Sex workers are among the highest risk groups for HIV. UNAIDS defines sex workers as: “Female, male and transgender adults and young people who receive money or goods in exchange for sexual services, either regularly or occasionally. Sex work varies between and within countries and communities. Sex work may vary in the degree to which it is more or less “formal” or organised, and in the degree to which it is distinct from other social and sexual relationships and types of sexual economic exchange.” 1 On average, sex workers are 10 times more likely to become infected with HIV than adults in the general population.2 However, there are significant variations between regions and countries. In low- and middle-income countries, HIV prevalence among sex workers is an estimated 12%. However, there are significant variations between regions and countries.3 In four countries, HIV prevalence is 50 times higher than in the general population.4 One study of 16 countries in sub-Saharan Africa found an average HIV prevalence of 37% among sex workers. In Nigeria and Ghana, HIV prevalence among sex workers is eight times higher than for the rest of the population.5 Although sex workers are one of the groups most affected by HIV, they are also one of the groups most likely to respond well to HIV prevention programmes. Proof of this can be seen in countries such as Cambodia, the Dominican Republic, India and Thailand, where reductions in national HIV prevalence have been helped by initiatives targeting sex workers and their clients. Why are sex workers at particular risk of HIV transmission? Sex workers often share common factors, regardless of their background, that can make them vulnerable to HIV transmission.6 Multiple partners and inconsistent condom use In general, sex workers have comparatively high numbers of sexual partners compared with the general population. However, this does not necessarily increase their likelihood of becoming infected with HIV if they use condoms consistently and correctly.7 In 2015, 32 out of 89 countries reporting on the proportion of sex workers using a condom with their last client reported greater than 90% coverage. Condom use reported by sex workers in Asia Pacific was 90% or greater in five countries, including the two largest, China and India. But elsewhere in the region, in countries with significant HIV epidemics among sex workers such as the Philippines, Indonesia and Pakistan, condom use was low. Most other regions show a similar pattern: a few countries perform reasonably well, while many others fall short. In Lesotho, for example, where HIV prevalence among female sex workers was estimated at 72% in 2015, condom use with the sex worker’s last client stood at 65%. Countries in the Middle East and North Africa generally have inadequate condom use to prevent HIV transmission to and from sex workers.8 In some cases, sex workers have no access to condoms or are not aware of their importance. In other cases, police are actively confiscating or destroying condoms found in sex workers’ possession. For example, a 2012 study by the Open Society Foundation in Kenya, Namibia, Russia, South Africa, the United States of America (USA) and Zimbabwe found evidence in all six countries of police harassing and physically and sexually abusing sex workers who carry condoms, or using the threat of arrest on the grounds of condom possession to extort and exploit them.9 We use condoms to protect ourselves from HIV/AIDS, but they don’t allow us to carry them, so how can we protect ourselves? – Sex worker, Cape Town, South Africa10 Sometimes, sex workers are simply powerless to negotiate safer sex. Clients may refuse to pay for sex if they have to use a condom, and use intimidation or violence to force unprotected sex.11 They may also offer more money for unprotected sex – a proposal that can be hard to refuse: 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) 12 The clients of sex workers act as a ‘bridge population’, transmitting HIV between sex workers and the general population. High HIV prevalence among the male clients of sex workers has been detected in studies globally.13 14 15 Social and legal factors Sex workers are often stigmatised, marginalised and criminalised by the societies in which they live. In various ways, these factors contribute to their vulnerability to HIV. Even though sex work is at least partially legal in some countries, the law rarely protects sex workers. Around the world, there is a severe lack of legislation and policies protecting sex workers who may be at risk of violence from both state and non-state actors such as law enforcement, partners, family members and their clients.16 For example, a sex worker who is raped will generally have little hope of bringing charges against their attacker. This lack of protection leaves sex workers open to abuse, violence and rape, creating an environment which can facilitate HIV transmission.17 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 18 In addition, the stigma that sex workers face can make it hard for them to access healthcare, legal, and social services. They may either be afraid to seek out these services for fear of discrimination, or be prevented from accessing them – for instance, if a nurse refuses to treat them after finding out about their occupation. 