Sex Work Stigma Research Articles

Healthcare for sex workers—access, barriers, and needs

BackgroundStigma has a significant impact on the health of different societal groups and contributes to inequalities in healthcare. Sex work is associated with significant social stigma, which has detrimental effects on sex workers’ access to healthcare. This exploratory study gives first insights into the perspectives of sex workers and counselors in Germany on sex workers’ access, needs, and barriers with respect to healthcare. We focused on an established network of services for sex workers in Bochum.MethodsWe conducted in-depth guideline-based interviews with four counselors at centers that provide social and medical support for sex workers and three sex workers who use these services. Interviews were analyzed using qualitative content analysis.ResultsThe main barriers reported with respect to sex workers’ access to healthcare were health insurance, language barriers, bureaucracy, mobility, and discrimination. Sex work stigma within healthcare was reported to intersect with other forms of discrimination, such as racism. Specific needs and barriers were reported regarding mental health, which emerged as an important topic for sex workers. Free and anonymous healthcare offers were evaluated positively. Interviewees noted a lack of services that address the needs of sex workers beyond sexually transmitted infections, such as mental healthcare.ConclusionSeveral barriers to accessing healthcare remain for sex workers, many of which are particularly relevant for migrant sex workers from Eastern European countries. The development of additional antidiscriminatory healthcare services is necessary and should give priority to sex workers’ perspectives.

Esengo ya Bosembo ("Joy of Equity"): Development of an Advocacy Video to Reduce Stigma and to Promote Sexual and Reproductive Health and Rights of Women Sex Professionals in Pointe-Noire, Congo Republic.

Sex workers experience elevated risks of sexual and gender-based violence (SGBV) from intimate partners, clients, and community members that harms health and human rights. While SGBV contributes to poorer sexual and reproductive health (SRH) outcomes among sex workers, including elevated human immunodeficiency virus (HIV) vulnerabilities, stigma targeting sex workers reduces SRH service access and uptake. The Congo Republic is an exemplar context to address stigma toward sex workers. Sex workers' HIV prevalence (8.1%) in Congo Republic is double the national prevalence, yet research indicates that nearly one-fifth (17.2%) of sex workers in Congo Republic avoid health care because of stigma and discrimination. This Resources, Frameworks, & Perspectives article describes the process of developing Esengo ya Bosembo ("Joy of Equity"), a culturally tailored advocacy video that aims to reduce health care and community stigma toward women sex professionals (e.g., sex workers) in Pointe-Noire, Congo Republic. This knowledge translation product stems from a participatory mapping intervention with sex professionals in Pointe-Noire that revealed the need for sensitization tools and activities to reduce sex work stigma among health care providers and community members. The video incorporates three overarching key messages: (1) sex professionals are human beings with equal rights to dignity, protection, and health services; (2) elevated risks of SGBV and stigma targeting sex workers reduce SRH service access and uptake; and (3) participatory mapping is a potential way to empower sex professionals to share their experiences and recommendations for change. This article details how health promotion practitioners and sex professionals may use the video to advocate for change.

Examining the Intrapersonal, Interpersonal and Community Level Correlates of Access to Medical Care Among Women Employed by Sex Work in Southern Uganda: A cross-sectional Analysis of the Kyaterekera Study.

Women employed by sex work (WESW) experience significant gaps in accessing necessary healthcare services, leading to unmet health needs. Yet, there is a dearth of literature on the barriers to medical care access among WESW in Uganda. We used data from the Kyaterekera baseline to examine the correlates of access to medical care among WESW, defined as the ability of individuals to obtain the necessary healthcare services they require in a timely, affordable, and equitable manner. The Kyaterekera study recruited 542 WESW aged 18-58 years from Southern Uganda. We conducted a multilevel linear regression model to determine the intrapersonal (age, education level, marital status, HIV knowledge, and asset ownership), interpersonal (family cohesion and domestic violence attitudes), and community (community satisfaction, sex work stigma and distance to health facility) level correlates of access to medical care among WESW. Intrapersonal and interpersonal factors were associated with access to medical care among WESW. There was no significant association between community level factors and access to medical care. WESW with secondary education (β = 0.928, 95% CI = 0.007, 1.849) were associated with increased access to medical care. WESW with high asset ownership (β = -1.154, 95% CI= -1.903, -0.405), high family cohesion (β = -0.069, 95% CI= -0.106, -0.031), and high domestic violence attitudes (β = -0.253, 95% CI= -0.438, -0.068) were associated with decreased access to medical care. The findings emphasize the critical need for targeted family strengthening interventions to enhance family support for WESW and address domestic violence.

