Sex Workers and HIV Prevention

back to top Introduction

Although sex workers are severely affected by AIDS in many parts of the world (as we discuss in our ‘AIDS and prostitution’ page), 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 the number of HIV infections 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 Bangladesh, Benin, 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.

So how can these campaigns be most effective? In order to fully answer this question, we first need to look at the problems that sex workers may encounter in their lives, and examine why so many are becoming infected with HIV.

back to top Understanding the factors that put sex workers at risk

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, and can differ greatly in the lives that they lead. In the same way, the levels of risk that they face in terms of HIV infection can be vastly different, 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, amongst other factors.¹ A wealthy escort 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. In India HIV prevalence ranges from 4.6 percent among sex workers in Mumbai to 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 the risk that they will be exposed to HIV.

Multiple partners, inconsistent condom use

In general, sex workers have relatively 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 then they will probably be protected no matter how many people they have sex with. The reality, however, is that sex workers and their clients do not always use condoms. Of 86 reporting countries, less than a third reported that 90 percent of sex workers used a condom with their last client, whilst more than half reported condom use by less than 80 percent of sex workers.³ In some cases, this is because 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, even if they try to do so. Clients may refuse to pay for sex if they have to use a condom, and use intimidation or violence to enforce 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)⁴

Social and economic factors

As well as having high rates of partner change, sex workers often share other factors in their lives, particularly in regards to their social and economic positions. 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.

For one thing, even though sex work is at least partially legal in many countries, sex workers are rarely protected by the law.⁵ 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, and in such an environment it is easier for HIV transmission to occur.⁶ 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.⁷ 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, USA⁸

“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.⁹

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 status.

“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, Nepal¹⁰

Without access to these services, sex workers may face a higher risk of HIV infection, and be more likely to pass on HIV if they do become infected.

Injecting drug use

In some countries, large numbers of sex workers are also injecting drug users. 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 – perhaps to escape from the intense emotional and physical burden of their work, or because other sex workers have introduced them to it. Since needle sharing is one of the most efficient ways of passing HIV between people, sex workers who inject drugs and share needles face a particularly high risk of becoming infected with HIV. 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.¹¹ See our Needle exchange page to read more about HIV transmission through needle sharing.

Migration, mobility and people trafficking

Migration and sex work are often linked, as poor migrants who have newly arrived in an area sometimes turn to sex work because they cannot find any other way to make money. As well as selling sex themselves, migrants may also become the clients of sex workers, sometimes as a means of escaping the loneliness that often accompanies migration.

Sex tourism is fuelling the demand for sex workers in many countries, such as parts of Asia and the Caribbean

In addition to voluntary migration, people trafficking – whereby people, usually women and children, are forcibly moved between areas – is also linked to the spread of HIV in some cases. Large numbers of trafficked women and children are forced into sex work every year. Even in countries where HIV is relatively uncommon, trafficked women are still vulnerable to HIV infection, because they are rarely able to negotiate condom use, are often forced to endure multiple sex partners, and may be subjected to violent sex.¹² 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.¹³ Sex trafficking also relates to a high risk of HIV infection for girls trafficked in Southeast Asia.¹⁴

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, such as parts of 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 they will find it easy to find paid sex with underage girls or boys.

back to top HIV prevention amongst sex workers: what works?

Experts recommend that campaigns aiming to prevent HIV amongst sex workers should initially focus on achieving three main outcomes:¹⁵

• 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.

There are several steps that can be taken towards 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); helping sex workers to group together; reducing the stigma that communities attach to sex work; and ensuring that laws and policies respect sex workers’ human and citizen rights.

back to top Examples of successful prevention programmes

Thailand: 100% condom programme

One of the best ways to prevent sex workers becoming infected with HIV is to foster an environment in which they are willing and able to use condoms. The 100% condom programme established in Thailand in the early 1990s is held up as a prime example of how this can be achieved. This government-run campaign aimed to enforce condom use in all of Thailand’s brothels and massage parlours, by distributing free condoms and making it a legal requirement for establishments to make clients use them. Under this programme, condom use amongst sex workers rose from 14% in 1989 to over 90% after 1992, and Thailand’s HIV prevalence declined substantially.¹⁶

India: Sonagachi and Avahan

The Sonagachi programme in India is named after the central district of central Kolkata (Calcutta) where it is based. Started in 1992 with the aim of helping sex workers to overcome HIV and AIDS on their own terms, the Sonagachi project has been based around the ‘three R’s’: ‘respect’ for sex work and those involved in it; ‘reliance’ on sex workers to run the programme; and ‘recognition’ of sex workers’ rights. As well as encouraging condom use, the project has addressed the wider social and economic challenges facing sex workers. In doing so it has achieved impressive results. Condom use amongst sex workers in the area rose dramatically, from 27% in 1992 to 86% by 2001.¹⁷ HIV prevalence amongst sex workers in the area also fell significantly as a result of the project.¹⁸

