HOW SERIOUS IS HIV FOR SEX WORKERS?
The term sex worker includes a broad range of people who trade sex for income or other items including food, drugs, medicine, and shelter. Sex workers are at increased risk of getting or transmitting HIV and other sexually transmitted infections (STIs) because they are more likely to engage in risky sexual behaviors (sex without a condom, sex with multiple partners) and substance use. Those who exchange sex more regularly as a source of ongoing income are at higher risk for HIV than those who do so infrequently.
Sex workers include: escorts; people who work in massage parlors, brothels, and the adult film industry; exotic dancers; prostitutes; and people who engage in survival sex (trading sex to meet basic needs of daily life). For any of the above, sex can be consensual or nonconsensual.
Globally, sex workers are 13 times more likely to become infected with HIV than adults in the general population. Sex workers make up 9% of the total number of new HIV infections in the world. In eastern and southern Africa, HIV prevalence among female sex workers is often extremely high and more than 50% of sex workers have HIV. In 2013, it was found that HIV prevalence was 50 times higher among sex workers than in the general population in four countries.
WHY ARE SEX WORKERS PARTICULARLY AT RISK FOR HIV?
Sex workers often share common factors, regardless of their background, that can make them vulnerable to HIV transmission. The following factors contribute to the global burden of HIV among sex workers:
Criminalization and marginalization: Sex workers face high levels of stigma and criminalization almost everywhere in the world. Modeling studies indicate that decriminalizing sex work could lead to a 46% reduction in new HIV infections in sex workers over 10 years; eliminating sexual violence against sex workers could lead to a 20% reduction in new HIV infections.
Even though sex work is at least partially legal in some countries, the law rarely protects sex workers. Around the world, there is a lack of legislation and policies protecting sex workers against violence from law enforcement, partners, family members, and clients. For example, a sex worker who is raped will generally be unable to bring charges against their attacker. This lack of protection leaves sex workers open to abuse, violence, and rape, creating an environment that facilitates HIV transmission.
In addition, the stigma that sex workers face can make it difficult or impossible to access healthcare, legal, and social services. They may be afraid to seek out services for fear of discrimination or be prevented from accessing them–for instance, if a healthcare professional refuses to treat them after finding out their occupation.
Socioeconomic factors: Many sex workers experience poverty, homelessness, unemployment, incarceration, mental health issues, violence, abuse, and drug use. In addition, lack of access to healthcare and other social services poses challenges to HIV testing, prevention, and treatment. Transgender people may turn to survival sex because of discrimination and lack of economic opportunities. They may exchange sex to generate income for rent, drugs, medicines, hormones, and gender related surgeries.
High-risk sex: In general, sex workers have more sexual partners than the general population. However, this does not necessarily increase their likelihood of becoming infected with HIV if they use condoms consistently and correctly. Rates of condom use vary greatly between regions and countries. For example, in India, Lao, and Sri Lanka condom use was over 90% among sex workers in 2017. However in nearby Pakistan, condom use was only at 35% in 2017.
In some cases, sex workers have no access to condoms or are not aware of their importance. In other cases, police actively confiscate or destroy condoms found in sex workers’ possession. Sometimes, sex workers are simply powerless to negotiate safer sex. Clients may refuse to pay for sex if they have to use a condom and may use intimidation or violence to force unprotected sex. Sex workers may get paid more for unprotected sex and often feel pressured to not use condoms, which makes them highly vulnerable to HIV.
Gender-based violence (GBV) and intimate partner violence (IPV): Violence prevents many sex workers, particularly adolescents and young people, from protecting themselves against HIV. In some regions it has been estimated that people who experience violence are 1.5 times more likely to acquire HIV.
Injection drug use: Sex workers who inject drugs and share needles are at particularly high risk of HIV infection. Sex work and drug use are illegal in most countries, so sex workers who use drugs are more vulnerable to frequent arrest, bribes, extortion, and physical and sexual abuse. In turn, this discourages many sex workers who inject drugs from seeking harm reduction services or HIV prevention and treatment. Read more about HIV among people who inject drugs.
Biological factors: In general, receptive sex is riskier than insertive sex. This means that sex workers who are receptive during sex are more likely to get HIV during vaginal or anal sex than their insertive clients.
Migration and mobility: Migration and sex work are often linked as some migrants may turn to sex work if they cannot find other ways of generating income. Migrant sex workers often become targets of both police and immigration officers, especially those who cross borders legally or illegally. Other than facing the criminalization of sex work, they may also face surveillance, racial profiling, arrest, detention, deportation, and other restrictions on mobility.
Human trafficking: Many trafficked people are forced into selling sex. Even in countries where HIV prevalence is low, trafficked people who are forced to sell sex are highly vulnerable to HIV infection because they struggle to access condoms, cannot negotiate condom use, and are often subjected to violence. In addition, they may have no access to testing, prevention, and treatment programs.