The epidemiology of HIV infection among female sex workers in Nairobi, Kenya: A structural determinants and life-course perspective.

High HIV prevalence among female sex workers (FSWs) is heavily influenced by structural determinants (e.g. criminalisation of sex work; violence) and significant life events (e.g. orphanhood, teenage pregnancy). This study aims to understand the epidemiology of HIV among FSWs in Nairobi, Kenya using a structural determinants and life-course perspective. Baseline cross-sectional survey data were collected June-December 2019 for the Maisha Fiti study with 1003 FSWs (aged 18-45 years). Odds ratios and 95% confidence intervals were estimated using multivariable logistic regression with a hierarchical modelling approach. HIV prevalence was 28.0%, and increased with age (<25 years 5.7%, 25-34 years 19.0%, ≥35 years 40.6%). In adjusted analyses, HIV seroprevalence was associated with childhood and adolescence including violence from militia or soldiers (AOR = 1.60; 95%CI:1.00-2.53), young age at sexual debut (≤15 years old vs. ≥18 years AOR = 0.57; 95%CI:0.39-0.84) and teenage pregnancy (AOR = 1.37; 95%CI:1.00-1.88). For adulthood the factors included lower SES score (lowest vs. highest tertile AOR = 0.63; 95%CI:0.40-0.98); reduced housing insecurity (AOR = 0.52; 95%CI:0.54-0.79); lower alcohol/drug use score (AOR = 0.44; 95%CI:0.31-0.61); and a longer duration of selling sex (0-5 years vs. ≥11 years AOR = 2.35; 95%CI:1.44-3.82). Among HIV-negative FSWs, prevalence of HIV risk factors was high (recent hunger 32.3%; internalised 67.7% and experienced 66.0% sex work stigma; recent police arrest 30.1%; recent physical or sexual violence 65.6%, condomless last sex intimate partner 71.1%; harmful alcohol or substance use 49.1%). Only 24.6% of HIV-negative FSWs reported taking PrEP. Taken together, adverse events in childhood and adolescence were associated with increased odds of living with HIV, and were more strongly associated with HIV serostatus than adulthood structural or behavioural risk factors. HIV-negative FSWs remain at high risk of HIV acquisition. This study highlights the importance of addressing adverse events throughout the life course to reduce HIV risk, and the need to continue multi-level HIV prevention and treatment efforts.

“Carefully Curated/For Heart and Soul”: Sensing Place Identity in Sex Workplaces

In the face of ongoing interpersonal and structural violence towards sex workers in Canada, this research inquiry explores nine women and gender-diverse sex workers’ experiences of place identity within their workplaces. Employing multisensory and arts-based ethnographic fieldwork, the co-researchers storied their embodied place-based experiences of identity. The research findings illuminate place-identity processes within sex workplaces, suggesting that the context, materiality, and multisensory atmospheres of the co-researchers’ work environments were entwined with internal and external self-concepts. The co-researchers created personalized multisensory atmospheres in their workplaces through the use of colour, visual art, and music. Having workplaces that positively supported place identity fostered workplace comfort, control, and empowerment. Ultimately, this research suggests that place-identity processes in sex workplaces have the possibility to resist and shift sex work stigma.

Individual and Collective Forms of Stigma Resistance: Pathways Between HIV and Sex Work Stigma and Viral Suppression Among Female Sex Workers in the Dominican Republic.

