The role of sex work laws and stigmas in increasing HIV risks among sex workers.
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ABSTRACT:
SUBMITTER: Lyons CE
PROVIDER: S-EPMC7028952 | biostudies-literature | 2020 Feb
REPOSITORIES: biostudies-literature
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The role of sex work laws and stigmas in increasing HIV risks among sex workers.
Lyons Carrie E CE Schwartz Sheree R SR Murray Sarah M SM Shannon Kate K Diouf Daouda D Mothopeng Tampose T Kouanda Seni S Simplice Anato A Kouame Abo A Mnisi Zandile Z Tamoufe Ubald U Phaswana-Mafuya Nancy N Cham Bai B Drame Fatou M FM Aliu Djaló Mamadú M Baral Stefan S
Nature communications 20200218 1
Globally HIV incidence is slowing, however HIV epidemics among sex workers are stable or increasing in many settings. While laws governing sex work are considered structural determinants of HIV, individual-level data assessing this relationship are limited. In this study, individual-level data are used to assess the relationships of sex work laws and stigmas in increasing HIV risk among female sex workers, and examine the mechanisms by which stigma affects HIV across diverse legal contexts in co ...[more]
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Project description:BackgroundEnvironmental quality of life (QoL) assesses individually perceived factors such as physical safety and security, accessibility, quality of healthcare, and physical environment. These factors are particularly relevant in the context of sex work and HIV, where stigma has been identified as an important barrier across several prevention and treatment domains. This study aims to examine the association between different types of HIV- and sex work-related stigmas and environmental QoL among female sex workers (FSW) living with HIV in Durban, South Africa.MethodsWe conducted cross-sectional analyses using baseline data from the Siyaphambili randomized controlled trial. FSW who reported sex work as their primary source of income and had been diagnosed with HIV for ≥ 6 months were enrolled from June 2018-March 2020, in eThekwini, South Africa. We evaluated the association between environmental QoL, dichotomizing the environmental domain score collected by the WHO Quality of Life HIV Brief (WHOQOL-HIV BREF) questionnaire at the median, and stigma using modified robust Poisson regression models. Five stigma subscales were assessed: sex work-related (anticipated, enacted, or internalized stigma) and HIV-related (anticipated or enacted stigma).ResultsAmong 1373 FSW, the median environmental QoL was 10.5 out of 20 [IQR: 9.0-12.5; range 4.0-19.0], while the median overall QoL was 3 out of 5 [IQR: 2-4; range 1-5]. One-third of FSW (n = 456) fell above the median environmental QoL score, while 67% were above the median overall QoL (n = 917). Reporting anticipated sex work stigma was associated with lower environmental QoL (adjusted prevalence ratio [aPR] 0.74 [95% CI 0.61, 0.90]), as was severe internalized sex work stigma (aPR: 0.64, 95% CI 0.48, 0.86). Reporting enacted HIV stigma versus none was similarly associated with lower environmental QoL (aPR: 0.65, 95% CI 0.49, 0.87). Enacted sex work stigma and anticipated HIV stigma were not statistically associated with environmental QoL.ConclusionsThis study highlights the need to consider the impact of multiple stigmas on FSW's non-HIV related clinical outcomes, including safety and physical well-being. Moreover, these results suggest that addressing underlying structural risks may support the impact of more proximal HIV prevention and treatment interventions. Trial registration NCT03500172 (April 17, 2018).
