The role of sex work laws and stigmas in increasing HIV risks among sex workers

The study addresses persistent high HIV burden among female sex workers despite overall global declines in HIV incidence. It situates sex work laws (criminalization, legal ambiguity, or partial legalization) and stigma as structural determinants that may elevate HIV risk beyond individual behaviors. Prior work has emphasized individual-level factors, with comparatively fewer analyses integrating structural-level determinants such as legal frameworks and stigma. The authors aim to quantify the association between legal status of sex work and HIV prevalence among female sex workers across sub-Saharan Africa and to examine how different forms of stigma (perceived, anticipated, and enacted) relate to HIV and whether these relationships vary by legal context. The purpose is to generate individual-level, multi-country evidence to inform policy and programs that address structural barriers to HIV prevention and care for sex workers.

Existing evidence demonstrates female sex workers bear a disproportionate HIV burden, with markedly higher odds of HIV compared to other women of reproductive age. Ecological and modeling studies suggest punitive legal environments increase vulnerabilities and that decriminalization could substantially reduce new infections by mitigating violence, policing-related harms, and unsafe work conditions. Systematic reviews indicate harms associated with criminalization and benefits with more protective policies, but individual-level cross-country data are limited. Stigma has been well-studied for sexual and gender minorities, but measurement specific to sex work is scarce. Intersecting stigmas (sex work and HIV status) impede engagement across the HIV cascade. Global agencies emphasize addressing legal and stigma barriers as essential to effective HIV responses. This study builds on these gaps by leveraging multi-country individual-level data to assess how legal contexts and stigmas jointly influence HIV risk.

Design and setting: Pooled cross-sectional analyses of 10 country-specific studies conducted across sub-Saharan Africa between 2011 and 2018. Participants: 7259 female sex workers recruited via respondent-driven sampling (RDS) in multiple urban sites per country. Eligibility: Adult women engaged in sex work and able to provide informed consent; country-specific inclusion criteria and ethical approvals were obtained from Johns Hopkins Bloomberg School of Public Health IRB and national/local ethics committees in participating countries. Data collection: Interviewer-administered socio-behavioral questionnaires captured demographics, sex work history, HIV-related behaviors, service access, and multiple stigma domains (perceived, anticipated, and enacted, including healthcare-related stigma, policing-related stigma, verbal harassment, blackmail, physical and sexual violence). Biological testing for HIV with pre/post-test counseling was conducted on-site; reactive cases were referred to care. Exposure classification: Country-level legal status of sex work categorized as partially legalized, not specified, or criminalized. Outcomes: Prevalent HIV infection (biologically confirmed). Statistical analysis: Descriptive statistics summarized sample characteristics. HIV prevalence was estimated overall and by legal status. Associations between legal status and HIV were assessed using logistic regression with adjustment for age, education, marital status, years in sex work, and country-level epidemic context, clustering by site and country; results reported as adjusted odds ratios (aOR) with 95% CIs. Separate multivariable models assessed associations between individual stigma indicators and prevalent HIV, adjusting for relevant covariates and clustering; disclosure-related covariates were included when conceptually relevant. Effect modification by legal status was evaluated using Mantel–Haenszel tests of homogeneity and stratified multivariable analyses where interaction was indicated. Sensitivity analyses included a random subsample from Cameroon to assess robustness. Ethics: All participants provided informed consent; testing and counseling followed standard protocols; referrals to care were provided.