Intersecting forms of stigma including both HIV and sex work stigma have been known to impede HIV prevention and optimal treatment outcomes among FSW. Recent research has indicated that intersectional stigma can be resisted at the community and individual level. We assessed pathways between HIV stigma, sex work stigma, social cohesion and viral suppression among a cohort of 210 FSW living with HIV in the Dominican Republic. Through Poisson regression we explored the relationship between HIV outcomes and internalized, anticipated and enacted HIV and sex work stigma, and resisted sex work stigma. We employed structural equation modeling to explore the direct effect of various forms of stigma on HIV outcomes, and the mediating effects of multi-level stigma resistance including social cohesion at the community level and occupational dignity at the individual level. 76.2% of FSW were virally suppressed and 28.1% had stopped ART at least once in the last 6 months. ART interruption had a significant negative direct effect on viral suppression (OR = 0.26, p < 0.001, 95% CI: 0.13-0.51). Social cohesion had a significant positive direct effect on viral suppression (OR = 2.07, p = 0.046, 95% CI: 1.01-4.25). Anticipated HIV stigma had a significant negative effect on viral suppression (OR = 0.34, p = 0.055, 95% CI: 0.11-1.02). This effect was mediated by the interaction between cohesion and dignity which rendered the impact of HIV stigma on viral suppression not significant. Findings demonstrate that while HIV stigma has a negative impact on viral suppression among FSW, it can be resisted through individual and collective means. Results reinforce the importance of community-driven, multi-level interventions.

Gains and gaps: addressing HIV in diverse sex worker groups

Over the past four decades of the HIV pandemic, diverse groups of sex workers have been disproportionately affected across settings. 1 UNAIDSHIV and sex work: human rights fact sheets series. https://www.unaids.org/sites/default/files/media_asset/05-hiv-human-rights-factsheet-sex-work_en.pdfDate: 2021 Date accessed: June 1, 2023 Google Scholar Social and structural factors including the criminalisation of sex work, financial insecurity, and intersectional stigma, discrimination, and violence have been identified as key drivers of sex workers' disproportionate HIV risk and poor treatment outcomes. 2 Shannon K Crago A-L Baral SD et al. The global response and unmet actions for HIV and sex workers. Lancet. 2018; 392: 698-710 Summary Full Text Full Text PDF PubMed Scopus (129) Google Scholar Although community-driven combination prevention interventions have shown promise in reducing new HIV infections and improving HIV care and treatment outcomes among sex workers, 3 Kerrigan D Kennedy CE Morgan-Thomas R et al. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up. Lancet. 2015; 385: 172-185 Summary Full Text Full Text PDF PubMed Scopus (209) Google Scholar investments to bring these efforts to scale have lagged far behind historical and current needs. Temporal trends in, and risk factors for, HIV seroconversion among female sex workers accessing Zimbabwe's national sex worker programme, 2009–19: a retrospective cohort analysis of routinely collected HIV testing dataWe identified high rates of seroconversion shortly after linkage to programme services, which emphasises the need to strengthen HIV prevention programmes from first contact with female sex workers in Zimbabwe. New infections among female sex workers remain challenging to measure, but longitudinal analysis of routine testing data can provide valuable insights into seroconversion rates and associated risk factors. Full-Text PDF Open AccessHIV prevalence, risk behaviour, and treatment and prevention cascade outcomes among cisgender men, transgender women, and transgender men who sell sex in Zimbabwe: a cross-sectional analysis of programme dataThese unique data show that people who sell sex and identify as cisgender men, transgender women, or transgender men in sub-Saharan Africa have high HIV prevalences and risk of infection, with alarmingly low access to HIV prevention, testing, and treatment services. There is an urgent need for people-centred HIV interventions for these high-risk groups and for more inclusive HIV policies and research to ensure we truly attain universal access for all. Full-Text PDF

Comparing Stigma and HIV Outcomes Between Transgender and Cisgender Women Sex Workers Living with HIV in the Dominican Republic.

