‘It has a lot of pressure’: the impossible everyday labours of sex worker community paralegal volunteers in Nairobi

Sex workers must not be forgotten in the COVID-19 response

Chapter 1: General Introduction This chapter introduces the HIV/AIDS epidemic in Tanzania, focusing on vulnerable populations such as female sex workers, men who have sex with men, and people who inject drugs. It highlights socio-economic challenges and gaps in the healthcare system that hinder HIV prevention and treatment. The study emphasizes the importance of targeted interventions tailored to the needs of these groups to meet UNAIDS 2030 goals. The chapter lays the foundation for integrating evidence-based strategies into national and global HIV efforts in Tanzania. Chapter 2: Predictors of HIV among High-Risk Male Populations in Tanzania This chapter explores factors linked to HIV seropositivity among high-risk male populations, including men who have sex with men and female sex workers. It identifies key risk factors such as lack of circumcision, sexually transmitted infections, and harmful alcohol use. These insights are vital for developing targeted interventions to reduce HIV transmission in these groups, which is critical for controlling the epidemic in Tanzania. Chapter 3: HIV Seroconversion Among Female Sex Workers This chapter examines high rates of HIV seroconversion among female sex workers, with contributing factors like inconsistent condom use and exposure to violence. The findings stress the need for comprehensive, tailored interventions that address individual behaviors and structural challenges. By improving healthcare access and reducing stigma, these interventions can significantly lower HIV transmission rates among female sex workers, contributing to broader efforts to control HIV in Tanzania. Chapter 4: Effect of Antiretroviral Therapy on Fertility Rate among Women Living with HIV This chapter investigates how antiretroviral therapy (ART) affects fertility rates among women living with HIV in Tanzania, revealing that ART use influences reproductive behavior. The study emphasizes integrating reproductive health services with HIV care to meet the comprehensive needs of women on ART. This integration is critical for improving maternal and child health outcomes and preventing mother-to-child transmission of HIV, offering valuable insights for public health policy. Chapter 5: Consistent Condom Use and Dual Protection among Female Sex Workers This chapter explores the factors influencing consistent condom use and dual protection among female sex workers. Barriers such as economic dependency and fear of violence are highlighted. The study stresses the importance of empowering female sex workers through community-based HIV prevention programs that address both sexual health and socio-economic challenges. Promoting safer sexual practices and socio-economic support is essential for reducing HIV transmission and preventing unintended pregnancies, contributing to improved public health in Tanzania. Chapter 6: Men's Comfort in Distributing or Receiving HIV Self-Test Kits This chapter investigates men's attitudes toward HIV self-testing, with a focus on challenges like stigma and privacy concerns. The study underscores the potential of HIV self-testing to increase access to testing services, especially for men who are less engaged with traditional health services. By addressing these barriers, self-testing can lead to earlier diagnosis and treatment, ultimately reducing HIV transmission. This chapter offers crucial guidance for expanding HIV testing initiatives and reaching underserved male populations. Chapter 7: General Discussion and Conclusion The final chapter synthesizes the key findings and examines their broader implications for HIV prevention and care in Tanzania. It highlights the need for targeted, evidence-based interventions focused on key populations as a critical component in controlling the HIV epidemic. The chapter provides actionable recommendations for policymakers and healthcare providers, advocating for integrated, multi-dimensional approaches to tackle the complex challenges of HIV/AIDS. These strategies are essential for achieving the goal of ending the epidemic by 2030, with collaboration between stakeholders being key to success.

views and personal experiences of people who have especially contributed to the evolution of ideas in the Journal's field of interest.

