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

Abstract

SUMMARY 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.

Fatores associados à violência contra mulheres profissionais do sexo de dez cidades brasileiras

“…The structural components of this profile, rooted in gender and class inequalities, reflect fundamental human rights violations and thus the high vulnerability of these women to violence, margin- alizing them and limiting their opportunities and the capacity to reduce the risks from their sexual activity, including HIV infection. A growing number of studies have demonstrated the convergence of structural factors and indirect risks 5,12,13 . A study on prevalence of gender violence against streetwalking female sex workers in Vancouver, Canada, found that 57% had suffered violence, correlated directly with macro-structural factors: lack of housing, criminalization of sex work, and difficult access to drug addiction treatment.…”

Sexual transactions between long distance truck drivers and female sex workers in South Africa

“…[5,9,14–16] Therefore, it is no wonder that FSWs are 13.5 times more likely to be living with HIV than other women, and are designated as a key population in relation to the HIV epidemic. [1,5,17–20] Yet, the industry of sex work continues to thrive despite the high prevalence of HIV among FSWs, with the continued risk of transmission to their clients who include other vulnerable groups, such as LDTDs. [2,12]…”

Criminalizing Sex Work Clients and Rushed Negotiations among Sex Workers Who Use Drugs in a Canadian Setting

“…Violence or the threat of violence by clients has been shown to reduce sex worker harm reduction practices such as safely negotiating male condom use, thereby increasing risk for HIV infection [11,[35][36][37][38][39]. Additionally, client-perpetrated violence has been highly associated with inability to access substance use treatment [7].…”