Global epidemiology of HIV among female sex workers: influence of structural determinants

Shannon K, Strathdee SA, Goldenberg SM, Duff P, Mwangi P, Rusakova M, Reza-Paul S, Lau J, Deering K, Pickles MR, Boily MC.

Global epidemiology of HIV among female sex workers: influence of structural determinants.

Lancet. 2015 Jan 3;385(9962):55-71. doi: 10.1016/S0140-6736(14)60931-4. Epub 2014 Jul 22. PMID: 25059947; PMCID: PMC4297548.

Abstract:

Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1-31) and 20% in Canada (95% UI 3-39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per μL could avert 34% (95% UI 25-42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8-36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33-46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.

Public Health Crisis: The Impact of Using Condoms as Evidence in New York City

Public Health Crisis: The Impact of Using Condoms as Evidence in New York City

PROS Network/Sex Workers Project. April 2012

From the Conclusion:

While the sample size for this study was small, the results demonstrated that people in the sex trade in all five boroughs have experienced, observed, or heard of the confiscation of condoms and the use of condoms as evidence, and that this has affected the number of condoms they carry and the frequency with which they carry them, as well as in some instances, their condom use. These findings are corroborated by the DOHMH Study, which found an even higher rate of confiscation of condoms by police.

While many survey participants expressed confusion about the number of condoms that they are legally allowed to carry, the results of this study revealed that people can be harassed or arrested for possessing even one condom. Despite the fact that most prostitution cases do not go to trial, condoms are frequently vouchered and cited in criminal court complaints and supporting depositions as arrest evidence in prostitution‐related cases.

These policies and practices may have a dangerous impact on safer sex practices in general. Of the participants in the survey who are involved in the sex trade, 45.7% reported that they have not carried condoms out of fear that it may get them in trouble with the police or lead to their arrest. For all too many people in the sex trade, the importance of safe sex is outweighed by the importance of avoiding police harassment, humiliation, sexual and physical abuse, and arrest, as well as the potential indirect consequences of arrest (including vulnerability to HIV transmission and/or violence while in detention).

Sex Workers at Risk: The Use of Condoms as Evidence in Four US Cities

Sex Workers at Risk: The Use of Condoms as Evidence in Four US Cities

Human Rights Watch. (July, 2012) [public health, HIV, United States]

From the Summary:

Human Rights Watch interviewed more than 300 persons for this report, which focuses on police use of condoms as evidence to enforce prostitution and sex trafficking laws, as part of an investigation into barriers to effective HIV prevention for sex workers in the four cities covered by this report. Those interviewed included nearly 200 sex workers and former sex workers as well as outreach workers, advocates, lawyers, police officers, district attorneys, and public health officials. In New York, Washington, DC, and Los Angeles our investigation focused on complaints of police using condoms as evidence while targeting sex workers on the street. In San Francisco, condoms were used as evidence for street enforcement to some extent, with police photographing rather than confiscating condoms, in what appeared to be a dubious nod to public health concerns. In San Francisco, much of the anti-prostitution enforcement using condoms as evidence targeted women working in businesses such as erotic dance clubs, massage businesses, and a nightclub with transgender clientele.

Police use of condoms as evidence of prostitution has the same effect everywhere: despite millions of dollars spent on promoting and distributing condoms as an effective method of HIV prevention, groups most at risk of infection—sex workers, transgender women, and lesbian, gay, bisexual, and transgender (LGBT) youth—are afraid to carry them and therefore engage in sex without protection as a result of police harassment. Outreach workers and businesses are unable to distribute condoms freely and without fear of harassment as well.

Associations Between Sex Work Laws and Sex Workers’ Health: A Systematic Review and Meta-Analysis of Quantitative and Qualitative Studies

Platt L, Grenfell P, Meiksin R, Elmes J, Sherman SG, Sanders T, et al. (2018) 

Associations Between Sex Work Laws and Sex Workers’ Health: A Systematic Review and Meta-Analysis of Quantitative and Qualitative Studies

PLoS Med 15(12): e1002680. [Global, international, criminalization, stigma] https://doi.org/10.1371/journal.pmed.1002680.

Abstract

Background. Sex 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 findings. We 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.

Conclusions. Together, 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.

Negotiating safety and sexual risk reduction with clients in unsanctioned safer indoor sex work environments: a qualitative study

Authors: Krüsi, Andrea, Jill Chettiar, Amelia Ridgway, Janice Abbott, Steffanie A. Strathdee, and Kate Shannon.

Negotiating Safety and Sexual Risk Reduction with Clients in Unsanctioned Safer Indoor Sex Work Environments: A Qualitative Study.

American Journal of Public Health 102 (6): 1154–59.

Abstract:

Objectives: We examined how unique, low-barrier, supportive housing programs for women who are functioning as unsanctioned indoor sex work environments in a Canadian urban setting influence risk negotiation with clients in sex work transactions.

Methods: We conducted 39 semistructured qualitative interviews and 6 focus groups with women who live in low-barrier, supportive housing for marginalized sex workers with substance use issues. All interviews were transcribed verbatim and thematically analyzed.