Using an intersectionality framework, we compared stigma and HIV care and treatment outcomes across transgender and cisgender women sex workers living with HIV in the Dominican Republic (DR). In 2018-2019, data were collected in Santo Domingo, DR, using interviewer-administered surveys among 211 cisgender women and 100 transgender women. We used t-tests and chi-square tests to examine differences in sex work stigma, HIV stigma, and HIV care and treatment. Transgender participants reported more anticipated HIV stigma (mean=13.61, standard deviation [SD]=2.39) than cisgender participants (mean=12.96, SD=2.21; p=0.018), but there were no statistically significant differences for internalized or enacted HIV stigma. Cisgender participants reported more anticipated sex work stigma (cisgender: mean=50.00, SD=9.22; transgender: mean=44.02, SD=9.54; p<0.001), but transgender women reported more enacted (cisgender: mean=49.99, SD=9.11; transgender: mean=59.93, SD=4.89; p<0.001) and internalized sex work stigma (cisgender: mean=50.00, SD=8.80; transgender: mean=57.84, SD=8.34; p<0.001), with no significant differences in resistance to sex work stigma. Cisgender women were significantly more likely to have received HIV care (cisgender: 99.53%, transgender: 91.00%, p<0.001), be currently taking antiretroviral therapy (cisgender: 96.21%, transgender: 84.00%, p<0.001), and be virally suppressed (cisgender: 76.19%, transgender: 64.00%, p=0.025). Transgender participants consistently had poorer HIV care and treatment outcomes compared with cisgender participants. Differences in stigma experiences between transgender and cisgender participants depended on the type of stigma. Findings reflect the intersectional nature of distinct types and forms of stigma among sex workers. Understanding the shared and unique experiences of transgender and cisgender women will improve HIV care engagement and viral suppression.

Violence Against Women Who Sell Sex in Eastern and Southern Africa: A Scoping Review.

Women who sell sex (WSS) are vulnerable to violence. We present a scoping review of the last decade of research on the prevalence and incidence of, factors associated with, and services regarding violence against WSS in Eastern and Southern African (ESA). A systematic search of various databases resulted in 20 papers being reviewed. Inclusion criteria, applied by the first two authors, were as follows: empirical papers, key research problem is violence against WSS, and conducted in ESA countries. The lifetime prevalence of violence revealed in the studies ranged from 21% to 82%. A pattern of generalized violence against WSS from paying clients, male partners, strangers, family members, friends/acquaintances, and the authorities emerged. Factors associated with violence included the context within which the sex work occurs, alcohol use, type of sex exchange interactions, and personal factors (low education, low income, marriage, youth, high client volume, time in sex work, forced sexual debut, and internalized sex work stigma). WSS seldom access services after violence. Evaluations of two programs, a woman-focused HIV intervention, and the Diagonal Interventions to Fast-Forward Reproductive Health project, showed improvements in gender-based violence services. Findings suggest that targeted programmes should be paired with improving general health services and focus on promoting collective agency among WSS.

Stigma and HIV Treatment Outcomes Among Transgender Women Sex Workers in the Dominican Republic.

Trans women experience multiple forms of intersecting stigma due to trans identity, HIV, and sex work, which can negatively affect their health. There is limited understanding of the relationships between stigma and HIV care and treatment outcomes. We assessed associations between multiple forms and types of stigma and HIV treatment outcomes among trans women who conduct sex work in Santo Domingo, Dominican Republic using cross-sectional survey data. Most participants had received HIV care (91%) and were currently taking anti-retroviral therapy (ART) (84%). Only 64% were virally suppressed. Nearly one-third (32%) had interrupted ART at some point; those who had never interrupted ART were more likely to be suppressed. Drug use was associated with ART interruption. Higher enacted HIV stigma was associated with current ART use. Higher enacted HIV stigma and higher anticipated sex work stigma were associated with ART adherence. Higher trans stigma was associated with being virally suppressed. Findings highlight the importance of addressing multiple forms of stigma at the individual and clinic levels to improve and sustain viral suppression. Future research is needed to assess if unexpected associations between stigma and HIV outcomes reflect processes of resilience. Future research is also needed to assess the pathways between drug use, ART interruption, and viral suppression among trans women.

