Sex work or transactional sex? Shifting the dialogue from risk to rights

Crankshaw, Tamaryn L.; Freedman, Jane

doi:10.1080/26410397.2023.2210859

Cited by 10 publications

(3 citation statements)

References 38 publications

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“…Previous literature has often conflated commercial and transactional sex (5). The more recent debate focuses on the similarities in their structural drivers (33,34) and questions the usefulness of having distinct categories (35). However, this study quantitatively highlights the differential risks taken by women engaging in commercial and transactional sex, meaning HIV prevention needs to be aware of the nuanced differences.…”

Section: Discussionmentioning

confidence: 99%

Protecting women from economic shocks to prevent HIV in Africa: Evidence from the POWER randomised controlled trial in Cameroon

Lépine,

Szawlowski,

Nitcheu

et al. 2024

Preprint

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Background: Women in Sub-Saharan Africa are disproportionately affected by the HIV epidemic. Young women are twice as likely to be living with HIV than men of the same age and account for 64% of new HIV infections among young people. Many studies suggest that financial needs, alongside biological susceptibility, are the main causes of the gender disparity in HIV acquisition. While the literature shows a limited understanding of the link between poverty and HIV, there is some new robust evidence demonstrating that women adopt risky sexual behaviours as a way to cope with economic shocks. Methods: We recruited 1,506 adolescent girls and women engaging in transactional or in commercial sex in Yaounde, Cameroon, using snowball sampling. Half of the study participants were randomly allocated to receive a free health insurance product covering themselves and their economic dependents over 12 months. We collected data on socio-economics, health and sexual behaviours and sexually transmitted infection and HIV biomarkers at baseline, 6-month post randomisation (midline) and 12-month post randomisation (endline). Results: We found that study participants engaging in transactional sex allocated to the treatment group were less likely to be infected with HIV (OR=0.109, p-value<0.05). We showed that the intervention allowed women to leave transactional sex. In addition, we found that for the participants remaining in transactional sex, the intervention increased condom use and reduced sex acts, these results were however only statistically significant at 10% given our sample size. There was no evidence of a change in risky sexual behaviours or in a reduction of HIV incidence among female sex workers. Conclusion: The study provides the first evidence of the effectiveness of a formal shock-coping strategy to prevent HIV among women in Africa. We showed that the intervention effectiveness operates through the reduction in health shocks since the increase in healthcare use following the intervention was low. We estimated that in our trial, the cost for each HIV infection averted is £4,667 among the cohort of women engaging in transactional sex. Policymakers should consider formal shock-coping strategies to prevent HIV among women in Africa.

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Section: Discussionmentioning

confidence: 99%

Protecting women from economic shocks to prevent HIV in Africa: Evidence from the POWER randomised controlled trial in Cameroon

Lépine,

Szawlowski,

Nitcheu

et al. 2024

Preprint

View full text Add to dashboard Cite

show abstract

“…They may also feel ostracized by older sex workers, thus limiting the extent to which they engage in FSW HIV prevention and treatment efforts such as drop-in centers which are not typically designed to serve youth. Thus, there is an urgent need to engage this population in both research and program design efforts, and to grow the evidence base of effective interventions for young women who participate in sexual-economic exchanges ( 67 ).…”

Section: Discussionmentioning

confidence: 99%

Transactional sex and age-disparate sexual partnerships among adolescent girls and young women in Tanzania

