Decriminalizing sex work could reduce HIV infections among female sex workers, according to a new series on HIV prevention and sex workers published by The Lancet.
Launched at the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia, the series of seven papers and a related infographic examines issues faced by sex workers around the world, and calls for the decriminalization of sex work in an effort to halt and reverse the global HIV epidemic.
Exploring the influence of structural determinants on HIV epidemiology in Canada, Kenya and India, the first paper in the series suggests decriminalizing sex work could reduce HIV infections worldwide.
"Modeling suggests that across both generalized and concentrated HIV epidemics, decriminalization of sex work could have the largest effect on the course of the HIV epidemic, averting 33% to 46% of incident infections over the next decade through combined effects on violence, police harassment, safer work environments, and HIV transmission pathways," the paper's lead author Kate Shannon explained.
The paper also found elimination of violence by clients, police and strangers could avert 17% to 20% of HIV infections among female sex workers and their clients in Canada and Kenya, where sexual violence had an immediate and sustained effect on non-condom use.
According to the Lancet series, sex workers experience higher rates of HIV and other sexually transmissible infections, as well as substantial barriers to prevention, treatment and care services because of stigma, discrimination and criminalization in the societies in which they live.
"It's clear in this series that sex workers, whether they're women, men or transgender, have experienced a disproportionate burden of HIV globally; that they're a population that has been largely overlooked," guest editor Steffanie Strathdee said on the series podcast.
The Lancet series calls for sex workers to be brought to the center of the global HIV response, particularly within sub-Saharan Africa, where the greatest burden of disease is felt.
"Ninety two percent of all HIV/AIDS deaths attributed to sex work occur among African women," guest editors Pamela Das and Richard Horton said in the opening comment of the series.
"When we think of the challenges of HIV prevention and treatment among sex workers, African women must be our first concern."
The Lancet series highlights the effectiveness of community empowerment-based HIV prevention interventions in reducing HIV risk among sex workers and curbing the epidemic among sex workers and the general population.
"Community empowerment-based HIV prevention interventions in sex workers are associated with significant reductions in HIV and STI outcomes and increases in consistent condom use with clients," lead author Deanna Kerrigan explained in the third paper of the series.
"However, evaluation designs have been weak and geographically restricted.
"Community empowerment approaches to combination HIV prevention in sex workers are rare and should be expanded and assessed."
The paper also emphasized the importance of addressing structural implementation barriers such as regressive international discourses, funding constraints and national laws criminalizing sex work.
Katherine Moriarty is a consultant and freelance writer, based in Vancouver. She has 10 years of experience in the intersecting fields of public health and community development, with a focus on bloodborne virus policy and programming.