In low-income and middle-income countries, such as those in sub-Saharan Africa and Latin America, the COVID-19 pandemic has had substantial implications for women's wellbeing. Policy responses to the COVID-19 pandemic have highlighted the gendered aspect of pandemics; however, addressing the gendered implications of the COVID-19 pandemic comprehensively and effectively requires a planetary health perspective that embraces systems thinking to inequalities. This Viewpoint is based on collective reflections from research done by the authors on COVID-19 responses by international and regional organisations, and national governments, in Latin America and sub-Saharan Africa between June, 2020, and June, 2021. A range of international and regional actors have made important policy recommendations to address the gendered implications of the COVID-19 pandemic on women's health and wellbeing since the start of the pandemic. However, national-level policy responses to the COVID-19 pandemic have been partial and inconsistent with regards to gender in both sub-Saharan Africa and Latin America, largely failing to recognise the multiple drivers of gendered health inequalities. This Viewpoint proposes that addressing the effects of the COVID-19 pandemic on women in low-income and middle-income countries should adopt a systems thinking approach and be informed by the question of who is affected as opposed to who is infected. In adopting the systems thinking approach, responses will be more able to recognise and address the direct gendered effects of the pandemic and those that emerge indirectly through a combination of long-standing structural inequalities and gendered responses to the pandemic.

ABSTRACTThe barrier HIV-stigma presents to the HIV treatment cascade is increasingly documented; however less is known about female and male sex worker engagement in and the influence of sex-work stigma on the HIV care continuum. While stigma occurs in all spheres of life, stigma within health services may be particularly detrimental to health seeking behaviors. Therefore, we present levels of sex-work stigma from healthcare workers (HCW) among male and female sex workers in Kenya, and explore the relationship between sex-work stigma and HIV counseling and testing. We also examine the relationship between sex-work stigma and utilization of non-HIV health services. A snowball sample of 497 female sex workers (FSW) and 232 male sex workers (MSW) across four sites was recruited through a modified respondent-driven sampling process. About 50% of both male and female sex workers reported anticipating verbal stigma from HCW while 72% of FSW and 54% of MSW reported experiencing at least one of seven measured forms of stigma from HCW. In general, stigma led to higher odds of reporting delay or avoidance of counseling and testing, as well as non-HIV specific services. Statistical significance of relationships varied across type of health service, type of stigma and gender. For example, anticipated stigma was not a significant predictor of delay or avoidance of health services for MSW; however, FSW who anticipated HCW stigma had significantly higher odds of avoiding (OR = 2.11) non-HIV services, compared to FSW who did not. This paper adds to the growing evidence of stigma as a roadblock in the HIV treatment cascade, as well as its undermining of the human right to health. While more attention is being paid to addressing HIV-stigma, it is equally important to address the key population stigma that often intersects with HIV-stigma.

An ethical and forward-looking health sector response to sex work aims to create a safe, effective, and non-judgemental space that attracts sex workers to its services. Yet, the clinical setting is often the site of human rights violations and many sex workers experience ill-treatment and abuse by healthcare providers. Research with male, female, and transgender sex workers in various African countries has documented a range of problems with healthcare provision in these settings, including: poor treatment, stigmatisation, and discrimination by healthcare workers; having to pay bribes to obtain services or treatment; being humiliated by healthcare workers; and, the breaching of confidentiality. These experiences are echoed by sex workers globally. Sex workers’ negative experiences with healthcare services result in illness and death and within the context of the AIDS epidemic act as a powerful barrier to effective HIV and STI prevention, care, and support. Conversely positive interactions with healthcare providers and health services empower sex workers, affirm sex worker dignity and agency, and support improved health outcomes and well-being. This chapter aims to explore the experiences of sex workers with healthcare systems in Africa as documented in the literature. Findings describe how negative healthcare workers’ attitudes and sexual moralism have compounded the stigma that sex workers face within communities and have led to poor health outcomes, particularly in relation to HIV and sexual and reproductive health. Key recommendations for policy and practice include implementation of comprehensive, rights-affirming health programmes designed in partnership with sex workers. These should be in tandem with structural interventions that shift away from outdated criminalized legal frameworks and implement violence prevention strategies, psycho-social support services, sex worker empowerment initiatives, and peer-led programmes.

Opportunities in mental health services research.

The AIDS pandemic in the 2020s: community responses bring female underserved populations into sharper focus.

