AIDS & prostitution

For years, ‘prostitution’ has been a major theme in discussions about the global AIDS and HIV epidemic. The media often run stories about HIV that focus on individuals who sell sex, and both governments and HIV related organisations frequently talk about prostitutes and prostitution in the context of AIDS.

Why is ‘AIDS and prostitution’ an issue?

This topic is significant for several reasons:

• High rates of HIV have been found amongst individuals who sell sex in many different and diverse countries. Even where HIV prevalence is low amongst this group, it is usually higher than the rate found amongst the general adult population.
• Sex workers usually have a high number of sexual partners. This means that if they do become infected with HIV, they can potentially pass it on to multiple clients.
• Preventing HIV infections amongst those involved in the sex trade has been proven to be an instrumental part of many countries’ fight against AIDS. We discuss this issue in our HIV prevention and sex workers page.

‘Prostitutes’ or ‘sex workers’?

Although the word ‘prostitution’ can be used to describe the act of selling sex, it can also mean ‘using a skill or ability in a way that is considered unworthy’. It seems to include a moral judgement, by implying that individuals who sell sex are somehow ‘unworthy’, or involved in a practice that is corrupt. A far more neutral and respectful alternative is the term ‘sex work’.
This issue may not matter so much in the context of everyday conversations or casual debates, but in serious discussions on the topic it is important that words are chosen carefully. Since this article seeks to discuss the issue of HIV and sex work in an open and non-judgemental way, we refer to sex workers rather than prostitutes.
Some authorities continue to talk about prostitutes, but they often do so because they wish to make a moral comment about the sex trade. In addition, some people talk about sex workers ‘fuelling the spread of HIV’. Not only is this an example of poorly chosen wording, but it is also a claim that is questionable in its accuracy.

What role do sex workers play in the global AIDS epidemic?

Sex workers, along with other marginalised groups such as men who have sex with men and injecting drug users, are often labelled a 'key risk group' in the context of HIV and AIDS. But the debate about sex workers’ wider role in the global AIDS epidemic often polarises opinion. Some argue that sex workers are being wrongly portrayed as ‘spreaders’ of HIV, while others claim that HIV transmission through paid sex is ‘driving’ the epidemic.
In truth, the situation differs vastly between different countries and regions. While HIV prevalence is high amongst sex workers in some areas, in others it is relatively low, and they seem to play a fairly minor role in the spread of HIV. For instance, in most parts of Western Europe and North America, HIV transmission through paid sex is not considered to be a major issue. In other regions, however, notably parts of Asia, large numbers of sex workers are living with HIV, and this is influencing the overall pattern of the AIDS epidemic.

A sex worker stands in a doorway at a brothel in Northern Thailand.

The factors that put sex workers at risk also vary between countries. In some places, sex workers commonly use drugs and share needles. The overlap between sex work and injecting drug use is linked to growing HIV epidemics in a number of countries, such as China, Indonesia, Kazakhstan, Ukraine, Uzbekistan and Vietnam.¹ Studies often find higher rates of HIV infection amongst sex workers who inject drugs than amongst those who do not. For example, in Ho Chi Minh City, Vietnam’s largest city, a 2003 study found that 49% of sex workers who injected drugs were HIV-positive, compared to 8% of those who did not use any drugs.²
As well as regional differences between sex workers, the picture is further blurred by a general lack of information on this group. Sex workers are a marginalised and often criminalised population, and are therefore very difficult to track and monitor. ³
Due to the lack of certainty, some people argue that labelling sex workers as a ‘high risk group’ is not helpful, and is simply used an excuse to further stigmatise sex workers by those who are morally opposed to their profession:

“Apart from the stigma already attached to [sex workers], society has further marginalised them as core transmitters of the HIV infection. It fails to understand and recognise that they are but links in the broad networks of heterosexual transmission of HIV. And that they constitute a community that bears and will continue to bear the greatest impact of the HIV epidemic.” Meena Seshu, SANGRAM (a project working with sex workers in India)⁴

It is certainly true that sex workers are simply one part of the wider network of HIV transmission, and that ‘blaming’ them for the spread of HIV is misguided. Those who do blame sex workers seem to take an ‘us and them’ approach to the issue, and talk about sex workers as if they are somehow inferior to other population groups. Ultimately, whatever moral stance you take on sex work, no one deserves to become infected with HIV.
While it is important that sex workers are protected from discrimination, and that their role in the global AIDS and HIV epidemic is not overstated, it is equally important that high rates of infection amongst sex workers are not overlooked. There is evidence that commercial sex is a significant factor in many countries’ AIDS epidemics.