Another example is the Avahan programme, aimed at sex workers across six high-prevalence states in India. This programme demonstrated that substantial gains can be made when prevention programmes are delivered to this high risk group. Since the India Avahan programme started in 2003, condom use has increased by 18 percent and HIV prevalence has declined by 4 percent in Karnataka.^{19 20}

Brazil: reducing stigma

The government of Brazil, and non-governmental organisations working in the country, have put a lot of effort into preventing HIV infections amongst sex workers. These interventions have taken a tolerant, respectful approach, with the government often referring to sex workers as ‘partners’ in Brazil’s fight against AIDS. HIV prevention campaigns have focused on reducing stigma, and encouraging sex workers to look after their sexual health. In one well-known campaign, a cartoon character known as ‘Maria without shame’ was placed on posters, leaflets and stickers in women’s toilet facilities, with the message: “You need have no shame, girl. You have a profession.”²¹

Kenya

In the Kenyan capital of Nairobi, HIV prevention campaigns aimed at sex workers were strengthened during the 1990s, including peer support and condom promotion. This resulted in a reduction in HIV incidence amongst sex workers in the city, from 25-50% to 4% by the end of the decade.²²

back to top Barriers to HIV prevention amongst sex workers

There is overwhelming evidence of the benefits that HIV prevention campaigns aimed at sex workers can bring. However, in many cases laws and policies are actively stopping HIV prevention campaigns from helping sex workers protect themselves from HIV. The number of countries reporting the existence of laws, policies and regulations which hinder sex worker's access to HIV prevention, treatment and care has increased from 41 percent in 2006 to 67 percent in 2010.²³

Sex work is still seen as morally corrupt or criminal in many places, and those involved are often neglected or ignored by wider society. In 2010, the need to protect high risk groups from stigma and discrimination was acknowledged by the majority of reporting countries (62% had laws protecting high risk groups from stigma and discrimination).²⁴ However, whether protection laws are enforced remains an area of concern.

Until June 2013, the U.S. government had a policy of refusing overseas aid to any HIV prevention programme that does not ‘explicitly oppose’ the practice of sex work.²⁵ This led to HIV prevention campaigns aimed at sex workers missing out on money that could otherwise have saved lives. It also led to tense relations 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.²⁶ It is hoped the overhaul of this policy will see barriers between sex workers and HIV prevention initiatives removed.

There are many more cases around the world where laws and policies have stopped HIV prevention campaigns from reaching sex workers. Another example comes from Goa, India, where 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 non-governmental organisations that had worked in the area for over a decade to prevent HIV amongst sex workers. As a result of the demolition, it became nearly impossible to continue these campaigns, condom distribution fell, and the newly homeless and destitute sex workers became even more vulnerable to HIV.²⁷

Since the introduction of an 'anti-human trafficking' law in Cambodia in 2008, violent crackdowns against sex workers in Cambodian brothels have increased.²⁸ Police violence has pushed sex workers into other settings such as karaoke bars, 'beer gardens' or 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 brothels²⁹ organisations working with sex workers have expressed concern that the crackdowns are a major setback to the government's successful '100% condom' enforcement programme. The programme had been credited with reducing HIV prevalence among brothel based sex workers from 44% in 1998 to 12.7% in 2006.³⁰

Crackdowns on sex workers in China are also common. In April 2010 sex workers held a rare protest following police raids on brothels, demanding an end to anti-prostitution laws.³¹

It is understandable that authorities may want to discourage sex work, and that some people find the notion of an individual exchanging sex for money to be objectionable. However, it needs to be understood that sex work is not always a choice, and that even when it is, the reasons behind this choice are often complex. Limiting sex workers’ access to services that could help them simply worsens the situation.

back to top Involving sex workers

Rather than simply criminalising sex workers and closing down brothels, the most effective approach to preventing HIV infections amongst this group is to respect them, view them as partners, and encourage them to group together. Involving sex workers directly in HIV prevention campaigns can raise their self-esteem and empower them, thereby encouraging them to look after their health and to access services that could help them. In many cases, such as the Sonagachi project in India, sex workers themselves, or former sex workers, have played an active role in leading successful HIV programmes. A five year study conducted in Kenya found that prevention initiatives that involved sex workers in educating fellow sex workers were associated with increased protected sex and reduced HIV prevalence.³² 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 2010.³³

As Mahooba Mahmood, director of the Bangladeshi women’s organisation Naripokkho, states:

“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.”³⁴

Sex work has evolved over the last decade, making it even more vital to involve sex workers in HIV prevention programmes for them to be successful. 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.³⁵

“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 Guinea³⁶

back to top Should sex work be legalised?

Laws around sex work differ between countries. In some, sex work is illegal, meaning that 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 – for example, soliciting sex or running a brothel – are. In a few, sex work is legalised and regulated. These different legislative systems can affect how HIV prevention is carried out amongst sex workers.

