Female Sex Workers
Sex workers, whose work involves sex with multiple partners, are a key group of women who need access to HIV prevention and services, most notably programs that enhance sex workers’ ability to use condoms. Pisani (2008) makes the case that sex workers should be receiving much more attention in programming to promote condom use. 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). While some progress has been made in providing HIV services for sex workers, much more remains to be done. Astoundingly, in 40% of countries with a generalized epidemic, no services for sex workers were available in 2007 and worldwide less than 50% of sex workers have access to VCT and to condoms that could save them from acquiring HIV in the course of their occupation (UNGASS, 2008 cited in Bertozzi et al., 2008).
Sex Workers Are a Diverse Population
Unprotected sex with multiple partners ultimately puts sex workers at risk of HIV, and human rights violations and lack of safe and supportive working conditions renders sex workers particularly vulnerable to HIV infection. The diversity of sex work means that interventions need to be adapted to meet the needs of women in different settings. The sex work industry 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). Women are sometimes trafficked into sex work. There is currently debate about how to assess whether a woman is trafficked or whether she is a sex worker (Vance, 2010; Bien-Aime, 2010). Transgendered men and women also work as sex workers and are at particularly high risk for HIV acquisition. Fifty-five independent studies from 19 countries (countries not specified) of 2,233 transgendered women sex workers found a 33% HIV prevalence rate (Friedman et al., 2008). [See also 4F. Transgendered Women and Men]
Criminalization of Sex Work Hinders HIV Prevention
“Sex work is currently a criminal offense in most southern African countries, as indeed it is in most 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., 2010: 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., 2010: 1 and 2). For example, 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. They also may have difficulty accessing both legal remedies and PEP in cases of rape. [See Chapter 11B. Strengthening the Enabling Environment: Addressing Violence Against Women]
“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). Participatory action research with sex workers and outreach workers from 13 sex worker projects in Central and Eastern Europe and Central Asia found that of 238 male, female and transgender sex workers from 12 countries more than 45% reported physical abuse by police and more than 41% reported sexual abuse, in addition to reports of forced HIV testing. Police increase risks by confiscating condoms as evidence of sex work (Crago et al., 2008). 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).
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., 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 have also been shown to be coercive to female sex workers, 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). A sex worker women’s group in Mongolia reported that violence by both clients and intimate partners were significant barriers to condom use when a 100% CUP was implemented (Jamts, 2008). Also, 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.
Yet, programs that facilitate increased condom use among sex workers during commercial sex, 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. They did not expect any help from the police (Gould and Fick, 2008).
Female sex workers do adopt safer sex behavior after educational interventions, and many programs have succeeded in encouraging sex workers to negotiate condom use with clients. A systematic review of published evidence from 1998 to 2006 on condom use found that fifteen of the 19 studies of condom use in commercial sex reported significantly increased levels of condom use (Foss et al., 2007). However, programs need to support sex workers to use condoms with regular clients as well as in their personal relationships as they are less likely to use condoms with their husbands, boyfriends and partners. Sex workers need access to condoms and appropriate water-based lubricants (Arnott and Crago, 2009).
Protecting Human Rights and Empowering Sex Worker are Vital
Programs that take a human rights and 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 and (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 agency is important both for the health of the sex worker herself and for effective HIV prevention programs. In contrast, punitive and mandatory measures—such as when governments have imposed compulsory HIV testing of sex workers, a measure that does not respect their confidentiality—violate human rights standards. “The strategy to end demand for sex work has not worked anywhere so far,” pushing sex workers “…beyond the reach of HIV prevention, health and treatment programs” (Sengupta and Tandon, 2008). A review of sex worker incarceration in China found that HIV prevention and treatment programs are “scarce” for detained sex workers (Tucker and Ren, 2008: 34). In the Sonagachi sex worker collective, sex workers have determined the priorities, and designed and implemented the programs. Condom use between 1999 and 2007 has increased from 2% to 85% and HIV prevalence has stabilized at around 5% (Ray, 2008), while other sex workers in India have much higher rates of HIV prevalence.
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.