Understanding drivers of female sex workers’ experiences of external/enacted and internalised stigma: findings from a cross-sectional community-centric national study in South Africa

To deepen our understanding of sex work stigma, and to its drivers and their interrelation, we conducted an analysis using structural equation modelling of the South African National Sex Worker Survey. We enrolled 3005 women in sex work using multi-stage sampling across all South Africa’s provinces. Experience of external/enacted and internalised stigma was widespread. Non-partner rape, intimate partner violence and partner controlling behaviour (often expressions of external/enacted stigma) compounded internalised stigma. These experiences of violence, other manifestations of external/enacted stigma and food insecurity, were key drivers of internalised stigma, and often had an impact on mental health. We found that considerable protection against stigma emanated from viewing sex work positively. This resistance to stigma provided opportunities to shift the narrative. Reducing sex workers’ exposure to external/enacted stigmatising behaviour, including by enabling more to work indoors, and providing greater protection from partner violence and rape, are critical for better health and well-being. Ending the criminalisation of sex work is foundational for safer working conditions and better health outcomes for sex workers, similarly providing adequately funded mental and physical health and social care through sex work specific programmes.

HIV- and sex work-related stigmas and quality of life of female sex workers living with HIV in South Africa: a cross-sectional study

BackgroundEnvironmental quality of life (QoL) assesses individually perceived factors such as physical safety and security, accessibility, quality of healthcare, and physical environment. These factors are particularly relevant in the context of sex work and HIV, where stigma has been identified as an important barrier across several prevention and treatment domains. This study aims to examine the association between different types of HIV- and sex work-related stigmas and environmental QoL among female sex workers (FSW) living with HIV in Durban, South Africa.MethodsWe conducted cross-sectional analyses using baseline data from the Siyaphambili randomized controlled trial. FSW who reported sex work as their primary source of income and had been diagnosed with HIV for ≥ 6 months were enrolled from June 2018–March 2020, in eThekwini, South Africa. We evaluated the association between environmental QoL, dichotomizing the environmental domain score collected by the WHO Quality of Life HIV Brief (WHOQOL-HIV BREF) questionnaire at the median, and stigma using modified robust Poisson regression models. Five stigma subscales were assessed: sex work-related (anticipated, enacted, or internalized stigma) and HIV-related (anticipated or enacted stigma).ResultsAmong 1373 FSW, the median environmental QoL was 10.5 out of 20 [IQR: 9.0–12.5; range 4.0–19.0], while the median overall QoL was 3 out of 5 [IQR: 2–4; range 1–5]. One-third of FSW (n = 456) fell above the median environmental QoL score, while 67% were above the median overall QoL (n = 917). Reporting anticipated sex work stigma was associated with lower environmental QoL (adjusted prevalence ratio [aPR] 0.74 [95% CI 0.61, 0.90]), as was severe internalized sex work stigma (aPR: 0.64, 95% CI 0.48, 0.86). Reporting enacted HIV stigma versus none was similarly associated with lower environmental QoL (aPR: 0.65, 95% CI 0.49, 0.87). Enacted sex work stigma and anticipated HIV stigma were not statistically associated with environmental QoL.ConclusionsThis study highlights the need to consider the impact of multiple stigmas on FSW’s non-HIV related clinical outcomes, including safety and physical well-being. Moreover, these results suggest that addressing underlying structural risks may support the impact of more proximal HIV prevention and treatment interventions.Trial registration NCT03500172 (April 17, 2018)

Relationships Between Stigma and Intimate Partner Violence Among Female Sex Workers Living With HIV: Social and Economic Exclusion.

Violence against female sex workers (FSWs) perpetrated by their intimate (i.e., non-commercial) partners, particularly against FSWs living with HIV, is understudied. Stigma can deplete the economic resources, social relationships, and mental well-being of stigmatized people, which may increase their intimate partner violence (IPV) risk. We quantitatively assessed relationships between HIV stigma and sex work stigma and IPV victimization among FSWs living with HIV in the Dominican Republic (n = 266). Enacted HIV stigma, in the form of job loss, and anticipated HIV stigma, in the form of fear of exclusion by family, were associated with increased IPV risk. Potential association mechanisms, including increased economic vulnerability and social isolation, and programmatic responses are discussed.

