Global epidemiology of HIV among female sex workers: influence of structural determinants, Kate Shannon et al, Lancet (2014)

Throughout the world, female sex workers are disproportionally affected by HIV. In what may be a surprise finding, researchers conclude that elimination of laws that make sex work illegal (decriminalization) would reduce HIV transmission among sex workers and their clients by the greatest amount. Specifically, a reduction of 33-46% of new HIV transmission in the next ten years would occur. The effect of decriminalizing sex work would be to reduce police harassment and violence, and increase access to safer work places. It would have more impact than other measures, such as improving the availability of HIV medication (antiretroviral therapy), although those are also important.

These conclusions resulted from a broad review of published studies on HIV rates, condom usage, and other factors among female sex workers.  The review found several drawbacks in the research on this issue, including too little emphasis on the importance of changing laws, policies or physical environments (structural interventions) and a large number of studies from Asia, rather than other areas of the world with high rates of HIV, such as parts of Africa, Russia and Eastern Europe. The findings highlight the complex interplay between different policy, social, economic, and physical aspects of the work environment for people engaged in the sex trade. To be effective, methods to reduce HIV among sex workers must be multi-pronged and community-led. 

As a structural intervention, decriminalization of sex work would have the greatest effect on reducing HIV transmission among sex workers and their clients, including relative to other critical measures such the elimination of sexual violence or scaled up access to antiretroviral therapy (ART).

Researchers conducted a systematic review of published studies on HIV prevalence and incidence, condom use, and other structural determinants of health among female sex workers. The review highlighted several limitations in research on this issue, including too little emphasis on the importance of structural interventions and a disproportionate number of studies from Asia, rather than other areas of the world with a high burden of HIV, such as sub-Saharan Africa.

To determine the effect of different structural interventions to reduce HIV transmission among sex workers, the researchers created a model to simulate the HIV transmission that would be prevented by different kinds of interventions across different epidemic settings (e.g., concentrated epidemic versus generalized epidemic, resource-poor versus higher income countries).

The researchers’ model assessed multiple interventions, such as the elimination of sexual violence and resulting impact on inconsistent condom use, scaling up access to ART, increased sex worker-led outreach, and decriminalization of sex work.  Decriminalization of sex work had the most significant impact across all settings, averting 33-46% of new HIV infections among sex workers and their clients over the next decade.  The powerful predicted effect is due to the effects decriminalization would have on violence, police harassment, and safer work environments. The findings highlight the complex interplay between different policy, social, economic, and physical aspects of the work environment for people engaged in the sex trade. Effective interventions to address HIV among sex workers should be multi-pronged and community-led.