HIV and sex work around the world

Asia

In Asia, which contains some of the fastest growing AIDS epidemics in the world, it is believed that a high proportion of new HIV infections are transmitted during paid sex.⁵
Historically, the AIDS epidemic in India was first identified amongst sex workers and their clients, before other sections of society became affected.⁶ The same is true in Thailand, although the Thai government were faster to act on this problem. In the early 1990s, they implemented the now famous ‘100% condom programme’, enforcing mandatory condom use in brothels throughout Thailand, which helped to significantly reduce the spread of HIV.
High HIV infection rates continue to be detected in India. The government estimates that 8% of sex workers nationally are infected with HIV, which is almost nine times higher than the overall HIV prevalence rate for Indian adults.⁷ What is more, studies of sex workers in individual areas have found much higher HIV prevalence rates, such as 44% in Mumbai, and 26% in Mysore.⁸ AVERT has more about HIV and sex workers in India.
In South and South-East Asian countries outside India, the United Nations estimates that sex workers and their clients accounted for almost half of all people living with HIV in 2005.⁹
There are also fears that commercial sex is having an increasing influence on the AIDS epidemic in China. China’s AIDS epidemic is expanding, and at the same time, it is thought that the demand for commercial sex is growing.¹⁰ The Chinese government estimates that in 2005, sex workers and their clients accounted for just under 20% of people living with HIV nationally.¹¹

Sub-Saharan Africa

More so than in many other regions, women in sub-Saharan Africa often turn to sex work because they are desperately poor and have no other way of earning an income. In some cases, women or girls are not involved in sex work as a long-term occupation, but may exchange sexual services for money as a temporary measure ­– for instance, to pay school tuition fees, or to provide food for their family at a time of crisis.¹²
The spread of HIV through commercial sex is a major issue in parts of West Africa. In Senegal, for instance, the AIDS epidemic appears to be driven by commercial sex, with around 27.1% of sex workers in the country’s capital, Dakar, found to be infected with HIV in 2005. Similarly, commercial sex seems to be a significant factor in Ghana’s AIDS epidemic. Studies of sex workers in 2005 also found high HIV prevalence rates in the West African nations of Togo (53.9%) and Burkina Faso (20.8%).¹³
In other parts of Africa, past studies of urban areas have found levels of HIV infection as high as 73% among sex workers in Ethiopia, and 68% among those in Zambia.¹⁴

The Caribbean

The Caribbean’s thriving sex industry, which serves both local clients and many tourists, features prominently in the AIDS epidemics of certain countries, such as the Dominican Republic and Jamaica.¹⁵ A handful of countries in the region have established creative HIV prevention campaigns aimed at sex workers; in Haiti, for example, a non-governmental organisation called FOSREF offer professional salsa dancing lessons to sex workers who are interested in leaving the sex trade and becoming dancers. In general, though, sex workers are being overlooked in the Caribbean, and this is holding back the region’s fight against AIDS.¹⁶

Latin America

Information about the role of sex workers in Latin America’s AIDS epidemic is sparse, and shows a varied picture. In 2005, it is thought that sex workers and their clients accounted for almost one in six people living with HIV in Latin America as a whole,¹⁷ and UNAIDS has reported that some of the AIDS epidemics in Central America are ‘strongly related’ to sex work.¹⁸
However, HIV prevalence rates amongst sex workers in South America seem to be relatively low. A study released in 2006, which analysed sex workers in nine South American countries over a thirteen-year period, concluded that “consistently low HIV seroprevalences were detected among female commercial sex workers in South America, particularly in the Andean region”.¹⁹

Eastern Europe/ Central Asia

The number of sex workers in Eastern European and Central Asian countries has risen dramatically in recent history. This is due to social, economic and political changes that led many to turn to sex work as a means of income.
HIV prevalence rates generally seem to be low amongst sex workers in the region. Levels of sexually transmitted infections, however, are high, suggesting that few sex workers are practising safer sex, and that there is scope for HIV to become more common among sex workers in coming years. Commercial sex is playing an increasingly prominent role in the AIDS epidemics of many countries in the region.²⁰
In Russia, sex workers commonly become infected with HIV through injecting drug use rather than sex. In the city of St Petersburg, 48% of sex workers were found to be living with HIV in 2003, and this high prevalence is attributed to the fact that most sex workers in the city also inject drugs.²¹ By contrast, in the capital city of Moscow, where the sex industry is more organised and actively discourages drug use, only 3% of sex workers were thought to be infected with HIV in 2005.²²