Background There is an increasing trend in the Female Sex Workers (FSWs) population in many Asian countries, as women are often entering the sex trade at younger ages than in the past. In Bangladesh, a small country in Asia, approximately 74000 FSWs are operating in brothel, hotel, and residence or on the streets. These FSWs are most at risk of mortality and morbidity related to sexual and reproductive health (SRH) which include HIV/AIDs, STIs, and unsafe abortion including other maternal health problems. This study aimed to document SRH related practices by FSWs, particularly on contraceptives, abortion, pregnancy, use of maternal healthcare services and sexually transmitted infections (STIs) and the barriers FSWs in Bangladesh face with regard to accessing SRH care, and to assess the satisfaction with the healthcare received with the aim of developing recommendations for action. Methods A mixed method study comprising of qualitative and quantitative methods of data collection had been implemented between March 2015 and September 2016 in Dhaka city of Bangladesh where community based drop-in-centers (DICs) were operating for STI/HIV prevention intervention among FSWs. The study population included street, hotel and/or residence based FSWs of reproductive age (15-49 years). It also included policy makers, researchers and key personnel of organizations which were currently providing services for female sex workers including DIC staffs. About 731 FSWs were surveyed using a stratified sampling technique. About 14 in-depth interviews with FSWs and 9 in-depth interviews with service providers were also conducted. A workshop with 23 participants consisted of policy makers, researchers, program implementers was conducted to formulate recommendations. SRH-related service utilization rates and reported barriers faced in service utilization were main outcome variables. Descriptive statistics, Pearson’s Chi-Square and Fisher’s Exact test, one way ANOVA analysis were used for quantitative data analysis. Atlas-ti data management software and content analysis was done for qualitative data analysis. Result Of 731 FSWs interviewed, 45% were 25 to 34 years old, 45% had no education and64% were married. Around half of the respondents had a daily income of 600 BDT (7.6 US$)or less per day. About 47% of them were living in residential while around one-fourth of them live on the street. About 36.8% respondents were involved in sex trade for 3 to 7 seven years. The majority (71.4%) of the FSWs were engaged in sex act for 4 or more times per day. Greater proportions (91%) of FSWs were using short acting methods, condom (71%), oral pill (21%) and injection (16%). The reported use of long acting and permanent methods (LAPM) - Intra-uterine device (IUD) (1.5%), implant (4.7%) or female sterilization (4.5%) was very low (11%). About 61.3% of 731 FSWs reported SRH-related experiences in the past one year, including abortion (15.5%), ongoing pregnancy (9.0%), childbirth (8.3%) or any symptoms of STIs (41.6%). Among FSWs who had an abortion (n=113), the most common methods included menstrual regulation through manual vacuum aspiration (47.8%), followed by Dilation and Curettage procedure (31%) and oral medicine from pharmacies (35.4%). About 57.5% of 113 cases reported post abortion complications. Among FSWs with delivery in the past year (n=61), 27.7% attended the recommended four or more antenatal care visits and more than half did not have any postnatal visit. Of 731 FSWs, 353 (51%) reported facing barriers when seeking sexual and reproductive healthcare. Financial problems (72%), shame about receiving care (52.3%), unwillingness of service providers to provide care (39.9%), unfriendly behavior of the provider (24.4%), and distance to care (16.9%) were mentioned as barriers. Only one-third of the respondents reported an overall satisfaction score of more than fifty percent (a score of between 9 and16) with formal healthcare. Inadequacy or lack of SRH services and referral problems (e.g., financial charge at referral centers, unsustainable referral provision, or unknown location of referral) were reported by the qualitative participants as the major barriers to accessing and utilizing SRH care. Adopting sustainable and effective strategies to provide accessible and adequate SRH services for FSWs was prioritized by workshop participants. Conclusion and recommendations There was substantial unmet need for SRH care among FSWs in urban areas in Dhaka, Bangladesh. Therefore, it is important to integrate SRH services for FSWs in the formal healthcare system or integration of abortion and maternal healthcare services within existing HIV prevention services.

