Understanding Sex Work and Its Links with HIV

Understanding Sex Work and Its Links with HIV
Sex workers include “female, male and transgender adults and young people7 who receive
money or goods in exchange for sexual services, either regularly or occasionally…”8. 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 organized, and in the degree to which it is
distinct from other social and sexual relationships and types of sexual-economic exchange9.
Where sex work is organized, controllers10 and managers generally act as clearly-defined,
power-holding intermediaries between the sex worker and client, and often between both
and local authorities. Self-employed sex workers usually find their clients through independent
means, increasingly through mobile telephones and the internet11, and may be
recruited or excluded from settings where an organized system is in place. Individuals maysell sex as a full-time occupation, part-time, or occasionally to meet specific economic
needs (such as education costs, or in a family financial crisis). Others are trafficked or
coerced into selling sex. Many people who exchange sex for money or goods do not selfidentify
as sex workers12, and do not seek nor have access to HIV prevention, treatment,
care and support advice or services for sex workers, including in humanitarian and postconflict
settings13.
The settings in which sex work may occur range from brothels or other dedicated
establishments to roadsides, markets, petrol stations, truck stops, parks, hotels, bars,
restaurants and private homes, and may be recognizable or hidden. Sex work settings may
cater to local communities or primarily involve transient, migrant and mobile populations
of both sex workers and clients. Depending on their individual circumstances, sex workers
may be further victimized by discriminatory gender-based attitudes, violence, and sexual
exploitation, and by membership in other populations that are highly vulnerable to HIV
exposure, such as men who have sex with men and injecting drug users14. Policies and
programmes to address the links between HIV and sex work must recognize the social and
geographic diversity of sex work, as well as the rapid changes that may occur in patterns of
sex work, including types of transactional sex15, and in sex work settings.16
The conditions in which sex work occurs may have a profound impact on HIV risk
and vulnerability17. While some sex work settings have served as excellent venues for
HIV-prevention programmes, many others neither promote safer sex nor protect sex
workers from violence perpetrated by clients, law enforcement officers, gangs, establishment
owners or controllers. In addition, debt-bondage, low pay and inadequate living conditions
may further compromise the health and safety of sex workers. Where sex workers are able
to assert control over their working environments and insist on safer sex, evidence indicates
that HIV risk and vulnerability can be sharply reduced. Excellent examples of community
organized HIV-prevention programming for sex workers include AVAHAN (India),
Clinque de Confiance (Cote d’Ivoire), CONASIDA (Mexico), DAVIDA (Brazil), Durjoy
Nari Shango (Bangladesh), EMPOWER (Thailand), FIMIZORE (Madagascar), Durbar
Mahila Samanwaya Committee (India), SWING (Thailand) and TAMPEP (Europe)18In many countries, laws, policies, discriminatory practices, and stigmatizing social attitudes
drive sex work underground, impeding efforts to reach sex workers and their clients with
HIV prevention, treatment, care and support programmes. Sex workers frequently have
insufficient access to adequate health services; male and female condoms and water-based
lubricants; post-exposure prophylaxis following unprotected sex and rape; management
of sexually transmitted infections, drug treatment and other harm reduction services19;
protection from violence and abusive work conditions; and social and legal support.
Inadequate service access is often compounded by abuse from law enforcement officers.
Documented and undocumented migrants working in sex work often face particularly
severe access barriers as a result of linguistic challenges, exclusion from the services that are
available locally, and minimal contact with support networks. Even where HIV information
and services are accessible to sex workers, such services often fail to comply with human
rights standards20 and insufficiently engage clients, the controllers and managers of sex work
or take account of the local social and cultural context.
Similarly, in many countries, official policies principally focus on reducing or punishing
the suppliers while ignoring the consistent demand for paid sex.21 The demand for sex
work may be affected by social and cultural norms and individual circumstances, including
work-related mobility and spousal separation; social isolation and loneliness; access to
disposable income22; and attitudes based on harmful gender norms, including a desire for
sexual dominance and sense of entitlement, which may manifest in sexual and economic
exploitation and violence against sex workers. When addressing HIV in the context of
sex work, policies and programmes should not only focus on the needs of sex workers
themselves but also address factors that contribute to the demand for paid sex.