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,” . 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).

A study of sex workers in Côte d’Ivoire found that increased national HIV/AIDS prevention campaigns have yielded significant increases in condom use and declines in prevalence of HIV and other STIs. Outcomes showed consistent condom use increased among sex workers from baseline measurements of 20% to 78% between 1992 and 1998, while reported condom use with most recent clients also increased from 63% to 91%. HIV infection rates decreased among female sex workers from 89% to 32%; for gonorrhea from 33% to 11%; for genital ulcers from 21% to 4%; for trichomoniasis from 26% to 11%; and for syphilis from 21% to 2%. However, infection from chlamydia increased from 5% to 7%. Due to sharp increases in demand, the clinic doubled its size by the end of the study in 1998. In response to intensified media and social marketing programs initiated by the Ministry of Health, Clinique de Confiance, a confidential STD/HIV clinic, began inviting sex workers and their stable partners to attend peer education programs for instruction on disease transmission and prevention in 1992. Sex workers were also encouraged to access a wide range of free services including the distribution of condoms (both male and female) and lubricating gels, gynecological examinations, general physicals and STD/HIV diagnosis, counseling, and treatment. The study reviewed multi-year cross-sectional studies conducted among users of the clinic and biannual community-based surveys between 1991 and 1997 in order to determine HIV/STD prevalence and socio-demographic trends among sex workers. Although there were major socio- demographic changes observed in this population that may have contributed to the decline of the diseases being monitored, “the increase in condom use and the decline in prevalence of HIV infection and other STDs may well have resulted from the prevention campaign for female sex workers, and such campaigns should therefore be continued, strengthened, and expanded”.

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 .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, 2006). (Gray III) The community empowerment model implemented in Sonagachi since 1992 has increased consistent condom use to 85% and HIV prevalence among sex workers has remained stable below 10%. Sonagachi has established high rates of partner notification through cohabitating partners acting as male peers for mobilizing clients for STI screening and promotion of safe sex; evening clinic hours for clients;. Partner treatment has increased from 40% in 2002 to 46% in 2007 at 13 STI clinics (Jana et al., 2008). (Abstract) Starting in 1992 and with sex workers in control of the project since 1999, the project has grown from 12 peer educator sex workers reaching 3,500 sex workers to 450 peer educators reaching 45,000 sex workers. Condom use between 1999 and 2007 has increased from 2% to 85% and HIV prevalence has stabilized at around 5% (Ray, 2008). (Abstract) (Gray III based on Basu et al., 2004 and Saha, 2006)

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.

An HIV prevention program developed a training program to enhance self- esteem, communication and leadership among sex workers in Karnakata, south India. Following the intervention, STI service utilization increased from 75 clinic visits per month in 2005 to over 900 clinic visits in 2007 . (Abstract)

A project with 700 female sex workers and MSM in India where beneficiaries such as sex workers manage all HIV program interventions – outreach, condom promotion and linkages with government health services resulted in 20% increase in condom use . (Abstract)

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%.

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 pre- and post-test study that compared condom use and policies in 68 sex establishments in two cities in the Dominican Republic from 1999 to 2000 with 200 female sex workers age 18 or older found that interventions that combined community solidarity with government policy were the 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 in another. Three interventions were implemented in both cities. First, a solidarity and collective commitment approach that involved sex workers, managers, owners, deejays, and other establishment employees in workshops and meetings in order to strengthen relationships and collective commitment for condom use. Second, environmental cues, such as 100% condom posters and stickers and glass bowls with condoms, as well as other awareness-raising activities. Third, confidential clinical services for sex workers (who were required by law at the time of the study to attend monthly STI checks), that included training for health workers and Ministry of Health inspectors on ethical procedures and HIV, among other things, and the establishment of sex worker peer educator pre- and post-test counseling. Use of condoms and adherence to the program was measured against four study elements: visibility of condoms in the establishment, stocks of at least 100 condoms, attendance of sex workers at monthly STI checks, and lack of positive STI diagnoses among sex workers (no individual STI results were shared with establishment owners. In Puerto Plata only, a regional government policy was established that required condom use between sex workers and their clients that was communicated to all participating sex establishment owners in the city. It was also communicated to owners in both cities that they had the ultimate responsibility for condom use, not the sex workers that worked for them. NGO staff and regional public health officials met with establishment owners on a quarterly basis in both cities to assess adherence. In both cities, intensified education was provided by the NGO to establishments that were lagging and award certificates were given to those that showed adherence with the strategy. In Puerta Plata, establishment owners were subject to graduated sanctions, such as notifications, fines, and closing, for lack of adherence. (Kerrigan et al., 2004: 2). 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). (Gray III) (condom use, sex workers, Dominican Republic) [See footnote]

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.

A 100% condom use program implemented in Banteay Meanchey Province, Cambodia where authorities met weekly with brothel owners concerning noncompliance decreased HIV seroprevalence among sex workers from 51% in 1999 to 16% in 2007. Among sex workers STI prevalence based on laboratory diagnosis declined from 90% in 2001 to 7% in 2008. Peer educators counseled sex workers on negotiating condom use. Authorities also met with brothel owners to discuss ways to support sex workers when clients refused condom use . (Abstract) (sex workers, STIs, peer education, condom use, Cambodia) [See footnote]

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 resurvey 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 onsite 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” (p. 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” (p. 460)..

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.

Peer education in Nigeria by sex workers resulted in increased condom use from 76.6% at baseline to 87.6% in 2004. Follow-up two years later in 2006 found condom use still at 86.4% . (Abstract)

A peer outreach program for sex workers in Myanmar, along with drop-in centers and clinics, resulted in 4,000 sex workers accessing VCT . (Abstract)

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.

An intervention in India that reached one million male clients of sex workers a month increased consistent condom use from 62% in May 2006 to 81% in May 2007. The intervention involved pre-tested single message focus by PSI integrated into street theater and interpersonal communications every three months, based on bi-annual quantitative studies. Recall of PSI’s activities was correlated with increased in consistent condom use . (Abstract)

A program by PSI in India targeting four million clients of sex workers in 100 high prevalence towns that increased access and demand to condoms resulted in consistent male condom use increasing from 63% in 2006 to 81% one year later. Areas meeting condom access standards increased from 40% in 2005 to 73% two years later . (Abstract)

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,” (p. 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…. “ (p. 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” (p. 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.

^[4] 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 should not be instituted for this reason.