OBJECTIVE: To understand the social context of female sex workers who use crack and its impact on HIV/AIDS risk behaviors. METHODODOLOGICAL PROCEDURES: Qualitative study carried out in Foz do Iguaçu, Southern Brazil, in 2003. Twenty-six in-depth interviews and two focus groups were carried out with female commercial sex workers who frequently use crack. In-depth interviews with health providers, community leaders and public policy managers, as well as field observations were also conducted. Transcript data was entered into Atlas.ti software and grounded theory methodology was used to analyze the data and develop a conceptual model as a result of this study. ANALYSIS OF RESULTS: Female sex workers who use crack had low self-perceived HIV risk in spite of being engaged in risky behaviors (e.g. unprotected sex with multiple partners). Physical and sexual violence among clients, occasional and stable partners was widespread jeopardizing negotiation and consistent condom use. According to health providers, community leaders and public policy managers, several female sex workers who use crack are homeless or live in slums, and rarely have access to health services, voluntary counseling and testing, social support, pre-natal and reproductive care. CONCLUSIONS: Female sex workers who use crack experience a plethora of health and social problems, which apparently affect their risks for HIV infection. Low-threshold, user-friendly and gender-tailored interventions should be implemented, in order to increase the access to health and social-support services among this population. Those initiatives might also increase their access to reproductive health in general, and to preventive strategies focusing on HIV/AIDS and other sexually transmitted infections.

Sex workers in Sub-Saharan Africa are vulnerable to a range of factors that dispose them to poor health outcomes. In particular, they are at high risk of violence, injury, rape, discrimination and a spectrum of human rights abuses. Their vulnerability to HIV and other STIs are many fold greater than the non-sex worker population of the same age. Health care systems world-wide, and particularly in Africa, are not adequately responsive to the needs of sex workers. As a result, many sex workers do not receive adequate health services, education or HIV prevention tools. While the literature on female sex work in Africa is fairly robust, troubling research gaps are evident on male and transgender sex work, as well as on the intersections of migration and sex work. Mega-sport events have been associated with increased anxiety about sex work and human trafficking, with few studies tracking the impact of such events on local sex work industries over time. These fears were prominent during the 2010 FIFA Soccer World Cup. This PhD project consisted of three research projects based in South Africa and Kenya. It aimed to evaluate the impact of social and behavioural factors on the health of sex workers. To achieve this objective, it examined the effects of sex worker characteristics, migration status, and their relationships with commercial and non-commercial partners on sexual behaviour and access to services. Such information may assist in designing more effective health policies in addition to providing insights into the structural factors that affect sex work settings and heighten sex worker vulnerability to ill-health. The first research project consisted of face-to-face surveys with 1799 male, female and transgender sex workers in Johannesburg, Rustenburg and Cape Town. The second research project involved telephonic interviews in three waves with 663 female sex workers who advertised online or in newspapers in South Africa. The third component was a prospective cohort of 400 female sex workers in Mombasa, Kenya. The research findings indicate the diversity of the sex industry and the people who work in it. Sex work is an important livelihood strategy that provides an income for sex workers and their extended network of dependents. Migration is a vital component for exploring and understanding how many sex worker lives and work are structured in South Africa. Sex workers are subject to violence from their non-commercial partners as well as from police, while unprotected sex with non-commercial partners emerges as an important risk factor for HIV. The PhD research detected little significant changes in the sex industry due to the 2010 Soccer World Cup, and documents how strategic opportunities were lost to alter some of the structural conditions of sex work during a time of heightened sex work awareness, funding and scrutiny. Moreover, this thesis highlights the shortcomings of health care services in responding to the needs of sex workers. It recommends the rolling-out of specialised, sex work-specific health care services in areas of sex work concentration, and sex work-friendly services in mainstream health care facilities in areas of lower sex work concentration. Non-judgemental and empathetic health workers are a key component of responsive services. Lastly and perhaps most importantly, it underscores the importance of decriminalising sex work in order to safeguard sex worker rights and to protect individual and public health.

