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

Despite global progress in slowing HIV infections, incidence remains stable or increasing among marginalized populations, including sex workers. Female sex workers consistently bear a disproportionate burden of HIV compared to other women. While sex work laws are considered structural determinants of HIV risk, individual-level data assessing this relationship are limited. This study addresses this gap by examining the interplay between sex work laws, stigma, and HIV risk among female sex workers in sub-Saharan Africa. The study aims to understand how punitive legal environments and associated stigmas contribute to higher HIV prevalence among sex workers by examining mechanisms through which stigma impacts HIV across various legal contexts. The lack of sufficient research integrating structural factors, particularly laws governing sex work, into HIV risk assessment among sex workers necessitates this investigation. Understanding these relationships is crucial for developing effective HIV prevention and treatment strategies.

Existing literature primarily focuses on individual-level factors and experiences affecting HIV among sex workers, with limited integration of structural determinants like sex work laws. Studies have shown that punitive legal environments increase vulnerabilities among sex workers through increased stigma, unsafe work environments, and risky behaviors. While ecological studies have observed a correlation between HIV prevalence and sex work laws, individual-level data are scarce. Research on stigma related to sexual behavior, including sex work, is also limited, particularly concerning the interplay between stigma and legal contexts. Previous work has shown that stigma can significantly hinder access to HIV prevention and treatment services. Overall, existing evidence underscores the need for individual-level studies examining the complex interaction of sex work laws, stigma, and HIV risk.

This study employed a cross-sectional design using data from 10 country-specific studies conducted between 2011 and 2018 across sub-Saharan Africa. Respondent-driven sampling (RDS) was used to recruit 7259 female sex workers. Data were collected through interviewer-administered socio-behavioral questionnaires and on-site biological HIV testing. The questionnaires assessed demographic characteristics, HIV risk behaviors, HIV status, disclosure of sex work, and various types of stigma (perceived, anticipated, and enacted). The legal status of sex work in each country was categorized as criminalized, partially legalized, or not legally specified. Data analysis included descriptive statistics, chi-square tests, and multivariable logistic regression models to assess the associations between sex work laws, stigma, and HIV prevalence, adjusting for confounding factors. Sensitivity analysis was conducted using a random sample from Cameroon to verify the robustness of the findings.

The study found a pooled HIV prevalence of 28.6% among the participants. HIV prevalence was significantly higher in countries where sex work is criminalized (39.4%) compared to countries with partial legalization (11.6%) and those with unspecified legal status (19.6%). Multivariable analysis showed that criminalized sex work status was strongly associated with increased odds of HIV infection compared to partial legalization. Various forms of stigma (verbal harassment, blackmail, physical violence) were positively associated with prevalent HIV infection. The relationship between stigma and HIV varied significantly depending on the legal status of sex work; the association was stronger in criminalized and unspecified legal contexts. In criminalized settings, fear of stigmatization in healthcare settings was associated with higher HIV prevalence. The interaction between stigma and legal status suggests a synergistic effect in increasing HIV risk. The lack of protection from uniformed officers, leading to violence and blackmail, was prevalent and contributed to higher HIV risk, particularly in criminalized settings.

The findings strongly support the hypothesis that punitive sex work laws and associated stigmas are major contributors to the high HIV burden among sex workers in sub-Saharan Africa. The significantly higher HIV prevalence in criminalized settings highlights the importance of structural determinants of HIV risk. The synergistic effect of stigma and punitive laws amplifies the barriers to accessing HIV prevention and treatment services and increases the overall vulnerability of sex workers. The study’s findings underscore the urgency of implementing evidence-based, human-rights affirming policies towards sex work. Decriminalization or legalization could significantly reduce HIV transmission by creating safer work environments and improving access to health services. Addressing stigma through targeted interventions within healthcare systems and communities is essential for reducing HIV risk among sex workers.

This study provides compelling evidence for the strong association between punitive sex work laws, stigma, and elevated HIV risk among female sex workers in sub-Saharan Africa. The synergistic effect of these factors underscores the urgent need for policy changes towards decriminalization or legalization of sex work, coupled with comprehensive stigma reduction interventions. Further research should explore the specific mechanisms through which these factors interact and evaluate the effectiveness of various policy and intervention strategies in different legal contexts.

The cross-sectional study design limits the ability to establish causality. The use of RDS may introduce sampling bias. Country-specific differences might be lost in the pooled analysis. The study did not assess the temporal relationship between the implementation of laws and the onset of HIV epidemics. Unmeasured confounders could influence the observed associations. The data collection period spanned seven years, potentially impacting the consistency of enforcement practices, program funding, and external factors.