Female Sex Workers
Sex workers, whose work involves sexual relations with multiple partners, are a key group of women who need access to comprehensive sexual health services, including HIV prevention, treatment and care. Programs that enhance sex workers' ability to use condoms are also vitally important (Lafort et al., 2010; Pisani, 2008). Unprotected sex with multiple partners puts sex workers at risk of HIV acquisition. Among sex workers, the median reported rate of condom use with their most recent client in 2008 was 86% in 56 low- and middle-income countries (UNAIDS, 2009e).
Sex work is defined by UNAIDS as selling sexual services (UNAIDS, 2008 cited in Ditmore, 2009). While some progress has been made in providing HIV services for sex workers, much more remains to be done. Human rights violations and lack of safe and supportive working conditions render sex workers particularly vulnerable to HIV infection through actions such as confiscating condoms, using condoms as evidence against sex workers and violence against sex workers (Ditmore, 2009). PEPFAR guidance notes: "Even where services are theoretically available, sex workers face substantial obstacles to accessing HIV prevention, treatment care and support, particularly where sex work is criminalized" (PEPFAR, 2011b: 27). "The most effective HIV programmes for sex workers are undertaken from a rights based perspective [and] are grounded in evidence..." (Ditmore, 2009).
Sex Workers are Disproportionately Vulnerable to HIV Infection in Many Parts of the World
A pooled analysis of 102 articles from 2007 to 2011 representing 99,878 female sex workers in 50 countries found that overall HIV prevalence was 11.8%, with female sex workers 13.5 times more likely to be living with HIV compared with all women of reproductive age in low and middle income countries (Baral et al., 2012a). A study from 2008 to 2009 in Uganda found that among 1,027 sex workers, HIV seroprevalence was 37% (Vandepitte et al., 2011). Additionally, access to condoms by sex workers is less than optimal (Pettifor et al., 2011). In Indonesia, surveys showed that HIV incidence is increasing among female sex workers (Magnani et al., 2010).
A study of sex workers in India found that targeted HIV interventions for female sex workers were highly cost-effective (Prinja et al., 2011). Astoundingly, in 40% of countries with a generalized epidemic, few services for sex workers were available in 2007 and worldwide less than 50% of sex workers have access to HIV testing and counseling and to condoms that could save them from acquiring HIV in the course of their occupation (UNAIDS, 2010 cited in Baral et al., 2012a). Some studies have found that programs for sex workers received limited resources despite the high vulnerability of sex workers to acquiring HIV (Lasry et al., 2011). A recent review of prevention efforts in Asia found that "the current reality is that the bulk of prevention resources are not allocated to sex workers or most-at-risk populations, despite the centrality of these populations in the Asian epidemic" (Greener and Sarkar, 2010).
Sex Workers Are a Diverse Population
"We get our condom supply from peer sex workers who are involved in doing outreach. ...I initiate condom use with my partners and use contraception as an excuse. Sometimes if my partners are against condom use I wear a female condom" Sex worker from Kiribati (McMillan and Worth, 2010:10)Interventions must be adapted to meet the needs of sex workers in different settings. The sex work industry is diverse and includes a broad range of workers operating in various locations including those who are street-based, brothel-based, those who work as escorts and those who work from their own homes. Some women exchange sex for cash or goods but do not see themselves as sex workers (Hawken et al., 2002; Buzdugan et al., 2010; Saggurti et al., 2011). Some sex workers are migrants and are at particularly high risk (Choi, 2011). Transgendered men and women face barriers to employment and therefore also work as sex workers and are at particularly high risk for HIV acquisition (Scheibe et al., 2011). [See also Transgender Women and Men] This resource focuses on women who describe themselves as sex workers. Women are sometimes trafficked into sex work and there is currently debate about how to assess whether a woman is trafficked or whether she is a sex worker (UNAIDS, 2011f). Adolescents, however, cannot be considered to have consented to sex work and need additional interventions (Silverman, 2011; van Blerk, 2011; UNAIDS, 2011f).
