Policies that criminalize sex work were linked to higher odds of sexually transmitted infections (STIs), HIV infection, unsafe sex practices for sex workers, and sexual violence from their clients or partners, a pooled meta-analysis found.
Repressive policing of sex workers was associated with an almost two-fold higher risk of HIV or STIs (OR 1.87, 95% CI 1.60-2.19), as well as a higher risk of condomless sex (OR 1.42, 95% CI 1.03-1.94), reported Lucy Platt, PhD, of the London School of Hygiene & Tropical Medicine, and colleagues.
These policies were also linked to an almost threefold increased risk of sexual or physical violence from clients or other parties (OR 2.99, 95% CI 1.96-4.57), the authors wrote in PLoS Medicine.
The criminalization of sex work and sex workers was a topic at a panel discussion at the 2018 International AIDS Conference (IAC) in Amsterdam, with researchers finding that not even “end demand” laws — which criminalize the clients and sex worker advertising, but not sex workers themselves — help with healthcare access. In some cases, researchers found that these laws resulted in decreased condom use and difficulty in accessing treatment for sex workers with HIV.
Platt and colleagues examined healthcare issues, as well as other issues related to the treatment of sex workers, in a pooled meta-analysis of 40 quantitative and 94 qualitative studies. Of the quantitative studies, 15 examined HIV and/or STI prevalence, five looked at condom use, and 10 at sexual or physical violence. The majority of studies focused on cisgender women, with only six including transgender women.
Overall, a meta-analysis of 12 studies found that repressive policing of sex workers (examples of which include recent arrest, prison, displacement from a work place, extortion, or violence by officers) was not only associated with higher risk of HIV or STI, but that sex workers who had experienced sexual or physical violence from the police were linked with higher odds of HIV or STIs compared with those who had not (OR 2.27, 95% CI 1.67-3.08).
When examining the nine studies that looked at physical or sexual violence against sex workers, the authors found that physical or sexual violence from clients was higher among those who had been exposed to repressive police activity (OR 2.71, 95% CI 1.69-4.36).
A subgroup analysis of the five studies examining condom use found that “odds of condomless sex with clients was higher following police exposure” (OR 1.42, 95% CI 1.03-1.94). The authors also noted that in studies based in Canada, fear of the police and police harassment was linked to avoiding healthcare services among both cis and trans women.
Notably, the U.S. is among one of three countries in the world, along with South Africa and Sri Lanka, with “full criminalization” of sex work examined in the review, meaning all aspects of selling and buying sex or organization of sex work are prohibited, with the exception of a “legalized brothel system” in Nevada.
However, Platt’s group noted that even in Nevada, it is a crime for a sex worker to test positive for HIV and deliberately expose another human to HIV. Workers who test positive can face up to 10 years in prison if “they are found selling sex in a licensed or an unlicensed environment.”
“[Repressive policing] violations [are] inextricably linked to increased unprotected sex, transmission of HIV and STIs, increased violence from all actors, and poorer access to health services,” the authors wrote.
Study limitations included high heterogeneity in the studies examining condom use and violence, and that studies were limited to those written in either English, Russian, or Spanish. They also noted that “there was a lack of comparable quantitative data on outcomes such as access to services, drug-related harms, and emotional ill health, which precluded the use of meta-analysis.”
Asked at the IAC how clinicians should treat this population when they seek health services, Linda-Gail Bekker, MBChB, PhD, of the Desmond Tutu HIV Centre in Cape Town, South Africa, and president of the International AIDS Society said, “my message to providers is do it anyway, do it with love and compassion, do it expertly and excellently.”
The study was supported by Open Society Foundations and the U.K. Department for International Development, as part of the STRIVE program.
Platt and co-authors disclosed no relevant relationships with industry.