Human trafficking is defined as the recruitment, transportation, transfer, harboring, or receipt of persons by means of the threat or use of force or other forms of coercion, abduction, fraud, deception, abuse of power, or a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person for the purpose of exploitation.
It must be emphasized that the relationship between sex work and human trafficking should not be overplayed as it can lead to false or exaggerated anti-sex work arguments and harmful action by authorities, ultimately undermining HIV prevention for sex workers.
Young people: Data on young people who sell sex is extremely limited, although evidence suggests that many sex workers begin selling sex while adolescents. Research shows that adolescents under 18 who sell sex are highly vulnerable to HIV and other STIs, have higher levels of HIV and STIs than older sex workers, and have limited access to HIV testing, prevention, and treatment.
Young sex workers face many of the same barriers to HIV prevention as their older counterparts including the inability to negotiate condom use and legal barriers to HIV and sexual health services, which are amplified by their age. Read more about HIV among adolescents and young people.
PREVENTING HIV INFECTION AMONG SEX WORKERS
In order to address the high burden of HIV among sex workers, UNAIDS recommends:
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- Addressing the violence against sex workers
- Decriminalizing sex work
- Empowering sex work communities
- Scaling-up and funding health and social services for sex workers
UNAIDS also emphasizes the importance of combining HIV prevention strategies for sex workers, including integrating condom distribution with other HIV services and increasing links between HIV services and other sexual and reproductive health services such as family planning, gynecologic, and maternal health services.
Encouraging condom use
Condoms are highly effective in preventing a person from getting or transmitting HIV infection if used the right way every time during sex. Read more about how to use condoms the right way: external condoms and internal condoms.
Pre-exposure prophylaxis (PrEP)
For sex workers who do not have HIV, prevention options like pre-exposure prophylaxis (PrEP) may be beneficial. However, PrEP availability is extremely limited, and recent UNAIDS modeling suggests that typical coverage will not be sufficient to slow new infections among sex workers at its current rate.
HIV counseling and testing
It is important for sex workers to get tested for HIV regularly and know their status. Knowing one’s status helps determine the best prevention or care options. The World Health Organization (WHO) recommends at least annual HIV testing for sex workers. Find an HIV testing site near you.
Law enforcement practices, human rights, and legal education
Sex worker-led, community-based services that address legal and social barriers can have a real and lasting impact on the lives of sex workers, including reducing their vulnerability to HIV.
Addressing stigma and discrimination
The Global Network of Sex Work Projects (NSWP) unites more than 160 sex-worker-led organizations from across 60 countries in Africa, Asia and the Pacific, Europe, Latin America, North America, and the Caribbean. It amplifies the voices of these organizations in order to advocate for rights-based services, freedom from abuse and discrimination, freedom from punitive laws, policies and practices, and self-determination for sex workers.
ANTIRETROVIRAL THERAPY (ART) AMONG TRANSGENDER PEOPLE
UNAIDS recommends that antiretroviral therapy (ART) coverage must reach approximately 80% of sex workers, accompanied by increased condom use, in order to have a significant impact upon the global HIV epidemic. However, in many countries sex workers’ access to ART continues to be lower than for the general population.
Uptake of ART among sex workers is hampered by punitive legal environments, the double stigma of HIV and sex work, and fear that a diagnosis of HIV may be disclosed to others without consent.
There is a lack of studies on sex workers, although some studies have been done in settings such as prisons and dance clubs. However, the illegal and often criminalized nature of sex work makes it difficult to gather data on HIV treatment among this population. This lack of data creates significant barriers to developing targeted HIV programs.
THE BOTTOM LINE
Globally, sex workers are 13 times more likely to become infected with HIV than the general population. With early testing and treatment, sex workers with HIV can live longer, healthier lives.
Factors that make sex workers vulnerable to HIV transmission include stigma, discrimination, poverty, alcohol and drug use, criminalization of their livelihood, and lack of access to testing, prevention, and treatment. Aspects of high-risk sex, such as multiple partners and inconsistent condom use, contribute to HIV vulnerability among sex workers.
Sex workers should get tested for HIV at least once a year, and in some cases more frequently. This is especially true for sex workers who inject drugs. If they test positive for HIV, they can take steps to reduce the risk of infecting their partners and clients and ensure their own health.
The best way to prevent infection is by using condoms, taking PrEP if HIV-negative, and taking strong ART if HIV-positive. Sex workers who use intravenous drugs should not share injection equipment and supplies.
MORE INFORMATION
CDC: HIV Risk Among Persons Who Exchange Sex for Money or Nonmonetary Items
Avert: Sex Workers, HIV And AIDS
WHO: Sex Workers
Reviewed July 2024
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