Women, men, and transgender people who engage in sex work face disproportionate burdens of HIV, HIV risks, and a scarcity of access to essential services. This is true in countries of low, middle, and high income, in concentrated HIV epidemics, and in generalised ones.1, 2 We must do better and we can. Improved efforts by and for people who sell sex can no longer be seen as peripheral to the achievement of universal access to HIV services and to eventual control of the pandemic.
Sex workers are an enormously diverse group working in a wide array of contexts—some in safety—and some in difficult and dangerous settings. In this Series, Shannon and colleagues show how structural measures can heighten risk of HIV, or markedly decrease it.1, 2 Although governments and security entities, most notably the police, have crucial roles in helping to establish environments that support public health goals of safety and HIV risk reduction, they are often impediments to protection.3 Widespread use of condom carriage as evidence of sex work by police is a vivid reminder of how life-threatening bad public policy can be.
There is great optimism regarding HIV prevention. Breakthroughs in HIV treatment, prevention science, programme implementation, and human rights realisation have led to assertions that an AIDS free generation is possible.4 Advances in HIV prevention science relevant to sex workers were reviewed by Bekker and colleagues5 for women, by Baral and colleagues6 for men, and by Poteat and colleagues7 for transgender women, and show substantial promise. Uptake, adaptation, and successful use of these innovations by sex workers are crucial steps for the future. Yet, however far the global response to HIV can move towards the goal of universal access to these new interventions, Decker3 and Kerrigan8 state that without a rights-based framework for HIV interventions, and participation, engagement, and empowerment of sex workers, HIV control will remain elusive.
Key messages
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HIV epidemics in female sex workers are generally similar to the HIV burden in heterosexual adults in their surrounding communities, but with substantially higher HIV incidence and prevalence. The most burdened sex workers are African women and all countries with more than 50% HIV prevalence in sex workers are in sub-Saharan Africa.
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Male sex workers have very high HIV risks and burdens, as a result of the high HIV incidence in gay, bisexual, and other men who have sex with men at risk worldwide.
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The burden of HIV among transgender women sex workers is very high and HIV prevention and care is challenged by significant structural and social barriers.
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Structural measures, including laws, policies, rights contexts, community organisation, and the physical and economic features of sex work have crucial roles in generation or mitigation of risks for HIV infection in sex workers. Models suggest that decriminalisation of sex work 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.
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Human rights violations against sex workers increase HIV susceptibility and undermine effective prevention. Many rights violations, including physical and sexual violence by police and other state groups, are the result of climates of impunity which must change.
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Decriminalisation, expanded access to antiviral treatment for sex workers living with HIV, and community empowerment and engagement could have synergistic effects on reduction of HIV infections in sex workers.
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Community-empowerment-based HIV prevention substantially reduces HIV risks, gonorrhoea, and chlamydia infections in female sex workers, and increases condom use with clients. Social and political changes that are related to the recognition of sex work as work, and scale-ups of empowerment-based approaches to HIV prevention for sex workers, are needed.
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Peer or community counselling and condom distribution among female sex workers are cost effective in south-east Asia and sub-Saharan Africa, more so than school-based education, voluntary counselling and testing, prevention of mother-to-child transmission, and treatment of sexually transmitted infections.
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Combined HIV-prevention programmes that address biological drivers of HIV infection, including tailored use of antiretroviral drugs in pre-exposure prophylaxis, post-exposure prophylaxis, and rectal microbicides, will probably be needed to prevent HIV in male and transgender sex workers.
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High coverage of HIV testing and ART treatment access will be key to health outcomes and reduction of HIV transmission. These approaches should be carefully added to tailored prevention packages that recognise and respect communities' human rights in programme design and implementation. Equitable funding for HIV programmes can support these efforts.
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Research is urgently needed about the epidemiology of HIV in sex workers, and novel effective interventions and combination interventions. The global scarcity of data for HIV in transgender women and male sex workers calls for more and better research in these populations to identify needs and inform prevention efforts and treatment access.
When we reviewed the evidence about HIV in sex workers, we identified striking trends and problematic gaps. For the first two decades of HIV, female sex workers were central to many HIV research and programme efforts. Studies of HIV in women were either routinely undertaken within populations of female sex workers or included a substantial number of them.9 Community-based and led-intervention efforts, including the Sonagachi Programme and other efforts in Bangladesh, Thailand, Cambodia, Kenya, the Gambia, and Brazil, showed impressive reductions in HIV risk, and in other sexually transmitted infections (STI), before the antiretroviral therapy (ART) era.8, 10, 11
Several events and trends markedly changed this situation and slowed further progress. Controversy regarding the ethics of the first oral pre-exposure prophylaxis (PrEP) trials in women, which had been designed for female sex workers in Cambodia in 2004 and Cameroon in 2005, halted both studies. Many researchers moved toward less-contested populations.12 The 2003 so-called Prostitution Pledge policy requirement for US Federal (PEPFAR) funding reduced programmatic engagement with sex workers in some settings.3, 13, 14 This reduction has been associated with reduced financing of HIV programmes for sex workers, particularly programmes which funded organisations led by sex workers.15 Finally, the very high HIV incidence in women in southern sub-Saharan Africa from 2001 to 2005, meant that HIV studies which required HIV seroconversion endpoints (eg, microbicides, HIV vaccines, and PrEP) could be undertaken in the general population of reproductive-aged women, and would markedly reduce the necessity of recruiting sex workers. These trends led to a challenging new situation: there has been a substantial increase in effective HIV-prevention techniques and approaches—yet none of these advances have specifically been investigated in sex workers. Adaptation of these methods, and assessment of sex workers' interest and effectiveness of their use in this group, is still to be done. Table 1 sets forth a research agenda to address these gaps.