Sex work stigma and the recuperation of moral personhood through gendered labour: sex worker diaries in Ukraine

Based on a diary writing exercise, this paper illuminates the complex ways in which sex workers in Ukraine actively work through and manage stigma in their daily lives. Pushing beyond the notion of stigma as a static and fixed psychosocial designation that can be readily measured, we argue that stigma is actively confronted by sex workers through various forms of gendered emotional and physical labour that enable them to recuperate a sense of moral personhood. This notion of moral personhood is often tied to wider gender-specific values pertaining to caregiving and motherhood.

Validating a measure of anticipated sex work-related stigma among male and female sex workers in Kenya

ABSTRACT Sex workers face different types of sex work-related stigma, which may include anticipated, perceived, experienced, or internalized stigma. Sex work stigma can discourage health care seeking and hamper STI and HIV prevention and treatment efforts. There is a paucity of validated sex work-related stigma measures, and this limits the ability to study the stigma associated with sex work. A cross-sectional survey was conducted that measured anticipated sex work-related stigma among male and female sex workers in Kenya (N = 729). We examined the construct validity and reliability of the anticipated stigma items to establish a conceptually and statistically valid scale. Our analysis supported a 15-item scale measuring five anticipated sex work stigma domains: gossip and verbal abuse from family; gossip and verbal abuse from healthcare workers; gossip and verbal abuse from friends and community; physical abuse; and exclusion. The scale demonstrated good face, content, and construct validity. Reliability was good for all subscales and the overall scale. The scale demonstrated good model fit statistics and good standardized factor loadings. The availability of valid and reliable stigma measures will enhance efforts to characterize and address stigma among sex workers and ultimately support the protection, health and well-being of this vulnerable population.

OnlyFans as gig-economy work: a nexus of precarity and stigma

ABSTRACT While online sex work in the form of the creation and sale of pornographic content is not a new phenomenon, the recent prominence of the platform OnlyFans drew additional attention to this sector. This article argues that OnlyFans, and other similar erotic-content platforms, can be understood as forms of platform-mediated gig-economy work, reflecting increased freedoms in some ways, but tempered with heightened financial precarity. Gig-economy work, with its linkages to discourses of entrepreneurialism, is intrinsically linked to neoliberalism, and in the context of online sex work, the division of labour is gendered. Conventional models of pornography production have been critiqued for the way they limit performers’ control over their working conditions, and direct-to-consumer marketing of self-shot footage has been offered as a remedy to this. However, creators are still reliant on third parties in the form of platforms and payment processors. The recent threat that OnlyFans might ban explicit content, displacing the online sex workers who depend on the platform for a living, as well as the demonetization of Pornhub and AVN Stars, highlights the way that online sex work is made vulnerable by existing at the nexus of sex work stigma, and the precarity inherent in platform-mediated gig-economy work.

Digital Exclusion and the Structural Barriers to Safety Strategies among Men and Non-Binary Sex Workers Who Solicit Clients Online

Background: Evidence shows that online solicitation facilitates sex workers’ ability to mitigate the risk of workplace violence. However, little is known about how end-demand sex work criminalization and the regulation of online sex work sites shape men and non-binary sex workers’ ability to maintain their own safety while soliciting services online. Methods: We conducted 21 semi-structured interviews with men and non-binary sex workers in British Columbia between 2020–2021 and examined their ability to enact safety strategies online in the context of end-demand criminalization. Analysis drew on a structural determinants of health framework. Results: Most participants emphasized that sex work is not inherently dangerous and described how soliciting services online facilitated their ability to enact personal safety strategies and remain in control of client interactions. However, participants also described how end-demand criminalization, sex work stigma, and restrictive website policies compromise their ability to solicit services online and to enact safety strategies. Conclusions: Alongside calls to decriminalize sex work, these findings emphasize the need to normalize sex work as a form of labour, promote access to online solicitation among men and non-binary sex workers, and develop standards for online sex work platforms in partnership with sex workers that prioritize sex worker safety.