| S-EPMC9724359 | biostudies-literature
Project description:BackgroundSex workers are at disproportionate risk of violence and sexual and emotional ill health, harms that have been linked to the criminalisation of sex work. We synthesised evidence on the extent to which sex work laws and policing practices affect sex workers' safety, health, and access to services, and the pathways through which these effects occur.Methods and findingsWe searched bibliographic databases between 1 January 1990 and 9 May 2018 for qualitative and quantitative research involving sex workers of all genders and terms relating to legislation, police, and health. We operationalised categories of lawful and unlawful police repression of sex workers or their clients, including criminal and administrative penalties. We included quantitative studies that measured associations between policing and outcomes of violence, health, and access to services, and qualitative studies that explored related pathways. We conducted a meta-analysis to estimate the average effect of experiencing sexual/physical violence, HIV or sexually transmitted infections (STIs), and condomless sex, among individuals exposed to repressive policing compared to those unexposed. Qualitative studies were synthesised iteratively, inductively, and thematically. We reviewed 40 quantitative and 94 qualitative studies. Repressive policing of sex workers was associated with increased risk of sexual/physical violence from clients or other parties (odds ratio [OR] 2.99, 95% CI 1.96-4.57), HIV/STI (OR 1.87, 95% CI 1.60-2.19), and condomless sex (OR 1.42, 95% CI 1.03-1.94). The qualitative synthesis identified diverse forms of police violence and abuses of power, including arbitrary arrest, bribery and extortion, physical and sexual violence, failure to provide access to justice, and forced HIV testing. It showed that in contexts of criminalisation, the threat and enactment of police harassment and arrest of sex workers or their clients displaced sex workers into isolated work locations, disrupting peer support networks and service access, and limiting risk reduction opportunities. It discouraged sex workers from carrying condoms and exacerbated existing inequalities experienced by transgender, migrant, and drug-using sex workers. Evidence from decriminalised settings suggests that sex workers in these settings have greater negotiating power with clients and better access to justice. Quantitative findings were limited by high heterogeneity in the meta-analysis for some outcomes and insufficient data to conduct meta-analyses for others, as well as variable sample size and study quality. Few studies reported whether arrest was related to sex work or another offence, limiting our ability to assess the associations between sex work criminalisation and outcomes relative to other penalties or abuses of police power, and all studies were observational, prohibiting any causal inference. Few studies included trans- and cisgender male sex workers, and little evidence related to emotional health and access to healthcare beyond HIV/STI testing.ConclusionsTogether, the qualitative and quantitative evidence demonstrate the extensive harms associated with criminalisation of sex work, including laws and enforcement targeting the sale and purchase of sex, and activities relating to sex work organisation. There is an urgent need to reform sex-work-related laws and institutional practices so as to reduce harms and barriers to the realisation of health.
| S-EPMC6289426 | biostudies-literature
Project description:IntroductionIn sub-Saharan Africa, accurate estimates of the HIV epidemic in female sex workers are crucial for effective prevention and care strategies. These estimates are typically derived from mathematical models that assume certain demographic and behavioural characteristics like age and duration of sex work to remain constant over time. We reviewed this assumption for female sex workers in South Africa.MethodsWe reviewed studies that reported estimates on either the age or the duration of sex work among female sex workers in South Africa. We used Bayesian hierarchical models to synthesize reported estimates and to study time trends. In a simulation exercise, we also investigated the potential impact of the "constant age and sex work duration"-assumption on estimates of HIV incidence.ResultsWe included 24 different studies, conducted between 1996 and 2019, contributing 42 estimates on female sex worker age and 27 estimates on sex work duration. There was evidence suggesting an increase in both the duration of sex work and the age of female sex workers over time. According to the fitted models, over each decade the expected duration of sex work increased by 55.6% (95%-credible interval [CrI]: 23.5%-93.9%) and the expected age of female sex workers increased by 14.3% (95%-CrI: 9.1%-19.1%). Over the 23-year period, the predicted mean duration of sex work increased from 2.7 years in 1996 to 7.4 years in 2019, while the predicted mean age increased from 26.4 years to 32.3 years. Allowing for these time trends in the simulation exercise resulted in a notable decline in estimated HIV incidence rate among sex workers over time. This decline was significantly more pronounced than when assuming a constant age and duration of sex work.ConclusionsIn South Africa, age and duration of sex work in female sex workers increased over time. While this trend might be influenced by factors like expanding community mobilization and improved rights advocacy, the ongoing criminalisation, stigmatisation of sex work and lack of alternative employment opportunities could also be contributing. It is important to account for these changes when estimating HIV indicators in female sex workers.
| S-EPMC10844672 | biostudies-literature
Project description:Female sex workers (FSWs) who work as peer outreach workers in HIV prevention programs are drawn from poor socio-economic groups and consider outreach work, among other things, as an economic activity. Yet, while successful HIV prevention outcomes by such programs are attributed in part to the work of peers who have dense relations with FSW communities, there is scant discussion of the economic implications for FSWs of their work as peers. Using observational data obtained from an HIV prevention intervention for FSWs in south India, we examined the economic benefits and costs to peers of doing outreach work and their implications for sex workers' economic security. We found that peers considered their payment incommensurate with their workload, experienced long delays receiving compensation, and at times had to advance money from their pockets to do their assigned peer outreach work. For the intervention these conditions resulted in peer attrition and difficulties in recruitment of new peer workers. We discuss the implications of these findings for uptake of services, and the possibility of reaching desired HIV outcomes. Inadequate and irregular compensation to peers and inadequate budgetary outlays to perform their community-based outreach work could weaken peers' relationships with FSW community members, undermine the effectiveness of peer-mediated HIV prevention programs and invalidate arguments for the use of peers.
