However, the distribution, scale, and intensity of STI prevention programs targeted towards sex work must be guided by better epidemic analysis, including analysis of HIV transmission dynamics and an understanding of geographic and population heterogeneity.
The overall investment in sex worker HIV prevention programs relative to total national spending on HIV prevention should be guided by the fraction of total HIV infections that are due to sex work. In some cases, sound analysis of an HIV epidemic within a country has been undertaken and has led to investment in HIV reduction programs for sex workers.
For example, in India a sound epidemic analysis has led to appropriate investments in HIV reduction interventions targeted towards sex work [ 27 , 36 — 38 ]—India recognized that its epidemic was driven by sex workers in four high burden southern and western states and focused its HIV prevention investments on sex worker HIV prevention programs in these high burden states. In short, the investments followed the epidemic and reflected HIV transmission patterns [ 38 ].
In Southern African countries where HIV is highly generalized and hyperendemic, epidemic analysis suggests very different transmission dynamics. For example, behavioral surveys in the highest prevalence countries, such as Swaziland, Botswana, and Lesotho, suggest that a small fraction of men visit sex workers. Even in potential client occupations such as soldiers, police, guards, and truckers, most men report having casual rather than commercial sexual partners [ 39 , 40 ].
In such contexts, studies of sources of new infections and HIV transmission dynamics suggest that sex work contributes only a small fraction of new HIV infections, and investment in HIV programs must reflect these wide epidemic gradations. Understanding the contribution of sex work to a local HIV epidemic is, however, only part of the solution, as political commitment to address the health needs of sex workers is critical.
In some contexts where HIV transmission sources are well characterized and sex work plays a major role, national programs do not prioritize sex worker HIV interventions [ 35 ]. Situation analyses and programmatic mapping are the foundation for high quality HIV programs.
While knowing the HIV prevalence and contribution of sex work to an epidemic at a national level is important for advocacy and broad allocative funding choices, understanding the local context is critical for program management and service delivery. Situation analyses and programmatic mapping are usually the first step in an iterative process that is typically undertaken by effective HIV programs that target HIV in the context of sex work. Effective sex worker HIV prevention programs typically undertake methodical situation analyses to develop typologies of sex work, such as seaters sex workers who operate from a fixed place or roamers sex workers who are mobile , or bar-based, street-based, or home-based, and to identify and map areas where sex workers live and meet clients [ 42 — 44 ].
Programmatic mapping is then used to situate services, such as STI and sexual and reproductive health clinics, assign mobile services, recruit and deploy peer educators, and target outreach and condom distribution. Programmatic mapping also helps to determine and assess coverage, set behavioral and biological targets, and monitor performance.
However, in contexts where serious human rights violations occur and sex workers face harassment or arrest from officials or the public, the risks of mapping and enumeration of sex workers outweigh the advantages and discrete programming that does not identify participants as sex workers may be required without systematic mapping and enumeration.
Even where human rights are robust, data protection and confidentiality must be carefully maintained, including adherence to best practice guidelines for the protection of geographically coded data that enable authorities to identify the precise location of sex work venues. Such data protection guidelines should be based not only on the current human rights context but prudent assessment of future worst-case changes in human rights [ 45 — 47 ].
The coverage, quality, comprehensiveness, and impact of HIV prevention interventions for sex workers are variable, and consistency may be improved using implementation science [ 7 — 9 , 48 — 50 ]. The Avahan project shows how implementation science may increase the scope, intensity, and impact of sex worker HIV prevention programs [ 29 , 38 , 52 — 55 ].
These implementation science lessons may be used to increase the scope, quality, and impact of sex worker HIV prevention and treatment programs. India has successfully transitioned from international to domestic financing and now largely finances its own HIV program, including sex work interventions.
India did so by developing mechanisms for the government to contract civil society partners to implement sex worker HIV prevention programs, developing financial and performance monitoring systems, and by progressively increasing the domestic share of the financing of the national HIV response. This must be urgently addressed, with domestic financing for sex worker HIV prevention programs where feasible. Access to treatment requires comprehensive services for sex workers, including actions to overcome stigma and discrimination.
Treatment adherence among sex workers has powerful behavioral determinants and is reinforced by sex worker friendly services, peer support, and a supportive policy and legal context. Consistent condom use, reinforced by client programs, offers sex workers additional protection from HIV-infected clients who may or may not be on treatment and virally suppressed.
Group solidarity and empowerment creates a powerful impetus for HIV prevention and treatment adherence and is cost-effective [ 62 ]. The assertion that sex worker HIV prevention programs are effective applies to formal, self-acknowledged, professional sex workers.
However, it is less true for informal non-self-identifying sex work and is even less true for transactional sex if transactional sex is considered a form of sex work. While transactional sex involves the exchange of gifts, this exchange may be delayed and the link not necessarily acknowledged by either party [ 63 ].
For this reason, programmatic and communications approaches to address informal sex work may have more in common with general population interventions than formal sex work interventions.
This makes transactional sex harder to address: The HIV response must develop and evaluate intervention models for informal sex work. This is urgently needed for several reasons: As virtual solicitation replaces physical solicitation, as it is doing rapidly among men who have sex with men, there is a growing danger that programs will continue to focus on the sex work industry of the past and not reach the sex work industry of today and the future.
Surveillance, programs, monitoring, and evaluation must rapidly evolve to address mobile- and internet-based sex work or risk irrelevance. This requires developing well-evaluated models that reach sex workers who seek clients through mobile phones or internet, providing them with effective behavior change communication, and linking them to HIV, STI, mental health, and addiction services as needed.
There Is Need to Increase Programs for Male and Transgender Sex Workers Male and transgender sex workers are at great risk of stigma, discrimination, gender-based violence, and HIV infection, yet receive fewer programs and services [ 72 — 75 ]. The accelerating global bifurcation of countries who embrace greater rights for sexual minorities, including much of the global north, parts of Latin America, India, Nepal, and South Africa, and countries with restrictive laws and policies including parts of the Caribbean, the Middle East, the former Soviet Union, and Africa presents a challenge for intensified male and transgender HIV programs [ 76 , 77 ].
The AIDS movement must continue to advocate for equal rights for sexual minorities, while seeking to expand services for sexual minorities. The global AIDS response must elevate political commitment to address male and transgender sex workers, increase investment in programs for male and transgender sex workers, and evaluate and promote effective models for reaching male and transgender sex workers.
They also face systematic barriers to accessing appropriate services [ 81 — 84 ]. Sex workers will not achieve equitable access to HIV treatment and health services without concerted strategies to ensure they can overcome these barriers to access and adhere to uninterrupted care.
Stigma, discrimination, and criminalization are not only obstacles to HIV treatment access but also to treatment adherence and viral suppression. The fear of arrest and consequent need to hide or move to avoid arrest, together with actual arrest and incarceration without access to services, present major obstacles to HIV treatment initiation and adherence and wider health care and require specially targeted and tailored approaches [ 84 ].
In short, extra, concerted effort is needed to overcome the barriers that sex workers face and provide equitable access to services. It underscores the need for concerted effort to ensure marginalized communities of sex workers receive equitable access to HIV and wider health services. Acknowledgments The author would like to acknowledge and thank Jessica Taaffe for her assistance with finding and formatting references.
Author Contributions Analyzed the data: Agree with manuscript results and conclusions: ICMJE criteria for authorship read and met: Increase in condom use and decline in HIV and sexually transmitted diseases among female sex workers in Abidjan, Cote d'Ivoire, —