Rucinski,

Mbita,

Atkins

et al. 2024

Front. Reprod. Health

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IntroductionAdolescent girls and young women (AGYW) continue to experience a high incidence of HIV in southern and eastern Africa, even in the context of large-scale HIV prevention interventions. In Tanzania, AGYW account for the largest proportion of new infections and have a higher risk of HIV acquisition than males of comparable age.MethodsWe used routinely collected data from the PEPFAR/USAID-funded Sauti Project, a large combination HIV prevention program, to examine the relationship between transactional sex and sex with older partners among AGYW in Tanzania (2015–2020). Out-of-school AGYW 15–24 years completed a vulnerability index and were tested for HIV. We estimated weighted prevalence ratios (PR) and 95% confidence intervals (CI) for the associations of transactional sex (sex exchanged for money/services/gifts outside of sex work) and sex with older partners (≥5-years older, ≥10-years older) with prevalent HIV. Age cutoffs of 5 and 10 years were used to align partner age differences with age-disparate and intergenerational sex, respectively. We assessed potential synergism between exposures, and subgroup analyses explored associations among girls 15–19.ResultsSixty seven thousand three hundred fifty seven AGYW completed the vulnerability index and 14,873 had captured HIV testing records. Median age was 20 years (IQR 18–22). Transactional sex and age-disparate sex were common (35% and 28%, respectively); 13% of AGYW reported both behaviors. HIV prevalence was associated with both transactional sex (PR: 1.28; 95% CI 1.00–1.63) and age-disparate sex (PR:1.26, 95% CI 0.99–1.60). In common referent analysis, transactional sex remained strongly associated with HIV, even in the absence of age-disparate sex (PR 1.41; 95% CI 1.02–1.94).DiscussionEvidence of statistical synergism was not present, suggesting both transactional sex and age-disparate sex operate through similar pathways to increase HIV risk. Increased specificity within HIV prevention programs is needed to better meet the sexual and reproductive health needs of AGYW at high risk of HIV in Tanzania, including investment in tailored youth-friendly strategies for AGYW who have been marginalized from the current HIV response.

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“…We previously reported that many AGYW who engage in formal SW, TS, and nontransactional sex (NTS) in Kenya experience a range of shared vulnerabilities including early age at first sex, intergenerational sex, and gender-based violence. 25 In many instances, the boundaries between TS and formal commercial sex are not distinct 18,26–31 ; for example, individuals who self-identify as sex workers may also engage in TS and can have nontransactional sexual partnerships.…”

Section: Introductionmentioning

confidence: 99%

Differential burden of HIV among adolescent girls and young women by places associated with sex work: an observational study in Mombasa, Kenya

BECKER,

MISHRA,

BHATTACHARJEE

et al. 2024

JAIDS Journal of Acquired Immune Deficiency Syndromes

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Background: The design of HIV prevention programs for adolescent girls and young women (AGYW) are informed by data on who is at highest risk, and where they can be reached. Places (hotspots) associated with selling sex are an established outreach strategy for sex work programs, but could be used to reach other AGYW at high risk. Setting: This study took place in Mombasa, Kenya. Methods: We conducted a cross-sectional, bio-behavioural survey among (N=1,193) sexually active AGYW aged 14-24 years recruited at hotspots. We compared HIV prevalence by sub-group (sex work, SW; transactional sex, TS; and non-transactional sex, NTS), stratified by hotspot type (venues and non-venues). We examined whether associations between HIV prevalence and hotspot/subgroup remained after adjustment for individual-level risk factors, and estimated HIV prevalence ratio (PR) with and without adjustment for these individual-level factors. Results: Overall HIV prevalence was 5.6%, 5.3% in venues and 7.3% in non-venues. Overall SW HIV prevalence was two-fold higher than among participants engaged in NTS. After adjusting for age and individual-level risk factors, HIV prevalence was 2.72 times higher among venue-based SWs (95% CI: 1.56-4.85) and 2.11 times higher among non-venue AGYW not engaged in SW (95% CI: 0.97-4.30) compared to venue-based AGYW not engaged in SW. Conclusion: AGYW who sell sex remain at high risk of HIV across types of hotspots. The residual pattern of elevated HIV burden by AGWY subgroup and hotspot type suggests that unmeasured, network-level factors underscore differential risks. As such, hotspots constitute a “place” to reach AGYW at high risk of HIV.

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Sex work or transactional sex? Shifting the dialogue from risk to rights

Cited by 10 publications

References 38 publications

Protecting women from economic shocks to prevent HIV in Africa: Evidence from the POWER randomised controlled trial in Cameroon

Protecting women from economic shocks to prevent HIV in Africa: Evidence from the POWER randomised controlled trial in Cameroon

Transactional sex and age-disparate sexual partnerships among adolescent girls and young women in Tanzania

Differential burden of HIV among adolescent girls and young women by places associated with sex work: an observational study in Mombasa, Kenya

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