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, Nepal 19 Injecting drug use Sex workers who inject drugs and share needles are at a particularly high risk of HIV infection. Sex workers who use drugs can be stigmatised in workplace venues where drug use is discouraged. This forces them onto the street where control over condom and drug use is compromised and exposure to violence is heightened, all of which compounds their vulnerability to HIV. Because sex work and drug use are illegal in most countries, sex workers who use drugs are more vulnerable to frequent arrest, bribes, extortion and physical and sexual abuse. In turn, this discourages many sex workers who inject drugs from seeking HIV prevention and treatment.20 Researchers investigating HIV prevalence among sex workers have raised particular concerns about epidemics in Eastern Europe and Central Asia, where there is a significant overlap between sex work and injecting drug use.21 A 2013 review of female sex workers in Europe concluded that their HIV vulnerability was linked primarily to unsafe injecting, rather than sex work itself.22 In Central Asia, HIV prevalence is estimated to be 20 times higher among female sex workers who inject drugs than those who do not.23 For example, an estimated 62% of women in Kyrgyzstan and 84% of women in Azerbaijan who inject drugs also engage in sex work.24 Similarly, a study in Manipur, India, found that HIV prevalence among female sex workers who injected drugs was 9.4 times higher than those who did not inject.25 Migration, mobility and sex work Migration and sex work are often linked as some migrants may turn to sex work if they cannot find an alternative means of making money. Migrant sex workers often become the targets of both police and immigration officers, especially those who cross borders (both legally and illegally) and do not have immigration status. Other than facing the criminalisation of sex work, they also may also face surveillance, racial profiling, arrest, detention, deportation and other restrictions on mobility imposed by criminal, immigration and trafficking laws.26 As well as selling sex themselves, migrants may also become the clients of sex workers as a means of escaping the solitude that often accompanies migration.27 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, particularly in 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 it will be easy to find paid sex.28 29 The relationship between human trafficking and sex work Human trafficking is defined as: “The recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation.” 30 Large numbers of trafficked people are forced into selling sex every year. Even in countries where HIV prevalence is low, trafficked people who are forced to sell sex are highly vulnerable to HIV infection because they struggle to access condoms, cannot negotiate condom use and are often subjected to violence.31 One study conducted among trafficked people in Mumbai brothels in India found that almost a quarter of trafficked girls and women were living with HIV.32 However, many emphasise that the relationship between sex work and human trafficking should not be overplayed as it can lead to false or exaggerated anti-sex work arguments and harmful action by authorities, ultimately undermining HIV prevention for sex workers.33 In fact, evidence suggests that fewer people enter into sex wok through trafficking than enter consensually. For example, it is estimated that one in five people in the sex trade in Andrah Pradesh, India and one in 10 in Thailand have been trafficked.34 Despite this, policies that conflate sex work and trafficking have dominated approaches to sex work over the past decade. In 2003, the US President’s Emergency Plan for AIDS Relief (PEPFAR) adopted a clause that required funding recipients to explicitly oppose sex work, its legalisation and sex trafficking. As a result, many countries- including Thailand, Cambodia, and Vietnam – implemented punitive measures targeting the sex industry. Many sex workers were forced into unsafe work environments, undermining their access to health care and increasing their vulnerability to violence, abuse and, ultimately, HIV. Although the USA revoked the clause in 2013, its legacy continues, and more must be done to ensure that anti-trafficking efforts target those who commit trafficking, rather than punishing consenting adults engaged in sex work.35 Young sex workers and HIV While there is near-universal agreement between countries on the need to prevent people under the age of 18 from selling sex, there is little agreement on how to meet the needs of the significant numbers of young people who are involved in selling sex.36 Data on young people who sell sex is extremely limited, although evidence suggests that a significant proportion of sex workers begin selling sex while adolescents.37 For example, a study from Ukraine found that 20% of female sex workers were aged between 10 and 19.38 Research shows that adolescents under 18 who sell sex are highly vulnerable to HIV and other sexually transmitted infections (STIs), have higher levels of HIV and STIs than older sex workers and have limited access to services such as HIV testing, prevention and treatment.39 Young sex workers face many of the same barriers to HIV prevention as their older counterparts including the inability to negotiate condom use and legal barriers to HIV and sexual health services, which are