In 2004 the UK Home Office published a consultation paper on sex work, after a review of the Sex Offences Act (2003). The paper, Paying the Price,1 was criticised by...

Introduction For years Sex Workers in Australia, especially QLD, have been incorrectly attributed to the increase of STI’s and HIV in the general community. This article will conclude that Sex Workers are not the cause of transmission increase in STI’s and HIV. To the contrary Sex Workers have very low levels of STI’s and HIV. Furthermore Sex Workers have helped to educated clients to reduce transmission of STI’s and HIV. This article demonstrates the important role of Respect Inc in health promotion of Sex Workers with provision in education of STI’s and HIV, so Sex Workers can keep themselves safe whilst doing Sex Work. Methods The team will use a number of methods to collect data, all methods are traditional and dependent on targets. For example, we have used paper questionnaires to collect information from Sex Workers, this reduced barriers when asking Sex Workers personal questions. We conducted face to face interviews with some of the Sex Worker friendly GPs (General Practitioners) who provide sexual health certificates to Sex Workers. We have conducted telephone interviews with Sex Workers who do FIFO (fly in fly out) to regional mining towns in QLD. We collated this data with data provided by Respect Inc. Results After collection of data we formatted charts and graphs. We found levels of STI’s and HIV among Sex Workers were relatively low. GPs confirmed, Sex Workers are informed about STI’s and HIV. Respect Inc provided data with hundreds of Sex Workers accessing offices across Qld for Safe Sex, STI’s and HIV information, with positive sexual health outcomes. Conclusion Sex Workers in Australia (QLD) have relatively low levels of STI’s and HIV. Sex Workers are not the cause of increasing transmissions of STI’s and HIV. Sex Workers often face stigma and discrimination in the wider community. Please respect Sex Work as a career of choice. SEX WORK IS REAL WORK

Protecting the health of sex workers in the EU

IntroductionAcross sub‐Saharan Africa, selling sex puts young women at high risk of HIV. Some young women who sell sex (YWSS) may self‐identify as sex workers, while others may not, having implications for how to reach them with HIV prevention. We describe characteristics, sexual behaviours and health service use of YWSS in Zimbabwe, comparing women who identified as female sex workers (FSW) and women who did not (non‐identifying‐YWSS), and explore factors associated with HIV infection.MethodsWe analysed data from respondent‐driven sampling (RDS) surveys among YWSS aged 18 to 24 implemented in six sites in Zimbabwe from April to July 2017. RDS was used to enrol YWSS into an impact evaluation of the multi‐country DREAMS (Determined, Resilient, Empowered, AIDS‐free, Mentored and Safe) Partnership, which provides comprehensive HIV prevention programming to adolescent girls and young women. Women completed an interviewer‐administered questionnaire and were offered HIV testing services. We used logistic regression (RDS‐II‐weighted, normalized by site) to identify factors associated with prevalent HIV infection.ResultsForty‐four seeds recruited 2387 YWSS. RDS‐adjusted HIV prevalence was 24%; 67% of women identified as FSW. FSW were older and had lower educational attainment than non‐identifying‐YWSS. While 40% of FSW reported 10+ clients in the previous month, 9% of non‐identifying‐YWSS did so. FSW were more likely to have accessed HIV‐related services, including HIV testing in the last six months (FSW: 70%; non‐identifying‐YWSS: 60%). Over half of all YWSS described selling sex as their main financial support (FSW: 88%; non‐identifying YWSS: 54%). Increasing age, lower educational attainment, younger age of first selling sex and higher number of clients in the previous month were associated with prevalent HIV.ConclusionsYWSS in Zimbabwe have a high prevalence of HIV, reported high numbers of sexual partners and depend financially on selling sex. Non‐identifying‐YWSS differed socio‐demographically to FSW, yet factors associated with HIV risk were similar for all women. Women not identifying as FSW were less likely to access services, suggesting they should be prioritized for HIV prevention. Network‐based recruitment may enhance their inclusion in programmes, like DREAMS, which aim to reach young women at highest‐risk with comprehensive health, HIV prevention and social protection services.