| S-EPMC4361609 | biostudies-other
Project description:ObjectivesIn 2014, Canada implemented end-demand sex work legislation that criminalises clients and third parties (eg, managers, security personnel, etc) involved in sex work. The focus of this analysis is to explore how the criminalisation of clients shapes the occupational health and safety of sex workers.DesignAs part of a longstanding community-based study (An Evaluation of Sex Workers' Health Access), this analysis draws on 47 in-depth qualitative interviews with indoor sex workers and third parties. Informed by an intersectional lens and guided by a structural determinants of health framework, this work seeks to characterise the impact of client criminalisation in shaping the occupational health and safety of indoor sex workers.SettingIndoor sex work venues (eg, massage parlour, in-call, brothel, etc) operating in Metro Vancouver, Canada.Participants47 predominately racialised sex workers and third parties working in indoor environments between 2017 and 2018.ResultsWhile participants highlighted that the majority of their client interactions were positive, their narratives emphasised how end-demand criminalisation impeded their occupational safety. The criminalisation of clients was linked to reduced ability to negotiate the terms of sexual transactions, including type of service, price and sexual health. Client preference for cash payments to maintain anonymity led to increased risk of robbery and assault due to knowledge of high cash flow in sex work venues and a reluctance to seek police protection. Workers also noted that client fear of being prosecuted or 'outed' by police enhanced feelings of shame, which was linked to increased aggression by clients.ConclusionPolicies and laws that criminalise clients are incompatible with efforts to uphold the occupational health and safety and human rights of sex workers. The decriminalisation of sex work is urgently needed in order to support the well-being and human rights of all those involved in the Canadian sex industry.
| S-EPMC9685237 | biostudies-literature
Project description:Female sex workers (FSWs) in South Africa experience a uniquely high prevalence of HIV. We describe the HIV cascade of care (CoC) in FSWs in South Africa, and explored service utilisation at sex work programmes. A cross-sectional, study enrolled FSWs across 12 sites in South Africa. Participants were recruited using chain-referral method. Inclusion criteria: ≥ 18 years, cis-gender female, sold/transacted in sex, HIV positive. 1862 HIV positive FSWs were enrolled. 92% were known positive, 87% were on antiretroviral treatment (ART). Of those on ART, 74% were virally suppressed. Younger FSWs were significantly less likely to be on ART or virally suppressed. Female sex workers using HIV services from specialised programs were 1.4 times more likely to be virally suppressed than non-program users. The pre-COVID-19 pandemic HIV CoC amongst FSWs in South Africa shows striking improvement from previous estimates, and approaches achievement of 90:90:90 goals.
| S-EPMC8897612 | biostudies-literature
Project description:BackgroundFemale sex workers (FSW) have a greater HIV burden compared to other reproductive-aged women and experience high incidence of pregnancies. However, there are limited data on mother-to-child transmission of HIV in the context of sex work. This study assessed the uptake of prevention of mother-to-child transmission (PMTCT) services to understand the vertical HIV transmission risks among FSW in South Africa.MethodsFSW ≥18 years were recruited into a cross-sectional study using respondent-driven sampling (RDS) between October 2014-April 2015 in Port Elizabeth, South Africa. An interviewer-administered questionnaire captured information on demographics, reproductive health histories, and HIV care, including engagement in PMTCT care and ART. HIV and pregnancy testing were biologically assessed. This analysis characterizes FSW engagement in HIV prevention and treatment cascades of the four prongs of PMTCT.ResultsOverall, 410 FSW were enrolled. The RDS-weighted HIV prevalence was 61.5% (95% bootstrapped confidence interval 54.1-68.0). A comprehensive assessment of the four PMTCT prongs showed gaps in cascades for each of the prongs. In Prongs 1 and 2, gaps of 42% in consistent condom use with clients among HIV-negative FSW and 43% in long-term high efficacy contraceptive method use among HIV-positive FSW were observed. The analyses for prongs three and four pertained to 192 women with children < 5 years; 101/192 knew their HIV diagnosis prior to the study, of whom 85% (86/101) had their children tested for HIV after birth, but only 36% (31/86) of those who breastfed retested their children post-breastfeeding. A substantial proportion (35%, 42/120) of all HIV-positive women with children < 5 years of age were HIV-negative at their last delivery and seroconverted after delivery. Less than half (45%) of mothers with children < 5 years (45/101) were on ART and 12% (12/101) reported at least one child under five living with HIV.ConclusionThese findings show significant gaps in engagement in the PMTCT cascades for FSW, evidenced by sub-optimal uptake of HIV prevention and treatment in the peri/post-natal periods and insufficient prevention of unintended pregnancies among FSW living with HIV. These gaps result in elevated risks for vertical transmission among FSW and the need for PMTCT services within FSW programs.
