condom use had increased and STI prevalence had decreased. From 1998 to 2002 monthly antibiotics to prevent STI and HIV transmission were provided along with regular counseling, condoms, screening and treatment. Quarterly community meetings for sex workers in the individual villages, as well as a larger meeting including all villages in the area to address sex worker risk reduction issues as a community were ongoing after the study.

An on-site clinic to provide sex workers with quality of care at a brothel in Johannesburg, South Africa found that condom use may have increased. Qualitative interviews showed that information sessions by nurses positively affected condom use.  Through nurse counseling, sex workers understood: “Even if he promises you more money [this] cannot buy your life” (Stadler and Delany, 2006: 461). Data were drawn from 12 focus groups and ten in-depth interviews with sex workers. Prior to the establishment of the on-site clinic, most sex workers reported not using public health services due to abusive provider attitudes to sex workers, lack of appropriate drugs and long lines. The onsite clinic provided treatment for STIs, education and condoms. Over a 15-month period, 1,243 women were screened and treated at least once for STIs. Sex workers incurred no travel costs to access the clinic. Sex workers reported that the clinic staff created an atmosphere of honesty and respectful treatment: “Everything is done through agreement…everything is explained” (Stadler and Delany, 2006: 460).

A study in Senegal found that a peer-mediated education and condom distribution program targeting male clients of sex workers was successful in increasing AIDS-related knowledge and consistent condom use. Twenty transport workers were elected by co-workers to attend a two-day training seminar to acquire general information on HIV/AIDS/STIs that included topics of transmission, symptoms, and preventative measures as well as condom negotiation and peer communication techniques. At the end of training peer educators were expected to provide basic HIV/AIDS information to their peers, distribute condoms and printed materials, and serve as a link to STD clinic staff. Weekly discussion groups for the educators were also held to review the training material. Baseline and follow-up surveys and interviews were conducted over a two-year period among 260 matched pairs of transport workers to determine the impact of the intervention. Forty-five sex workers were also administered pre- and post-intervention surveys concerning client behavior. Although AIDS-related knowledge was determined to be high at baseline, with 95% of the transport workers reporting at least some awareness concerning HIV/AIDS transmission and other related issues, a significant increase to 100% was observed in the follow-up interviews. Consistent condom use with regular, nonmarital partners increased from 49.4% to 90.4% and men reporting having ever used a condom increased from 30.4% to 53.5%.  Sex worker survey results showed that the number of clients “always” agreeing to use a condom increased significantly from 2.2% to 42.2% and the proportion of clients offering more money for sex without a condom decreased significantly from 82.2% to 46.7%. Lastly, although the majority of sex workers reported being the supplier of condoms during sexual encounters, 29.6% of the men who had received a condom from a peer educator were carrying a condom at the time of the follow-up interview. Commercial sex work has been legal in Senegal since 1970.

The Avahan project in India resulted in consistent condom use by male clients of female sex workers. Five stratified two-stage cluster sample surveys conducted between 2006 and 2008, with sample sizes from 1,741 to 2,041 found that two thirds of men in each survey round recalled some aspect of the intervention, which included: 1) outdoor promotional materials, 2) interpersonal communication and 3) street theater and/or interactive game shows, with small group discussions following these activities. Consistent condom use with female sex workers increased significantly from 63.6% at baseline to 86.5% at end line. Men exposure to two parts of the intervention reported higher consistent condom use than men exposed to no part of the intervention, included condom use at last sex. Affordable condoms were introduced in 65,000 retail outlets. The Avahan program with male clients was conducted from 2004 to 2008 and reached an estimated 700,000 men monthly.