amplified by their age.40 In many countries, organisations cannot legally provide HIV services to people under 18 years old because it is seen as encouraging ‘prostitution’ or the trafficking of minors and may bring the organisation into conflict with the law.41 Testing for HIV and STIs is impossible. In Kazakhstan, the law states that a person under 18 cannot be tested for HIV without [an] accompanying parent or guardian. As a rule, parents do not know that their daughter sells sex; therefore, girls are afraid of disclosure and do not get tested for HIV or STIs. – Sex worker, Kazakhstan42 Even where programmes for sex workers exist, the presence of ‘youth-friendly’ services to address the specific needs of young people who sell sex are normally lacking. Furthermore, young people who sell sex are often excluded from much of the research on sex work and HIV.43 This enables authorities to ignore the existence and needs of young people who sell sex.44 Preventing HIV among sex workers Sex work is diverse and occurs in various contexts around the world. Although some sex workers sell sex through brothels or other venues, others might work independently and solicit clients directly in public places or online. Effective HIV prevention packages for sex workers are those that account for the contexts in which they work and the particular risks they face.45 In order to address the high burden of HIV sex workers face, UNAIDS recommends the following: address violence against sex workers decriminalise sex work empower sex work communities scale-up and fund health and social services for sex workers46: UNAIDS also emphasises the importance of combining HIV prevention strategies for sex workers, including integrating condom distribution with other HIV services and increasing links between HIV services and other sexual and reproductive health services such as family planning services, gynaecological services and maternal health.47 Despite this, in 2015 just 3.8% of total global spending on prevention was used to fund prevention programmes for sex workers. International donors supplied 3.1% of funding, compared to 0.7% from domestic sources.48 Successful HIV prevention programmes for sex workers Studies have estimated that addressing specific key societal factors such as violence, police harassment, safer work environments and decriminalisation could reduce the number of female sex workers newly infected with HIV by 33%, to 46% over the next decade.49 In 2013, the WHO, UNFPA, UNAIDS, NSWP, the World Bank and UNDP released a new tool offering advice on building HIV programmes for sex workers that are led by the sex worker community.50 The tool, Implementing comprehensive HIV/STI programmes with sex workers: practical approaches from collaborative interventions, also contains examples of best practice from around the world to support efforts in planning programmes and services.51 A number of successful HIV programmes targeting sex workers are given below. Encouraging condom use The 100% Condom Use Programme, established in Thailand in the early 1990s, enforced condom use in all of Thailand’s brothels and massage parlours, distributing free condoms and making it a legal requirement for establishments to make clients use them. The programme saw condom use among sex workers rise from 14% in 1989 to more than 90% since 1992, with Thailand’s overall HIV prevalence reflecting this.52 Between 1998 and 2003, a similar programme in Cambodia reduced HIV prevalence among sex workers over the age of 20 from 44% to 8%.53 However, concerns have been raised about the absence of sex workers from participation in the design and implementation of the programme. With police, local authorities and brothel owners charged with enforcing the policy, sex workers remain vulnerable to abuse and exploitation.54 In South Africa, a 2015 study found that condom distribution and HIV communication programmes have reduced HIV incidence in female sex workers by 76% and clients by 65%.55 The Avahan programme has been working with key affected populations in six southern India states since 2003. In 2015, the programme was estimated to have increased condom use to such an extent that new HIV infections among female sex workers had reduced by between 48% and 67%.56 Similar reductions have been estimated in assessments of Project SIDA in Benin, which has promoted condoms and STI screening for female sex workers.57 HIV counselling and testing (HTC) services for sex workers The World Health Organization (WHO) recommends at least annual voluntary testing for sex workers. In a review of 52 low-income and middle-income countries in 2010 – the most recent data available – the median percentage of sex workers who had tested for HIV in the last 12 months and knew their results was 49%, with wide variation across countries.58 Several successful interventions have increased HIV counselling and testing (HTC) in sex workers. For example, in Ethiopia the Organisation for Support Services for AIDS (OSSA) implemented a peer education and outreach project with young people who sell sex (aged between 15 and 24) as part of the International HIV/AIDS Alliance’s Link Up project. Within 12 months, more than 16,000 young people who sell sex had been reached with peer education sessions, with around 5,600 referred to clinics of whom more than 1,700 took up services, the most common of which was