Sex workers experience a disproportionately high burden of HIV in Canada and globally, in large part driven by structural factors (such as criminalization, physical and sexual violence, stigma, lack of access to services) that impact sex workers' vulnerability to HIV. There is growing international evidence of the social and health-related harms that the criminalization of sex work causes. This has increased calls for sex work to be decriminalized in Canada and elsewhere. This article looks at some of the approaches in Canada and globally that help improve sex workers' access to HIV prevention and care services in a criminalized environment. Combination HIV prevention approaches, which include structural and community-led responses, have been shown to be critical to an effective HIV response.
Global HIV Burden Amongst Sex Workers
Sex workers -- consenting adults who exchange sex for money -- experience a disproportionate burden of HIV both in Canada and globally due to structural factors (criminalization, violence, stigma, poor working conditions) that limit sex workers' ability to engage in HIV prevention including the consistent and correct use of condoms.1,2 In Canada, HIV burden is highest among street-involved sex workers, and often acquired through non-commercial intimate partners.
Sex workers represent a diverse population. Although most are women who are serviced by male clients (sex buyers), there are also sizable populations of male and trans (transgender, transsexual and two-spirit) sex workers in Canada and most settings globally.3,4 Sex workers may work either independently (for example, self-advertising online or in newspapers, or the street) or through a third party (such as a manager, book keeper, escort agency) in a variety of locations:
- formal sex work establishments and in-call venues (for example, massage parlours, health enhancement centres, brothels);
- entertainment venues (such as bars, clubs);
- out-call, home-based, or other informal indoor venues (for example, hotels, saunas);
- on the street or in public spaces (such as alleys, parks).
A 2015 comprehensive review of all HIV and sex work research over the last six years identified that individual biomedical and behavioural prevention interventions alone have only had modest impact in shifting the course of the HIV epidemic among sex workers. Instead, the review found that structural factors (those that are external to the individual) have been consistently shown to play the largest role in affecting HIV transmission risks in sex work.2 This review was part of a special sex work and HIV series in the medical journal The Lancet that was launched at a special session of the AIDS 2014 conference in Melbourne, Australia, and includes a diverse team of academic and sex work co-authors and editors.5
Structural Determinants: Barriers and Facilitators if HIV Prevention
Criminalization of Sex Work
Research has consistently demonstrated that the criminalization of sex work and the police response to it continues to force sex workers to move to more hidden street and indoor locations; reduces their ability to screen prospective clients and to negotiate terms of sexual transactions, such as condom use; and limits access to health services including HIV care.6 Police harassment and enforcement have been independently linked to increased violence, refusal of clients to use condoms, and fear of sex workers to carry condoms.7
Physical and Sexual Violence
In Canada, as in other settings where sex work is criminalized, there are alarmingly high rates of workplace physical and sexual violence against sex workers by clients, individuals posing as clients, police, exploitative managers and others.8 Such physical and/or sexual violence has been one of the strongest drivers of HIV risk for sex workers. Violence or threats of violence have been shown to reduce the control sex workers have over transactions with their clients, including their ability to negotiate sexual risks and the use of condoms.6,8
Violence and fear of violence have also been linked to reduced access to health and social services and police protections, particularly for more criminalized and visible sex workers including Indigenous, immigrant, migrant and other racialized sex workers.
In Canada, the current and ongoing violence toward sex workers and the failure of police and services providers to respond have led to a deep-rooted mistrust of health, social and police services.9
Stigma has been shown to significantly increase the HIV risks for sex workers by isolating sex workers from the HIV continuum of services (prevention, testing, treatment, care and support).10 In Vancouver, sex work stigma, fear of disclosure as a sex worker, and discrimination by health providers are among the strongest institutional barriers to care reported by sex workers.11 Stigma disproportionately impacts the most marginalized and criminalized, including Indigenous, immigrant, migrant, and gender and sexual minority sex workers. Trans and male sex workers experience stigma associated with transphobia, homophobia, and perceptions of transgressing gender norms.3,4
Lack of Access to Services
Sub-optimal access to HIV prevention, treatment and care among sex workers remains a major concern across diverse settings globally. Evidence suggests these gaps in access and coverage can only be met alongside changes in structural and community-led efforts.
For example, in Mombasa, Kenya, large scale-up of outreach and programming led by sex workers was compromised by police targeting of service providers and the use of condoms as evidence for arrest.2 Of concern, there is also limited research in both developing and developed countries that documents sex workers' lived experiences, and their interest in and the barriers they face accessing biomedical interventions, particularly HIV treatment and pre-exposure prophylaxis (PrEP).12 Available evidence suggests that many of the same structural drivers of increased HIV risks, including criminalization, policing, violence and stigma, impact sex workers' access and retention in sexual and reproductive health and HIV care services.2,4