Results: Women’s accounts indicated that unsanctioned indoor sex work environments promoted increased control over negotiating sex work transactions, including the capacity to refuse unwanted services, negotiate condom use, and avoid violent perpetrators. Despite the lack of formal legal and policy support for indoor sex work venues in Canada, the environmental-structural supports afforded by these unsanctioned indoor sex work environments, including surveillance cameras and support from staff or police in removing violent clients, were linked to improved police relationships and facilitated the institution of informal peer-safety mechanisms.

Conclusions: This study has drawn attention to the potential role of safer indoor sex work environments as venues for public health and violence prevention interventions and has indicated the critical importance of removing the sociolegal barriers preventing the formal implementation of such programs.

HIV Criminalization Beyond Non-Disclosure: Advocacy Toolkits on Intersections with Sex Work and Syringe Use

HIV Criminalization Beyond Non-Disclosure: Advocacy Toolkits on Intersections with Sex Work and Syringe Use

The Center for HIV Law and Policy and National LGBTQ Task Force (2017)

Description:

The Center for HIV Law and Policy (CHLP) and the National LGBTQ Task Force are pleased to announce the release of an exciting new resource that can help foster more intersectional advocacy for HIV criminal law reform. HIV Criminalization Beyond Non-Disclosure: Advocacy Toolkits on Intersections with Sex Work and Syringe Use is the sum of two toolkits designed for advocates who care about ending the disproportionate criminalization of people living with HIV.

The toolkits highlight the intersections between advocacy for HIV criminal law reform, decriminalization of sex work, and safe syringe access. These different advocacy communities share many common goals and constituencies, yet do not generally work in close collaboration or collectively strategize. The toolkits underscore the ways in which certain HIV criminal laws specifically target sex workers and people who inject substances, but also how these laws and those that prohibit sex work and drug use represent the systemic criminalization of safety and survival of Black and Brown bodies and of sexual and gender minorities. 

Police-Related Correlates of Client-Perpetrated Violence Among Female Sex Workers in Baltimore City, Maryland

Police-Related Correlates of Client-Perpetrated Violence Among Female Sex Workers in Baltimore City, Maryland

Authors: Footer KHA, Park JN, Allen ST, Decker MR, Silberzahn BE, Huettner S, Galai N, Sherman SG.

Police-Related Correlates of Client-Perpetrated Violence Among Female Sex Workers in Baltimore City, Maryland.

Am J Public Health. 2019 Feb;109(2):289-295. doi: 10.2105/AJPH.2018.304809. Epub 2018 Dec 20. PMID: 30571295; PMCID: PMC6336048.

Abstract:

Objectives. To characterize interactions that female sex workers (FSWs) have with the police and explore associations with client-perpetrated violence.

Methods. Baseline data were collected April 2016 to January 2017 from 250 FSWs from the Sex Workers and Police Promoting Health in Risky Environments (SAPPHIRE) study based in Baltimore, Maryland. Interviewer-administered questionnaires captured different patrol or enforcement and abusive police encounters, experiences of client-perpetrated violence, and other risk factors, including drug use. We conducted bivariate and multivariable analysis in Stata/SE version 14.2 (StataCorp LP, College Station, TX).

Results. Of participants, 78% reported lifetime abusive police encounters, 41% reported daily or weekly encounters of any type. In the previous 3 months, 22% experienced client-perpetrated violence. Heroin users (70% of participants) reported more abusive encounters (2.5 vs 1.6; P < .001) and more client-perpetrated violence (26% vs 12%; P = .02) than others. In multivariable analysis, each additional type of abusive interaction was associated with 1.3 times (95% confidence interval [CI] = 1.1, 1.5) increased odds of client-perpetrated violence. For patrol or enforcement encounters, this value was 1.3 (95% CI = 1.0, 1.7).

Conclusions. Frequent exposures to abusive police practices appear to contribute to an environment where client-perpetrated violence is regularly experienced. For FSWs who inject drugs, police exposure and client-perpetrated violence appear amplified.

A systematic review of the correlates of violence against sex workers

A Systematic Review of the Correlates of Violence Against Sex Workers

Authors: Kathleen N. Deering, PhD, Avni Amin, PhD, Jean Shoveller, PhD, Ariel Nesbitt, MPH, Claudia Garcia-Moreno, MD, MSc, Putu Duff, MSc, Elena Argento, MPH, and Kate Shannon, PhD

A Systematic Review of the Correlates of Violence Against Sex Workers

American Journal of Public Health vol. 104,5 (2014): e42-54. doi:10.2105/AJPH.2014.301909

Abstract:

We conducted a systematic review in June 2012 (updated September 2013) to examine the prevalence and factors shaping sexual or physical violence against sex workers globally.

We identified 1536 (update = 340) unique articles. We included 28 studies, with 14 more contributing to violence prevalence estimates. Lifetime prevalence of any or combined workplace violence ranged from 45% to 75% and over the past year, 32% to 55%. Growing research links contextual factors with violence against sex workers, alongside known interpersonal and individual risks.

This high burden of violence against sex workers globally and large gaps in epidemiological data support the need for research and structural interventions to better document and respond to the contextual factors shaping this violence. Measurement and methodological innovation, in partnership with sex work communities, are critical.