voluntary HTC.59 In Guatemala, a sexual health clinic that offered HTC and follow-up services over a six-month period witnessed a four-fold decrease in HIV among sex workers. HIV prevalence among sex workers in Chile and El Salvador has also fallen significantly following the targeting of sex workers with similar prevention programmes.60 Access to antiretroviral treatment (ART) for sex workers UNAIDS recommended that ART coverage must reach approximately 80% of sex workers, accompanied by increased condom use, in order to significantly impact upon the global HIV epidemic. However, in many countries sex workers’ access to antiretroviral treatment (ART) continues to be lower than access for the general population, with uptake hampered by punitive legal environments, the double stigma surrounding HIV and sex work and fear that a diagnosis of HIV may be disclosed to others without consent.61 In 2015, the UNAIDS Key Population Atlas found female sex workers only had similar levels of access to treatment as other women in three out of 12 countries reporting data.62 The use of pre-exposure prophylaxis (PrEP), whereby someone who is at higher risk to HIV takes antiretrovirals before possible exposure to HIV in order to decrease their likelihood of contracting the virus, is another area of prevention that could reduce HIV transmission rates among sex workers. For example, a study from South Africa reported that combining PrEP with HTC could reduce HIV transmission between sex workers and their clients by up to 40%.63 However, PrEP availability is extremely limited, and recent UNAIDS modelling suggests that typical ART coverage will not be sufficient to slow new infections among sex workers at its current rate.64 Law enforcement practices, human rights and legal education Sex worker-led, community-based services that address legal and social barriers can have a real and lasting impact on the lives of sex workers, including by reducing their vulnerability to HIV.65 In Thailand, the Service Workers in Group (SWING) is a partnership between sex workers and the police formed in 2004, which aims to foster law enforcement practices that protect rights, and supports effective HIV programming. SWING sensitises young police cadets by giving them the opportunity to interact with sex workers in a neutral setting. Positive changes have already been noted in Bangkok constabularies, with fewer reported arrests and incidents of harassment.66 Similarly, the PT Foundation in Kuala Lumpur, Malaysia works on HIV prevention for sex workers and other key affected populations. This includes outreach strategies and workshops targeted at key community leaders, law enforcement officers and state-level religious authorities who frequently arrest or fine sex workers. The PT Foundation has also developed a leaflet to inform sex workers of their rights should they get arrested.67 This [sex worker rights leaflet] has been very helpful…when the authorities come I tell them I know my rights. As soon as we start talking about rights they just move away. – Jlofa, sex worker from Kuala Lumpur68 Addressing stigma and discrimination The Global Network of Sex Work Projects (NSWP) unites more than 160 sex-worker led groups from across 60 countries 69 in Africa, Asia and the Pacific, Europe, Latin America, North America and the Caribbean. It amplifies the voices of these organisations in order to advocate for rights-based services, freedom from abuse and discrimination, freedom from punitive laws, policies and practices, and self-determination for sex workers.70 Examples of NSWP country level organisations include:71: The Survival Advocacy Network (SAN), a transgender and female sex worker network founded by and for sex workers in Fiji, which trains healthcare providers to enable sex workers to access healthcare without fear of stigma or discrimination.72 PARCES NGO, a sex worker-led organisation in Bogotá, Colombia, which identifies the different forms of discrimination experienced by sex workers and fights oppression and violence against sex workers and others from key affected populations. The Veshya Anyay Mukti Parishad (VAMP) collective, which takes a rights-based approach to sex work. Barriers to accessing HIV prevention services In many cases, laws and policies are actively stopping HIV prevention campaigns for sex workers. In 2012, the most recent data available, 60% of all countries reported such laws, policies and regulations.73 Sex work is viewed as morally corrupt or criminal in many places, and those involved are often neglected and marginalised by wider society. In 2012, 61% of countries had laws protecting key affected populations from stigma and discrimination. However, the enforcement of these laws remains an area of concern.74 In China, widespread violations of sex worker rights have been documented. A 2013 report estimates that 15,000 sex workers were detained in so-called custody and education centres that year.75 A 2009 change in the law criminalising sex work in Fiji has led to round-ups, detentions, beatings and torture. Sex work has been driven underground, isolating sex workers from each other and from government-supported HIV prevention services.76 Sex workers and human rights Some laws not only criminalise sex work but also deny sex workers fundamental civil rights. They may be unable to own property, access education, justice, healthcare, banking services or purchase utilities. The social exclusion and poverty that results leaves sex workers vulnerable to exploitation, abuse and HIV infection. 