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HIV Prevention & Sex Workers

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 and Thailand, where general reductions in the national HIV prevalence have been largely attributed to HIV prevention initiatives aimed at sex workers. ¹

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 why so many are becoming infected with HIV.

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. 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 India.

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 should 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. In some cases, this is because sex workers have no access to condoms, or are not aware of their importance. In others, 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) - ²

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. Around the world, there is a severe lack of legislation and policies protecting sex workers from the unscrupulous 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. ³

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 profession. 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. See our injecting drug use page to read more about HIV transmission through needle sharing.

Migration, mobility and people trafficking

Both sex workers and their clients are often highly mobile. This can both increase the vulnerability of these groups to HIV, and facilitate the spread of HIV between countries and regions.

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.

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. There is little information available about HIV prevalence rates amongst these populations, but even in countries where HIV is relatively uncommon, they are still highly 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. ⁴

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. As well as being morally deplorable, the actions of these clients can also lead to HIV being transmitted. ⁵ There is a high risk of HIV transmission occurring when a HIV-positive adult forces sex upon a child, because the violent nature of such an act is likely to cause cuts or wounds, making it easier for HIV to be passed on.

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: ⁶

• 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.

The best programmes not only seek to protect and help those involved in sex work; they also look at ways to prevent individuals becoming involved in the sex trade in the first place, and offer those who are involved opportunities to leave the profession, if they want to do so.

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. ⁷

India: Sonagachi

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. ⁸ HIV prevalence amongst sex workers in the area has also fallen significantly in recent years as a result of the project. ⁹

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.” ¹⁰

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. ¹¹

Barriers to HIV prevention amongst sex workers

Despite overwhelming evidence of the benefits that HIV prevention campaigns aimed at sex workers can bring, only a handful of countries have organised national interventions to help this group. In many cases this is due to the failure of governments and societies to ‘recognise’ sex workers, and reach out to them. Sex work is still seen as morally corrupt or criminal in most places, and those involved are generally neglected or ignored by wider society. In many cases, laws and policies are actively stopping HIV prevention campaigns from helping sex workers.

An example is the U.S. government’s policy of refusing overseas aid to any HIV prevention program that does not ‘explicitly oppose’ the practice of sex work. Since many of those working with sex workers rightly feel that they cannot effectively help this population while simultaneously sending out the message that sex work is morally wrong, they are not usually eligible for U.S. money. This has led to HIV prevention campaigns aimed at sex workers missing out on money that could otherwise have saved lives. It has also led to tense relations with authorities that are seeking to reach out to sex workers. In Brazil, where efforts to reduce the stigma surrounding sex work have been understood as part of the overall fight against AIDS, 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. ¹²

The U.S. ‘prostitution loyalty oath’ has been criticised by many other groups and individuals involved in the global fight against AIDS, including Dr. Dennis Broun, the UNAIDS India country co-ordinator:

"[The U.S. sex work policy] will not solve the problem. There has and always will be prostitution. We have to choose methods of AIDS control that have proven efficacy." ¹³

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. ¹⁴

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. Allowing moral views to stand in the way of HIV prevention campaigns, and limiting sex workers’ access to services that could help them, simply worsens the situation.

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.

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.” ¹⁵

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. There are many cases where legal restrictions stand in the way of HIV prevention amongst sex workers – for instance, in some countries members of organisations working with sex workers have been threatened with arrest for ‘promoting prostitution’. ¹⁶ By removing such restrictions, HIV prevention campaigns could arguably be carried out much more effectively.

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 many 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.

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, moral judgements about sex work need to be put aside, and countries need to focus on what really 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. 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.

There is a tendency to talk about the spread of HIV between sex workers and ‘the wider population’, but doing so seems to suggest that sex workers are somehow less human than other members of society. Ultimately, the death of a sex worker from AIDS is no less tragic than that of anyone else. HIV prevention amongst sex workers needs to 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.

WHERE NEXT ?

AVERT.org has more about:

• HIV and AIDS prevention
• ‘AIDS and Prostitution’ around the world
• Condoms
• Groups that are highly affected by HIV in India