Sex work
Socio-demographic characteristics and behavioural risk factors of female sex workers in sub-Saharan Africa: a systematic review
Scorgie F, Chersich MF, Ntaganira I, Gerbase A, Lule F, Lo YR. AIDS Behav. 2011 Jul 13.
Sex work remains an important contributor to HIV transmission within early, advanced and regressing epidemics in sub-Saharan Africa, but its social and behavioural underpinnings remain poorly understood, limiting the impact of HIV prevention initiatives. This article systematically reviews the socio-demographics of female sex workers in this region, their occupational contexts and key behavioural risk factors for HIV. In total 128 relevant articles were reviewed following a search of Medline, Web of Science and Anthropological Index. Female sex workers commonly have limited economic options, many dependents, marital disruption, and low education. Their vulnerability to HIV, heightened among young women, is inextricably linked to the occupational contexts of their work, characterized most commonly by poverty, endemic violence, criminalisation, high mobility and hazardous alcohol use. These, in turn, predict behaviours such as low condom use, anal sex and co-infection with other sexually transmitted infections. Sex work in Africa cannot be viewed in isolation from other HIV-risk behaviours such as multiple concurrent partnerships-there is often much overlap between sexual networks. High turn-over of female sex workers, with sex work duration typically around 3 years, further heightens risk of HIV acquisition and transmission. Tailored services at sufficiently high coverage, taking into account the behavioural and social vulnerabilities described here, are urgently required to address the disproportionate burden of HIV carried by female sex workers on the continent.
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Editor’s note: This exhaustive review examines the structural and occupational contexts that shape sex worker vulnerability to HIV exposure in sub-Saharan Africa. It distinguishes between sex work and more ‘socially accepted’ transactional sex (exchanges of material goods¾such as food, cosmetics, transport, school fees, items for children, or a place to sleep for sex). Sex work is defined using the 2000 UNAIDS definition as ‘any agreement between two or more persons in which the objective is exclusively limited to the sexual act and ends with that and which involves preliminary negotiations for a price’. Sex work in sub-Saharan Africa is not typically based in large-scale brothels, as are found in Asia, and does not commonly involve intermediaries, although there are pimps in some settings and middlemen on the highways. The settings for solicitation are at the place of sex, e.g. outdoors in some settings, or different from the place of sex, e.g. sex may be negotiated in a drinking venue but take place at the sex worker’s home. As virtually everywhere worldwide, sex in the man’s space, e.g. his car or room, entails increased risk of violence and forced unprotected sex. Overall, clients come from all corners of society. Although mobility, employment in seasonal agriculture or the military, and separation of workers from family are factors that predict purchase of sexual services, frequently men residing in surrounding communities are also clients. Condom use, anal and oral sex practices, alcohol and other substance use, harmful legislation, human rights violations, coercion, stigma, and poor access to services¾you will find them all mentioned in this review. The challenge is to move from epidemiological studies that treat sex workers as a ‘core group’ to implementation of rights-based, evidence-informed initiatives that are designed for and by sex workers to reduce vulnerability by improving sex work conditions and contexts. This would be greatly facilitated by structural interventions to decriminalise sex work, as Senegal has done.