| S-EPMC6538543 | biostudies-literature
Project description:Research increasingly recognizes the importance of social and built environments in shaping health, including risks for and outcomes related to HIV and sexually transmitted infections (STI), but research on sex work venues is limited. We use latent class analysis to identify patterns of sex work venue characteristics and factors associated with class membership in two México-US border cities. Among 603 female sex workers (FSW), three classes of sex work venues were identified: low, medium, and high disorder venues, characterized by level of violence, policing and drug activity. In multivariable analysis, risk exposures and outcomes varied by class, suggesting the need for place-based interventions that are tailored to specific venue profiles and that promote FSW health and safety in the workplace.
| S-EPMC10399957 | biostudies-literature
Project description:Between 20 and 40 % of female sex workers (FSWs) began sex work before age 18. Little is known concerning whether early initiation of sex work impacts later experiences in adulthood, including violence victimization. This paper examines the relationship between early initiation of sex work and violence victimization during adulthood. The sample included 816 FSWs in Mombasa, Kenya, recruited from HIV prevention drop-in centers who were 18 years or older and moderate-risk drinkers. Early initiation was defined as beginning sex work at 17 or younger. Logistic regression modeled recent violence as a function of early initiation, adjusting for drop-in center, age, education, HIV status, supporting others, and childhood abuse. Twenty percent of the sample reported early initiation of sex work. Although both early initiators and other FSWs reported commonly experiencing recent violence, early initiators were significantly more likely to experience recent physical and sexual violence and verbal abuse from paying partners. Early initiation was not associated with physical or sexual violence from non-paying partners. Many FSWs begin sex work before age 18. Effective interventions focused on preventing this are needed. In addition, interventions are needed to prevent violence against all FSWs, in particular, those who initiated sex work during childhood or adolescence.
| S-EPMC5126017 | biostudies-literature
Project description:BackgroundThe Yunnan province is located near the "Golden Triangle" border region between China, Myanmar and Thailand, which has the highest HIV/AIDS prevalence in China. Female sex workers (FSWs) in the Yunnan province are highly vulnerable to HIV infection. The objective of this study was to examine the experiences of FSWs in the Yunnan to better understand the risk of infection and the potential for transmission of HIV.MethodsSemi-structured interviews were conducted between May 2018 and June 2018 with 20 FSWs recruited in Hekou County, Yunnan Province, China. Thematic analysis was conducted to identify themes that highlighted increased exposure of FSWs to the risk of HIV infection and transmission.ResultsThe findings showed that FSWs' primary source for HIV information was gynecologists, with few visiting the local HIV charity Red Ribbon. FSWs reported infrequent visits for check-ups with some seeing a gynecologist once a year. FSWs felt that the onus was on them to prevent STI/HIV infection by using a condom during sex, regardless of their ability to negotiate use. FSWs were also reluctant to see a gynecologists for treatment. Instead, they resorted to douching as a way of preventing HIV/STIs and treating vaginal health problems, such as leucorrhea. Most FSWs worked without the influence of alcohol and drugs. A small number of FSWs reported heroin addiction and injecting drug use.ConclusionThe findings suggest a need for innovative HIV prevention strategies among FSWs and their clients in the Chinese border region. Governmental agencies should continue to implement practical strategies in terms of HIV prevention education and condom use through tailored interventions that are localized. Such strategies should include localized tailored interventions that dispel myths about douching as a method of HIV/STI prevention and incorporate a mobile outreach approach, similar to the 'roadside restaurant' outreach that has been successful in rural China.
| S-EPMC7789185 | biostudies-literature