HIV Programs for Sex Workers: Lessons and Challenges for Developing and Delivering Programs.

David Wilson

doi:10.1371/journal.pmed.1001808

Abstract

There is evidence that HIV prevention programs for sex workers, especially female sex workers, are cost-effective in several contexts, including many western countries, Thailand, India, the Democratic Republic of Congo, Kenya, and Zimbabwe. The evidence that sex worker HIV prevention programs work must not inspire complacency but rather a renewed effort to expand, intensify, and maximize their impact. The PLOS Collection “Focus on Delivery and Scale: Achieving HIV Impact with Sex Workers” highlights major challenges to scaling-up sex worker HIV prevention programs, noting the following: sex worker HIV prevention programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; sex worker HIV and sexually transmitted infection services receive limited domestic financing in many countries; many sex worker HIV prevention programs are inadequately codified to ensure consistency and quality; and many sex worker HIV prevention programs have not evolved adequately to address informal sex workers, male and transgender sex workers, and mobile- and internet-based sex workers. Based on the wider collection of papers, this article presents three major clusters of recommendations: (i) HIV programs focused on sex workers should be prioritized, developed, and implemented based on robust evidence; (ii) national political will and increased funding are needed to increase coverage of effective sex worker HIV prevention programs in low and middle income countries; and (iii) comprehensive, integrated, and rapidly evolving HIV programs are needed to ensure equitable access to health services for individuals involved in all forms of sex work.

Highlights

Many sex worker HIV prevention programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; receive limited domestic financing in many countries; are inadequately codified to ensure consistency and quality; and have not evolved adequately to address informal sex workers, male and transgender sex workers, and mobile and internet-based sex workers
In 2012, the Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that over 90% of all sex worker HIV prevention programs in low and middle income countries relied on international funding [61]
The HIV response must develop and evaluate intervention models for informal sex work. It must develop and evaluate better “hotspot” models to address a gradation of formal and informal sex work and transactional sex. This is urgently needed for several reasons: (i) as HIV epidemics mature and clients perceive formal sex workers and formal sex work venues as “higher risk,” formal networks may disperse and fragment and become harder to define and reach, a process intensified by the increasing role of mobile phones and internet in sexual solicitation [66,67]

Summary

Summary Points

HIV prevention programs for sex workers, especially female sex workers, are costeffective. There are opportunities to further increase the impact of HIV prevention programs for sex workers and to adapt interventions to a changing context. Many sex worker HIV prevention programs are insufficiently guided by understanding of epidemic transmission dynamics, situation analyses, and programmatic mapping; receive limited domestic financing in many countries; are inadequately codified to ensure consistency and quality; and have not evolved adequately to address informal sex workers, male and transgender sex workers, and mobile and internet-based sex workers. We recommend increasing our understanding of HIV epidemic transmission dynamics, improving situation analyses and programmatic mapping, increasing domestic financing for sex worker HIV prevention programs where feasible, delivering well-codified, comprehensive programs using “Science of Delivery” principles and developing more effective models to reach informal sex workers, male and transgender sex workers, and mobile and internet-based sex workers. Given their marginalization, concerted efforts must be made to ensure sex workers have equitable access to HIV prevention, care, and treatment services, as well as wider health services, for STIs, mental health, and addictions

Introduction

Conclusion

Findings

58. Sex Worker Health and Rights