When the Law Fails to Protect: Stigma, Violence and Sex Workers’ Multi-Layered Responses in the Kenyan Cities of Nairobi, Mombasa, Kisii and Meru

In Kenya, criminal laws on sex work and same-sex activities, combined with stigma on sex work and homosexuality, shape sex workers’ vulnerability to violence. This paper explores sex workers’ responses to violence at various levels of social and legal organisation. Drawing from a community-based participatory research (CBPR) approach including qualitative interviews and focus group data, the paper illustrates a close and mutually reinforcing nexus between criminalisation, sex work stigma and homophobia as well as a resulting climate of impunity for perpetrators. By understanding sex workers as agentic actors, it demonstrates how sex workers respond to, rework and resist this repressive landscape of violence. It argues that sex workers mitigate the risk of experiencing violence by ‘getting by’ and ‘getting ahead’, while sex worker organisations support them to engage in collective resistance. The paper demonstrates a need to reform sex work-related laws and argues that action should extend beyond legal reform to include efforts to mediate the social processes that undercut sex workers’ access to rights and social justice.

Global assessment of existing HIV and key population stigma indicators: A data mapping exercise to inform country-level stigma measurement.

Stigma is an established barrier to the provision and uptake of HIV prevention, diagnostic, and treatment services. Despite consensus on the importance of addressing stigma, there are currently no country-level summary measures to characterize stigma and track progress in reducing stigma around the globe. This data mapping exercise aimed to assess the potential for existing data to be used to summarize and track stigma, including discrimination, related to HIV status, or key population membership at the country level. This study assessed existing indicators of stigma related to living with HIV or belonging to 1 of 4 key populations including gay men and other men who have sex with men, sex workers, people who use drugs, and transgender persons. UNAIDS Strategic Information Department led an initial drafting of possible domains, subdomains, and indicators, and a 3-week e-consultation was held to provide feedback. From the e-consultation, 44 indicators were proposed for HIV stigma; 14 for sexual minority stigma (including sexual behavior or orientation) related to men who have sex with men; 12 for sex work stigma; 10 for drug use stigma; and 17 for gender identity stigma related to transgender persons. We conducted a global data mapping exercise to identify and describe the availability and quality of stigma data across countries with the following sources: UNAIDS National Commitments and Policies Instrument (NCPI) database; Multiple Indicator Cluster Surveys (MICS); Demographic and Health Surveys (DHS); People Living with HIV Stigma Index surveys; HIV Key Populations Data Repository; Integrated Biological and Behavioral Surveys (IBBS); and network databases. Data extraction was conducted between August and November 2020. Indicators were evaluated based on the following: if an existing data source could be identified; the number of countries for which data were available for the indicator at present and in the future; variation in the indicator across countries; and considerations of data quality or accuracy. This mapping exercise resulted in the identification of 24 HIV stigma indicators and 10 key population indicators as having potential to be used at present in the creation of valid summary measures of stigma at the country level. These indicators may allow assessment of legal, societal, and behavioral manifestations of stigma across population groups and settings. Study limitations include potential selection bias due to available data sources to the research team and other biases due to the exploratory nature of this data mapping process. Based on the current state of data available, several indicators have the potential to characterize the level and nature of stigma affecting people living with HIV and key populations across countries and across time. This exercise revealed challenges for an empirical process reliant on existing data to determine how to weight and best combine indicators into indices. However, results for this study can be combined with participatory processes to inform summary measure development and set data collection priorities going forward.

Stigma and Service Provision for Women Selling Sex. Findings from Community-based Participatory Research

ABSTRACT This article presents findings from a community-based participatory research project undertaken with sex workers in North East England. The research included peer-led interviews with 26 women who sell sex in public spaces and/or from private flats or online. Community stakeholders were also interviewed. Focusing on local service provision and interactions with the police and the criminal justice system, this article documents how stigma frames sex worker’s experiences of local service provision and interactions with local criminal justice agencies. Although those selling sex in public and private spaces described different interactions with, and experiences of, local service providers, stigma remained a pervasive and dominant feature of all sex worker’s experiences. In the research, those selling sex ‘on street’ describe the impact of public stigmatisation while those selling sex ‘off street’ describe employing strategies of identity management to avoid the social consequences of sex work stigma. In this article, we explore how service provision is constructed through the current governance of sex work in England and Wales, and how sex work stigma could be challenged through service provision designed by sex workers, for sex workers.