Some argue that legalising or decriminalising sex work is beneficial to the fight against AIDS, 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.³⁷

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 legalisation debate is complicated, and has to take into account political and moral opinions as well as issues like HIV and AIDS. Whatever people feel about this issue, there needs to be a greater level of discussion and debate about how laws are affecting HIV prevention efforts, and whether countries should review their legislation if the fight against AIDS is to be successful.

back to top The way forward

Sex work is a highly disputed topic, and many different views exist about whether it should be legal, how governments should address it, and whether it is morally acceptable. When it comes to responding to the AIDS epidemic, however, experience shows us what works – reaching out to sex workers, empowering them, and involving them in the fight against HIV. By addressing the underlying social and economic problems that make sex workers so vulnerable to HIV – for instance, by giving them greater legal protection against violence, and by working to reduce the discrimination they face – HIV infection rates amongst sex workers could be cut dramatically. Harassment and abuse of sex workers by the police is a widespread issue that needs particular attention from authorities.³⁸ Governments and organisations need to foster an environment where sex workers are able to protect themselves against HIV, and have widespread access to HIV prevention, testing and treatment services.

With less than one percent of global funding for HIV prevention being spent on HIV and sex work, UNAIDS calls for a substantial increase in efforts and resources from governments and international organisations.³⁹ HIV prevention amongst sex workers should be seen not only as a strategic move to stem the wider spread of HIV, but also as a means of helping sex workers and saving their lives.

• Back to top
• Sign up to our Newsletter
• Donate
• 

References back to top

1. UNAIDS (2009, February), 'UNAIDS guidance note on HIV and sex work'.
2. WHO/UNAIDS/UNICEF (2011) ‚'Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
3. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
4. VOA News (2007, 13th February), 'Africa's sex workers have hard time leaving streets'
5. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
6. World Health Organisation (2005), 'Violence against women and HIV/AIDS: critical intersections, Violence against sex workers and HIV prevention', Information series bulletin, Number 3
7. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
8. Human Rights Watch (2012, July) 'Sex Workers at Risk: Condoms as Evidence of Prostitution in Four US Cities'
9. UNAIDS (2011) 'HIV in Asia and the Pacific: Getting to zero'
10. UNAIDS (2011) 'HIV in Asia and the Pacific: Getting to zero'
11. WHO/UNAIDS/UNICEF (2011) ‚'Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
12. UNAIDS/WHO (2008) 'Report on the Global AIDS Epidemic'
13. Silverman JG (2006, December) 'HIV prevalence and predictors among rescued sex-trafficked women and girls in Mumbai, India' 43(5):588-93
14. UNDP Regional Centre in Colombo (2009, July) 'Sex Trafficking and STI/HIV in Southeast Asia: Connections between Sexual Exploitation, Violence and Sexual Risk'
15. World Health Organisation (2004), Sex Work Toolkit
16. Rojanapithayakorn W. (2006), 'The 100% condom use programme in Asia', Reproductive Health Matters 14:28(41)
17. Dutta et al. (2002) 'Strategizing peer pressure in enhancing after safer sex practices in brothel setting', Abstract TuPeF5332, The XIV International AIDS Conference
18. UNAIDS/WHO AIDS Epidemic Update: December 2005
19. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
20. Ng M (2011) 'Assessment of population-level effect of Avahan, an HIV-prevention initiative in India' Lancet 378(9803)
21. Ministry of Health of Brazil (2002), Resposta positiva: a experiencia do programa brasileiro de AIDS
22. World Health Organisation (2004), Sex Work Toolkit
23. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
24. UNAIDS (2010) 'UNAIDS report on the global AIDS epidemic'
25. The Washington Post (2013) ‘Supreme Court strikes down anti-prostitution pledge as condition of AIDS funding’
26. BBC News (May 2005), 'Brazil turns down US AIDS funds'
27. Shahmanesh M. and Wayal S. (2004, 9th October), 'Targeting commercial sex-workers in Goa, India: time for a strategic rethink', The Lancet 364 (1298)
28. Human Rights Watch (2010) 'Cambodia: Off the Streets'
29. PlusNews (2008, October 21st) 'CAMBODIA: Human trafficking crackdown also hits HIV prevention'
30. The National AIDS Authority, Cambodia (2010) 'Cambodia Country Progress Report'
31. The Guardian (2010, August 3rd) 'Chinese sex workers protests against crackdown'
32. Luchters, Stanley (2008) 'Impact of five years of peer-mediated interventions on sexual behavior and sexually transmitted infections among female sex workers in Mombasa, Kenya' BMC Public Health 8:143
33. PlusNews (2010, August 11th) 'Kenya: HIV Prevention for sex workers by sex workers
34. United Nations (2003, 22nd January), 'Sex workers mobilize to fight HIV/AIDS, UNAIDS says', press release
35. The Indian Express (2012, July 1st) 'Rise in number of sex workers leaving brothels hits HIV programmes'
36. UNAIDS (2011) 'HIV in Asia and the Pacific: Getting to zero'
37. UNDP (2012) 'Sex Work and the Law in Asia and the Pacific'
38. UNDP (2012) 'Sex Work and the Law in Asia and the Pacific'
39. UNAIDS (2009, February), 'UNAIDS guidance note on HIV and sex work'.