The HIV epidemic continues to have a profound effect on female, male, and transgender sex workers.1, 2, 3, 4 The median worldwide estimates show that female sex workers (FSWs) are 13·5 (95% CI 10·0–18·1) times more likely to be living with HIV than other women,3 15% of female HIV infections in 2011 were attributed to sex workers, with the highest attributable fraction in sub-Saharan African populations (17·8%).5 Substantial proportions of new infections (10–32%) occurred as a result of sex work in West African countries. In Uganda, Swaziland, and Zambia, 7–11% of new infections could be due to sex work, sex-worker clients, and clients' regular partners.6 The UNAIDS 2015 goal of zero infections and discrimination will need effective HIV prevention strategies for those who sell or barter for sex in every region.1, 4
Sex work is diverse and occurs in various contexts around the world. Although some women sell sex through formal structures such as brothels or other venues, others might work independently and solicit clients directly in public places or via cell phone or internet.7, 8 Tailoring of an effective, safe HIV prevention package for FSWs to account for the contexts in which they work and the particular risks they face is needed.7
Here, we have focused on prevention interventions for FSWs and have defined sex work as exchange of sex for money or goods. Prevention options for men (Baral and colleagues9) and transgender persons who sell sex (Poteat and colleagues10) are reviewed in this Series. HIV prevention for women is a continuing challenge, and is an area where biology, physiology, gender dynamics, and behaviour have made HIV prevention research challenging, particularly in the subset of women who sell sex. We assessed interventions in three categories: biological, behavioural, and structural.11, 12 Effective HIV prevention approaches for FSWs exist but have not been taken to scale or adequately resourced in most parts of the world.13 Additionally, we explored complementary strategies that can be added to a combination prevention package tailored for FSWs. An existing ecological model14 was modified to visualise multi-level domains of HIV risk for FSWs (figure 1). We present within these multi-level risks the evidence for biological, behavioural, and structural prevention interventions (table 1). In this model, we recommend that social justice principles are fully integrated into any package of combination approaches and that FSWs are meaningfully included in all aspects of programme design and implementation.11, 14, 15, 16 The prevention strategies enable FSWs to exert more control over their ability to prevent HIV. In addition to reducing infections in FSWs, these strategies will positively affect networks, communities, and country epidemics in different social, economic, and legal contexts.17 We modelled the effect of one such combination prevention package within the setting of the South African epidemic.
Key messages
- •
Effective HIV prevention approaches for female sex workers exist but have not been taken to scale or adequately resourced in most parts of the world.
- •
Prevention interventions should integrate principles of social justice and meaningfully include sex workers in programme design and implementation.
- •
Existing and effective prevention interventions include condom promotion, sexually transmitted infection prevention and treatment, HIV counselling and testing, gender-based violence prevention, and economic and community empowerment.
- •
Stigma and criminalisation form barriers to such interventions and a less punitive more enabling legal and medical environment is required.
- •
Modelling suggests that condom promotion may have already reduced incidence in sex workers and their clients by up to 70% in South Africa. Additional biomedical interventions such as pre-exposure prophylaxis or treatment as prevention could further reduce this by 40%.
- •
Both topical and oral pre-exposure prophylaxis have been proven to reduce HIV incidence in high-risk men and women. However, its effectiveness in sex workers has yet to be determined.
- •
Earlier initiation of antiretroviral therapy, with the requisite access to services is likely to benefit the health of sex workers and reduce HIV incidence in their clients and others sexual partners.
- •
New biomedical technologies must be additive to, and not replacements for, more established prevention modalities. Interventions that combine behavioural, biological, and structural factors have the potential to have the greatest effect on the health of sex workers, their clients, and the wider population.