Criminalization of Sex Work Hinders HIV Prevention
"Sex work is currently a criminal offense in most southern African countries, as indeed it is in [much] of the world... and much of the vulnerability of sex workers to HIV in southern Africa stem directly from the criminalization of their work" (Richter et al., 2010b: 1 and 2). Simply decriminalizing sex work would not eliminate HIV. However, when "sensibly applied, legislative processes can be a most powerful public health ally. Equally, harmful law may obstruct and hinder public health" (Richter et al., 2010b: 1 and 2). In New Zealand, which has explicitly decriminalized sex work and adopted a human rights and public health framework, sex workers report being able to negotiate safe sex and report abuse to the police (New Zealand Government, 2008 cited in Richter et al., 2010b).
Criminalization of sex work as practiced in many parts of the world makes access to health services difficult. Sex workers in some studies state that the reason they do not access services is fear of arrest. Criminalization means that sex workers are less able to negotiate condom use and are more subject to violence from clients. Many have argued that impunity for violence against sex workers reduces the ability of sex workers to negotiate condom use (Shannon and Csete, 2010). They also may have difficulty accessing both legal services and post-exposure prophylaxis (PEP) in cases of rape.
Sex workers face particular challenges when confronting violence (Beattie et al., 2010) [See also Addressing Violence Against Women]. A young man in India stated: "...Prostitutes are like rough notebooks which anyway have many lines drawn upon them. One does not have to bother for condom, as an additional line on the notebook would not spoil it" (Pradhan and Ram, 2010: 550). These attitudes that devalue sex workers can only increase HIV risks for both the sex workers and their male clients. "The illegal status of sex work creates conditions in which exploitation and abuse can thrive" (Gould and Fick, 2008: 55). As one South African sex worker stated, "There is nothing you can do if someone is violent with you... you can't go to the police..." (Gould and Fick, 2008: 49). A survey of 118 sex workers in South Africa found that 12% had been raped by police officers and 28% reported that policemen asked them for sex in exchange for release from custody (Gould and Fick, 2008).
Forcibly shutting down brothels is ineffective and can be harmful to women. A study in India found that when police destroyed a red-light district, sex workers had fewer clients and were more likely to engage in unprotected sex. In a sample of 326 female sex workers, those from the 55.3% who came from non-red light district were one hundred times more likely to report consistent condom use with clients as compared to those who used to work in a red light district that was destroyed by police and who had to disperse following demolition. According to the peer educators, "without money to eat, health became the lowest priority" (Shahmanesh et al., 2009a: 609). "Unfamiliar territory, increased secrecy and greater reliance on intermediaries for customers weakened the women's negotiating position" (Shahmanesh et al., 2009a: 609). A study conducted by sex workers and academics interviewing 164 sex workers in Cape Town, South Africa found that "sex workers would rather have their work treated as a legitimate job with the legal protection that comes with that" (Gould and Fick, 2008: 7).
Police involvement can be beneficial for sex workers. Forging partnerships between police and sex workers has demonstrated effectiveness in reducing stigma and improving access to treatment. For example, after a campaign in India whereby sex workers met with police to establish lines of communication, the number of stigma and discrimination cases reported to police grew from none to 11, all of which police responded to and resolved. The percent of HIV-positive female sex workers seeking care and treatment services at antiretroviral therapy centers increased from 30% to 60% following the project (Stangl et al., 2010).
Condom Use in Sex Work is Critical to Prevent Infection but Implementation of 100% Condom Use Policies Can Violate Human Rights
While Thailand is renowned for its 100% condom use policy that had a large impact on the HIV epidemic in that country (Hanenberg et al., 1994), subsequent evidence, for example from Cambodia (Lowe, 2002), suggest that policies and programs that denigrate the rights of sex workers tend not to be successful. While 100% condom use policies may have increased condom use, they are coercive, rather than protective. In an analysis of 100% condom use policies (CUP), CASAM found that "while not all aspects of 100% CUP are negative, there exists a need to re-center HIV programming targeting sex workers within the framework of a rights-based and justice-based sex worker empowerment model" (CASAM, 2008: 2). And because 100% CUP programs tend to target sex workers rather than their male clients, these programs have not necessarily affected condom use in regular (non-transactional) partnerships. [See also Male and Female Condom Use]
Yet, programs that facilitate increased condom use among sex workers during sex with clients, as well as during sex with regular partners are critical from both public health and human rights perspectives. Condom negotiation skills are essential skills for sex workers. A study in South Africa found that "sex workers identify demands for unprotected sex as one of their most significant problems" (Gould and Fick, 2008: 52). Sex workers reported a high proportion of clients seek unprotected sex. As one sex worker put it: "We haven't really got problems with the clients here, except with the ones we call 'condom missions,' because it's a real mission to get them to use the condoms. You would be surprised how ignorant they are. You actually have to educate them about condoms... you say to them you have a wife and family to worry about" (Gould and Fick, 2008: 74). Most cases of violence were triggered by the refusal of the sex worker to comply with a demand for unprotected sex, with a third of street-based sex workers reporting being raped by a client.