77 Under these circumstances, sex workers are not recognised by the law and cannot exercise human rights like other people can. For example, the Swaziland Girls’ and Women’s Protection Act offers no defence for girls under the age of 16 if they are forced to have sexual intercourse: “[A]t the time of the commission of the offence the girl was a prostitute.” 78 Under this law, a girl under 16 years cannot consent to sex regardless of whether she is a sex worker or not, and is therefore considered a ‘non-person’.79 Respecting, protecting and meeting the human rights needs of sex workers is vital in order to maintain their health and wellbeing.80 For more than a decade, empowering sex worker communities to address their own HIV needs has been recognised as UNAIDS Best Practice, and continues to underpin key UN policy documents regarding the HIV response.81 Community empowerment-based responses have been shown to be most effective in addressing underlying social and structural barriers to the health and human rights of sex workers.82 For example, Mynamar’s Targeted Outreach Project (TOP) began in Yangon in 2004 and has been implemented in 18 cities across the country, reaching more than 62,000 sex workers a year. TOP establishes drop-in centres where sex workers can access free health care, which is free from the stigma they often encounter from other healthcare providers. TOP provides the technical and financial support needed to open new centres, but insists that local sex workers take responsibility and control over their own centres through empowerment, advocacy, and emotional support. All ‘community educators’ that work in the centres are sex workers from the local area.83 Ashodaya Samithi (Dawn of Hope) began in 2005 as a collaboration between researchers and sex workers. Within three years it had become community-led, with more than 4,000 sex worker members. Monitoring of the programme in 2014 showed a saturation in intervention coverage and progress in HIV prevention, such as increased condom use and decreased STIs.84 Community empowerment interventions have been prominent in Asian responses to HIV over the past decade. However, a 2015 systematic reviews of sex worker interventions in Africa found fewer examples of sex worker mobilisation or empowerment being implemented there.85 Should sex work be legalised? In some countries, sex work is illegal, meaning the law prohibits it. In others, it is criminalised, meaning that the act of sex work itself is not illegal, but that associated activities such as soliciting sex or running a brothel are. In a few countries, sex work is legalised and regulated. It is argued that legalising or decriminalising sex work is beneficial to curbing the HIV epidemic, 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 protect them 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 programmes could be carried out much more effectively. In 2014, The Lancet published a study which estimated that decriminalisation and the promotion of safe working environments for sex workers could avert 33–46% of new HIV infections in sex workers and clients during a decade, through its iterative effects on violence, policing, safer work environment, and HIV transmission.86 It then joined a growing number of international health and human rights organisations including UNAIDS, UNFPA and Amnesty International to call for the full decriminalisation of adult, voluntary sex work in order to address the HIV epidemic more effectively.87 This approach is in line with the International Labour Organisation’s Recommendation 200, which recognises sex work as informal labour and gives sex workers the same rights as other workers, including the right to safe working conditions that are conducive to HIV prevention efforts.88 The way forward When responding to the HIV epidemic among sex workers, empowering them and involving them in HIV prevention has had positive results. By addressing the underlying social and structural problems that make sex workers vulnerable to HIV – by giving them greater legal protection against violence, and by reducing the discrimination they face – HIV prevalence could be cut dramatically. Harassment and abuse of sex workers by the police is also a widespread issue that needs particular attention from authorities. Governments and organisations need to create an environment where sex workers are able to protect themselves against HIV, and easily access HIV prevention, testing and treatment services. Only about one third of countries report having risk reduction programmes for sex workers, but they tend to vary in quality and reach. The remaining two thirds of countries expect sex workers to obtain services through general healthcare settings, where they may not be, or may not feel, welcome. This situation is even graver for male and transgender sex workers than it is for female sex workers.89 Although spending on the global HIV response has reached unprecedented levels, funds directed at programmes for sex workers remain far below the estimated need.90 Without addressing these gaps, sex workers will continue to be left behind in the global HIV response and the world will not meet the goals it needs to end the HIV epidemic.91