What Works to Prevent HIV Among Sex Workers?

“Female sex workers [FSWs] are affected by HIV more than any other group. In low and middle income countries (LMICs) HIV prevalence among sex workers is 11.8%. FSWs are 13.5 times more likely to be living with HIV than other women.”

This brief, published by the United Nations Population Fund (UNFPA) East and Southern Africa (ESA), looks at the evidence on what works to prevent HIV infection among sex workers and identifies some of the challenges to implementation as well as strategies to overcome barriers. The literature for this review was sourced through multiple electronic databases and grey literature. Literature deemed eligible for review included systematic reviews, reviews, and intervention evaluations of specific HIV/sexually transmitted infection (STI) interventions conducted worldwide, and focused on FSWs. In total, seven systematic reviews were found and summarised (two of which are from LMICs, including Sub-Saharan Africa and South Africa between, 2005 and 2015), and a total of 28 papers were included in this evidence review.

The paper starts off by looking at factors that impact upon FSWs' vulnerability to HIV at macro societal level, community level, work/relationship level, and individual level - both harmful and protective factors. Harmful factors that contribute to HIV infection, for example, include criminalisation of sex work, harmful law enforcement practices, stigma and discrimination related to both sex work and HIV, unsafe working conditions, sexual violence, multiple concurrent sexual partners, unprotected anal and vaginal sex, and barriers to the negotiation of consistent condom use. The review highlights the direct and indirect causal pathways between violence against FSWs) and HIV risk. This violence is perpetrated by the police, intimate partners, and clients, and also includes stigma and discrimination (which prevents access to HIV testing and treatment and seeking timely medical attention following rape, including post-exposure prophylaxis (PEP)).

Based on the review of evidence, the paper outlines in table format what works and what the challenges to implementation are and provides strategies to overcome barriers. The table is broken down by types of intervention, which are then categorised into levels of effectiveness and the amount of evidence there is to back up that finding (strong or limited evidence). Types of interventions are: community empowerment approach, combination HIV prevention, HIV testing and counselling, condom promotion and distribution, and biomedical approaches/treatment as prevention. Effectiveness is highlighted in relation to the intervention’s impact on HIV, as well as other types of impact such as improvement in education and health outcomes, empowerment, treatment seeking behaviour, reduction in violence, and stigma and discrimination.

In brief, the review showed that there was strong evidence of the impact of the community empowerment approach, and there was limited evidence for interventions using a combination HIV prevention approach. HIV testing and counselling was shown to be effective in combination with other intervention; however, evidence for this was limited. Condom promotion and distribution was also found to be effective, although evidence was limited. Finally, biomedical approaches/treatment as prevention approaches were found to be not effective as a standalone activity, although evidence was limited.

The table also identifies barriers to implementation and scale-up and offers recommended strategies for each of the intervention types. To mention examples from two intervention types - for the community empowerment approach, barriers include the fact that it is difficult to reach street-based FSWs and that gender-based violence (GBV), criminalisation, and stigma restrict ability of FSWs to organise. Barriers to HIV testing and counselling include poor awareness of services and accessibility, fear of authorities, and confidentiality concerns.

In summary, the review recommends the following strategies and interventions:

Macro societal level

• Legal reform to decriminalise sex work and remove punitive measures.
• Awareness raising and communications campaigns
• Training/advocacy with police, judges, and others
• Promoting gender equality
• Increasing access to and reducing cost of condoms

Community level

• Community empowerment initiatives
• Stigma reduction programmes
• Building capacities of and accessibility of sexual and reproductive health and rights (SRHR) services
• Broad condom and lubricant programmes
• Preventing violence against sex workers
• Economic and community empowerment
• Drug use programmes

Work/relationship level

• HIV education for clients, FSWs, and brothel/venue owners (especially to discourage unprotected sex)
• Behaviour change communication to encourage condom use among clients and regular partners
• Peer education programmes
• injection drug user (IDU) networks

Individual level

• HIV education, voluntary HIV testing, counselling, and access to HCT
• Condom distribution and education
• Treatment as prevention
• Harm reduction in FSWs who inject drugs
• Biomedical interventions to reduce exposure, transmission, infection

Overall, the document recommends adopting a holistic combination approach that addresses the underlying drivers of the epidemic for FSWs in order to prevent HIV and contribute to the economic, social, and health wellbeing of FSWs. Community empowerment should be at the centre of the combination prevention approach and be guided by the following principles:

• Tailor to FSWs according to age, ethnic origin, marital status, citizenship status, migration, type of sex work, drug use, socio-demographic factors, and the epidemic context in which sex work occurs;
• Use a combination of long-term, coordinated structural, biomedical and behavioural approaches to address the risks at the different levels;
• Actively involve FSWs in the design and implementation of programmes, with a focus on social justice and human rights;
• Have a clear theory of change and be clear about the pathways of risk being addressed;
• Address the multiple vulnerabilities of FSW risk identities (IPV, drug and alcohol abuse, bonded FSWs, street-based FSWs).

In conclusion, the review points to the overall dearth of evidence around HIV and FSWs and identifies gaps in research in this field. Overall, it calls for more research to better understand the drivers of HIV and structural determinants among FSWs from Sub-Saharan Africa.