Preventing sexually transmitted and blood borne infections (STBBIs) among sex workers: a critical review of the evidence on determinants and interventions in high-income countries

Abstract

Background Across diverse regions globally, sex workers continue to face a disproportionate burden of HIV and other sexually transmitted and blood borne infections (STBBIs). Evidence suggests that behavioural and biomedical interventions are only moderately successful in reducing STBBIs at the population level, leading to calls for increased structural and community-led interventions. Given that structural approaches to mitigating STBBI risk beyond HIV among sex workers in high-income settings remain poorly understood, this critical review aimed to provide a comprehensive synthesis of the global research and literature on determinants of HIV and other STBBIs and promising intervention practices for sex workers of all genders in high-income countries. Methods We searched for publications over the last decade (January 2005–March 2016) among sex workers (cis women, cis men, and trans individuals). Data obtained from quantitative peer-reviewed studies were triangulated with publicly available reports and qualitative/ethnographic research where quantitative evidence was limited. Results Research demonstrates consistent evidence of the direct and indirect impacts of structural factors (e.g., violence, stigma, criminalization, poor working conditions) on increasing risk for STBBIs among sex workers, further compounded by individual and interpersonal factors (e.g., mental health, substance use, unprotected sex). Sub-optimal access to health and STBBI prevention services remains concerning. Full decriminalization of sex work has been shown to have the largest potential to avert new infections in sex work, through reducing workplace violence and increasing access to safer workspaces. Promising practices and strategies that should be scaled-up and evaluated to prevent STBBIs are highlighted. Conclusions The high burden of STBBIs among sex workers across high-income settings is of major concern. This review uniquely contributes to our understanding of multilevel factors that potentiate and mitigate STBBI risk for sex workers of all genders. Research suggests that multipronged structural and community-led approaches are paramount to addressing STBBI burden, and are necessary to realizing health and human rights for sex workers. Given the heterogeneity of sex worker populations, and distinct vulnerabilities faced by cis men and trans sex workers, further research utilizing mixed-methods should be implemented to delineate the intersections of risk and ameliorate critical health inequalities.

Global Burden of Violence and Other Human Rights Violations Against Sex Workers

“…Violence from the state, clients, individuals posing as clients, or intimate partners-together with unlawful arrest, detention, and discrimination-have severe effects on the HIV/STI-related inequities faced by sex workers. Punitive approaches to sex work hinder HIV prevention [84,85], criminalisation, incarceration, and legal restrictions on sex work constrain sex workers' agency and access to safe working conditions. They also elevate HIV/STI exposure through increased violence [29,76,83].…”

The Effects of Trauma, Violence, and Stress on Sexual Health Outcomes Among Female Clinic Clients in a Small Northeastern U.S. Urban Center

“…5 Threats to sexual health can involve individual behaviors, interpersonal and ecological factors that heighten one's exposure to acquiring or transmitting an STI, or a context that compromises volitional control over one's sexuality, sexual behavior, and sexual safety. [5][6][7] The current study is a secondary data analysis that investigates threats to sexual health among women recruited from health clinic in a small US northeastern urban center. Although previous research has recognized the importance of ecological frameworks to understand the complexity of health and health behaviors in marginalized communities, there continues to be a dearth of research that truly utilizes this perspective to gain insight into the multifaceted factors that can concurrently influence threats to sexual health among women.…”

“…These three outcomes have been associated with one another, recurrent HIV/STI transmission, other nonsex-based adverse health outcomes, and contextual behaviors that have implications for one's sexual health and autonomy. 6 A history of STIs among women is not only indicative of unprotected sex acts, 7 but in some contexts has also been associated with early childhood sexual trauma, IPV as an adult, and community/society-level detriments. [8][9][10][11] One systematic review found relationships between increased vulnerability to HIV/STI acquisition via decreased condom and oral contraceptive use and women experiencing IPV.…”

Exploring associations between place of sex work and HIV vulnerabilities among sex workers in Jamaica

“…12 Safer work environments in urban Canada, such as working indoors in managed and supported settings, have been associated with reduced violence, less exposure to criminalization, and lower HIV and STI risks. 11 , 13 Conducting sex work in public spaces can be isolating with limited violence protection and reduced access to health and social services, 13 and has been associated with lower enforcement of client condom use. 11 , 13…”

“…11 , 13 Conducting sex work in public spaces can be isolating with limited violence protection and reduced access to health and social services, 13 and has been associated with lower enforcement of client condom use. 11 , 13…”