Western Europe and North America

In Western Europe, levels of HIV infection seem to be relatively low amongst sex workers who do not inject drugs. For sex workers who do inject drugs, the risk is often significantly higher. In many areas, it also seems that male and transgender sex workers are more vulnerable to HIV than female sex workers.²³ As with other regions, however, there is a lack of recent data available on HIV infections among sex workers in Western Europe.
The same is true in the United States, where the government takes a strong stance against sex work, as demonstrated by its refusal to grant overseas aid to any HIV/AIDS projects that do not ‘explicitly oppose’ the practice. Domestically, sex work is illegal in the U.S. (with the exception of a few counties in the state of Nevada), and very little information is gathered about workers and their clients. As with Western Europe, many of the HIV cases that do occur amongst sex workers in the U.S. are attributed to injecting drug use rather than sex.²⁴

The way forward

It is clear that sex workers are not ‘universally’ at high risk of becoming infected with HIV, and that the situation varies widely between regions. However, it is also apparent that in many of the countries where AIDS is taking its heaviest toll, large number of sex workers are being affected by HIV, and this is a major issue.
Improving the situation will require greater efforts by governments, groups, and individual members of society to help sex workers. It is particularly important that sex workers gain access to HIV prevention and treatment programmes. Such programmes not only save sex workers’ lives; they can also help to stem the wider impact that HIV is having on societies around the world.
To read a detailed account of what needs to be done, and to find out about some of the most famous examples of campaigns that have reduced the impact of AIDS on sex workers, see our HIV prevention and sex workers page.

References

1. UNAIDS/WHO 2006 Report on the Global AIDS Epidemic, Chapter 5
2. MAP (2005). Sex work and HIV/AIDS in Asia.
3. UNAIDS (2009, February), 'UNAIDS guidance note on HIV and sex work'.
4. UNDP (2007, 7th February),Interview - Meena Seshu, director, Sangram
5. UNAIDS/WHO AIDS Epidemic Update: December 2006
6. Kakar D.N. and Kakar S.N. (2001), 'Combating AIDS in the 21st century Issues and Challenges', Sterling Publishers Private Limited, p.31
7. NACO (April 2006), HIV/AIDS epidemiological Surveillance & Estimation report for the year 2005
8. NACO, Observed HIV Prevalence Levels State Wise: 1998-2004
9. UNAIDS/WHO AIDS Epidemic Update: December 2006
10. Tucker J. D. et al. (2005), 'Surplus men, sex work, and the spread of HIV in China', AIDS 2005 (19:539)
11. Ministry of Health People’s Republic of China/UNAIDS (2005). Update on the HIV/AIDS epidemic and response in China. Beijing.
12. UNAIDS (2002, June), 'Sex Work and HIV/AIDS, UNAIDS Technical Update'
13. UNAIDS/WHO Report on the Global AIDS Epidemic, May 2006
14. UNAIDS/WHO Report on the Global AIDS Epidemic, May 2006
15. UNAIDS/WHO AIDS Epidemic Update: December 2006
16. Cohen, J. (2006, 28th July), ‘HIV/AIDS: Latin America and the Caribbean’, Science Vol. 313 Issue 5786
17. UNAIDS/WHO AIDS Epidemic Update: December 2006
18. UNAIDS/WHO AIDS Epidemic Update: December 2005
19. Bautista C. T. et al. (2006), 'Seroprevalence of and risk factors for HIV-1 infection among female commercial sex workers in South America', Sexually Transmitted Infections 82:311
20. UNAIDS (2006), 'HIV and sexually transmitted infection prevention among sex workers in Eastern Europe and Central Asia'
21. Smolskaya T et al. (2005), “Sentinel sero-epidemiological and behavioural surveillance among female sex workers, St Petersurg, Russian Federation, 2003”
22. UNAIDS/WHO Report on the Global AIDS Epidemic, May 2006
23. Hamers F. F. and Downs A. M (2004), 'The changing face of the HIV epidemic in western Europe: what are the implications for public health policies?', The Lancet 364(83)
24. World Health Organisation (2004), Sex Work Toolkit