- Sample: N=7259 female sex workers from 10 countries; median age 27 years (IQR 22–34); median 4 years in sex work (IQR 2–8). Overall pooled HIV prevalence: 28.6% (2007/7230; 95% CI 27.6–29.7). - Legal status and HIV prevalence: Partially legalized settings: 11.6% (219/1894); legal status not specified: 19.6% (248/1265); criminalized: 39.4% (1603/4071); χ² p<0.001. - Adjusted associations (vs partially legalized): - Criminalized: aOR 7.17 (95% CI 2.71–18.95), p<0.001. - Not specified: aOR 2.35 (95% CI 1.06–5.21), p=0.036. - Stigma and HIV (pooled adjusted models): - Police refused protection: aOR 1.39 (95% CI 1.20–1.61), p<0.001. - Verbally harassed: aOR 1.23 (95% CI 1.02–1.49), p=0.029. - Blackmailed: aOR 1.32 (95% CI 1.13–1.54), p<0.001. - Denied health services: aOR 1.29 (95% CI 1.18–1.50), p=0.004. - Forced to have sex (sexual violence): aOR 1.93 (95% CI 1.44–2.59), p=0.001. - Fear of being in public spaces showed a negative association with prevalent HIV (aOR 0.67; 95% CI 0.48–0.94), p=0.024. - Effect modification by legal status (Mantel–Haenszel homogeneity tests generally p<0.01 for many stigma indicators): - In criminalized settings, fear of stigmatization in healthcare was associated with higher odds of HIV (aOR 1.51; 95% CI 1.13–2.13; p<0.001) compared with partially legalized settings. - Police refusal of protection associated with higher odds of HIV in settings with non-specified legal status (aOR 1.64; 95% CI 1.29–20.8; p<0.001) and criminalized settings (aOR 1.38; 95% CI 1.10–1.72; p=0.005) versus partially legalized. - Blackmail associated with HIV in non-specified (aOR 1.50; 95% CI 1.37–1.65; p<0.001) and criminalized (aOR 1.35; 95% CI 1.07–1.71; p=0.010) settings relative to partially legalized. - Sensitivity analyses with a Cameroon subsample were consistent with main results.

Findings demonstrate that punitive and non-protective legal environments are strongly associated with higher HIV prevalence among female sex workers. Stigma is prevalent and independently associated with HIV, with several forms of stigma (healthcare-related discrimination, police refusal of protection, verbal harassment, blackmail, and sexual violence) linked to higher odds of HIV. The strength of these associations varies by legal context, indicating that stigmas and legal status may act synergistically, with greater harmful effects in criminalized or legally non-specified settings. These environments likely amplify barriers to safety and access to effective HIV prevention and treatment services, while partially legalized settings may confer some protection through improved social capital, resilience, and institutional support. Violence—particularly physical and sexual violence—remains a critical driver of HIV risk, and its association with HIV is more pronounced in criminalized settings. The results align with ecological and modeling studies suggesting that decriminalization and protective policies could substantially reduce HIV incidence by mitigating violence, policing-related harms, and unsafe work conditions. Programmatically, the study underscores the necessity of integrating structural interventions—law and policy reform, anti-discrimination enforcement in healthcare, law enforcement training and accountability, and safe work environments—alongside biomedical and behavioral strategies to reduce HIV burden among sex workers.

This multi-country, individual-level analysis provides evidence that punitive and non-protective sex work laws and pervasive stigmas are linked to higher HIV prevalence among female sex workers, and that the impact of stigma on HIV is generally stronger in criminalized or legally ambiguous contexts. The study highlights the critical need for human-rights affirming, evidence-based policies, including decriminalization of sex work, anti-discrimination protections in healthcare, accountability mechanisms in policing, and interventions to prevent and respond to violence. Future research should employ longitudinal designs to clarify causal pathways, measure the periodicity and dynamics of stigma over time, evaluate stigma-reduction interventions tailored to sex workers within differing legal contexts, and more fully characterize intersectional stigma (sex work and HIV) and its impact on the HIV prevention and treatment cascades.

- Cross-sectional design precludes causal inference and temporal ordering between stigma exposures and HIV status. - Pooled multi-country analysis may mask important site or country-specific heterogeneity despite clustering adjustments. - Legal context classification relied on country legislation and did not capture enforcement practices or subnational variations; the study included no fully decriminalized settings, limiting comparisons. - Potential unmeasured confounding affecting both legal environments/stigma and HIV outcomes. - Data collection spanned approximately seven years; changes in programs, enforcement, and epidemics over time could influence findings. - Some stigma constructs (e.g., frequency/periodicity of experiences) were not measured; intersectional stigma due to both sex work and HIV status warrants deeper evaluation. - Self-reported behavioral and stigma measures are subject to recall and social desirability biases.