Academic journal article Bulletin of the World Health Organization

HIV and Female Sex Workers

Academic journal article Bulletin of the World Health Organization

HIV and Female Sex Workers

Article excerpt


At the beginning of the acquired immunodeficiency syndrome (AIDS) pandemic it was thought that female sex workers might constitute a high-risk group for the transmission of human immunodeficiency virus (HIV). Because seroprevalence studies showed high rates of infection among female sex workers in Africa, it was feared that in Europe and the USA also such women might spread HIV heterosexually. This belief has resulted in increased stigmatization of sex workers, and in some places has led to restrictive legislation, such as mandatory HIV testing and the quarantining of infected persons (1).

Sex workers are, however, a heterogeneous group in terms of their working environment, socioeconomic situation, health status, and knowledge and practice of protective measures. The HIV seroprevalence rates among them vary considerably from country to country, within the same country, and from one type of sex worker to another. More than sexual promiscuity per se, HIV infection is associated with other risk factors, such as drug injection behaviour, having a steady sexual partner who is an injecting drug user, and infection with sexually transmitted diseases (STDs).

In this article, we review the literature published in English, French, and Spanish on HIV infection among female sex workers in various parts of the world

and discuss the principal risk factors associated with acquisition of the virus. We also comment on some HIV studies that have been carried out on the clients of sex workers. Finally, we make proposals for future research efforts and discuss various interventions that need to be undertaken to reduce HIV transmission among sex workers and their clients.

Types of sex work

Although most of the studies do not report HIV seroprevalences by type of sex workers, it is important to recognize that there are many forms of sex work, which frequently vary from country to country. in general, individuals who "work the streets" are the most visible in all cultures. However, sex workers also recruit clients in hotels, bars, bus stations, or truck stops; they may be attached to brothels, saunas, or massage parlours, or work as hostesses in clubs; they may maintain a private list of clients and operate from their own homes as independent call-girls; or they may be employed by private agencies such as escort services[1, 2]. Some forms of sex work, such as Amsterdam's "window prostitutes"[3] or India's high-class courtesans, who are accomplished in music and dancing[4], may be exclusive to a particular country.

One difficulty in attempting to classify sex workers by type is what criteria to select. Depending on how commercial sex is organized in a particular country or the purpose of the investigation, it may be more useful to categorize such workers by place of client recruitment (e.g., on the streets, in hotels or clubs, from home), type of client (local or foreigner), amount charged, registered versus "freelance", etc. Furthermore, although the different types of sex workers may be well-known in a particular country or area, not all subgroups are equally accessible. It may be possible to recruit a relatively large street sample, since these women can be approached directly and offered incentives to participate (e.g., health care, free condoms, an opportunity to discuss their problems). However, it may be much more difficult to recruit women who work in clubs or brothels, particularly if there is management opposition; and it is virtually impossible to reach women who work privately, such as call-girls or housewives who occasionally supplement the family income in this way. Since representative samples of sex workers are notoriously difficult to obtain, researchers frequently resort to "convenience samples" recruited using various techniques; for example, from STD clinics, drug-treatment centres, through sex workers' organizations, and by advertising in newspapers or magazines. …

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