Sex workers are 10 times more at risk of HIV compared with the general population, due to an increased likelihood of being economically vulnerable, unable to negotiate consistent condom use, and experiencing violence, criminalisation and marginalisation. Where HIV prevention programmes are available they are generally well received, however sex workers often face many barriers in accessing them. HIV prevention services that are sex-worker led and community based are proven to be most effective when they address the legal and social barriers that affect sex workers.
Sex workers are among the highest risk groups for HIV. 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. In Nigeria and Ghana, HIV prevalence among sex workers is eight times higher than the rest of the population.
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. Sex workers often share common factors, regardless of their background, that can make them vulnerable to HIV transmission.
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. This lack of protection leaves sex workers open to abuse, violence and rape, creating an environment which can facilitate HIV transmission.
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 counselling and testing] clinic, health personnel were not polite and immediately asked me if I was a sex worker.
However, this does not necessarily increase their likelihood of becoming infected with HIV if they use condoms consistently and correctly. 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: Countries in the Middle East and North Africa generally have inadequate condom use to prevent HIV transmission to and from sex workers.
For example, a 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. Clients may refuse to pay for sex if they have to use a condom, and use intimidation or violence to force unprotected sex.
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. High HIV prevalence among the male clients of sex workers has been detected in studies globally.
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.
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 may also face surveillance, racial profiling, arrest, detention, deportation and other restrictions on mobility imposed by criminal, immigration and trafficking laws. 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. 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.
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.
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.
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 healthcare and increasing their vulnerability to violence, abuse and, ultimately, HIV.
Although the USA revoked the clause in , 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.