"Effectively seen by society as criminals sex workers may be unable to own or inherit property; register the births of their children; gain access to education, justice, health care or banking services; get a loan or purchase a house" (UNAIDS, 2011f: 7).Educational interventions for female sex workers have proved effective in building condom negotiation skills and increasing safe sex behavior with paying partners. A systematic review of published evidence from 1998 to 2006 on condom use interventions found that fifteen of the 19 studies of condom use in commercial sex reported significantly increased levels of condom use (Foss et al., 2007) after an educational intervention.
Condom promotion campaigns can be cost effective. The Avahan project in India "is surely the world's largest HIV prevention programme in a country with a concentrated epidemic..." (Bertozzi et al., 2010: i4). A significant reduction in costs was achieved during rapid scale up of a public campaign to promote rights, ensure access to justice, and meet the needs of sex workers, along with promoting condom use among sex workers and their male clients. The median cost of the Avahan program was $76 per person based on those reached by Avahan between 2004 to 2006, including female sex workers, transgender people and men who have sex with men in 63 districts in India. Within four years, the program had scaled up to reach 226,855 people at high risk of HIV acquisition. The total cost of the program was $16,759,189. However, the median cost of $76 per person was higher than that expended by the Indian government, which was between $31.02 to $50.88 (Chandrashekar et al., 2010), raising questions about whether the Government of India would increase expenditures, leaving the legacy of Avahan in doubt (Rao, 2010).
Protecting Human Rights and Empowering Sex Worker are Vital
Government officials from the Programme National de Lutte contre le SIDA (PNLS) (National Program to Combat AIDS) in Benin have referred to sex workers as "an important mode of transmission" (Ahoyo et al., 2009: 457). In Vietnam, sex workers are considered "social evils" (Vijeyarasa, 2010). But blaming sex workers as vectors of HIV to male clients and the wives of male clients, rather than in need of services for themselves, hinders prevention, testing and treatment efforts.
Legal frameworks are needed to protect human rights. Sex workers are frequently subject to punitive and mandatory measuressuch as when governments impose compulsory HIV testing of sex workers, a measure that does not respect their confidentialitythat violate human rights standards. In addition to legal reform, programs that take an empowerment approach, such as the Sonagachi Project and Sagram in India, have been shown to create better working conditions and be the most effective to reduce HIV acquisition among sex workers (Pillai et al., 2008; Gooptu and Bandyopadhyay, 2007). Sex workers themselves have led some of the most effective, evidence-based responses (Reynaga, 2008). Evidence suggests that empowering sex workers with the means to protect themselves is important both for the health of the sex worker herself and for effective HIV prevention programs.
Sex Workers Need Equitable Access to Antiretroviral Therapy
"Last but not least, sex workers have a basic human right to prevention, care and treatment" (Pettifor et al., 2011: 325). Most interventions currently focus on prevention and condom use; few have ensured that sex workers have equitable access to antiretroviral therapy, and many sex workers face numerous barriers. In many countries, such as India, there is no published data on the number of female sex workers receiving antiretroviral therapy (Chakrapani et al., 2009). But as a vulnerable population, it is critical that sex workers with HIV have access to treatment (Piot, 2010). Peer educators may increase the numbers of sex workers who access antiretroviral therapy (Chakrapani et al., 2009), as well as trained, nonjudgmental providers. Antiretroviral therapy can decrease the number of sexually transmitted infections experienced by sex workers (McClelland et al., 2010), thus improving their sexual and reproductive health as well.
Interventions that improve HIV knowledge and protective behaviors, particularly condom use, as well as those that respect human rights are the key to successfully preventing HIV among sex workers. A review of the evidence highlights several strategies that have proven effective in doing this.