Since the beginning of the HIV epidemic, sex workers have been at a substantially increased risk for HIV infection. The disproportionate burden of disease in these individuals has been further emphasised with epidemiological data from several geographical settings and epidemic types.1 Despite the global expansion of access to care and treatment, sex workers with HIV continue to face many barriers to access of services2, 3, 4, 5, 6, 7, 8, 9, 10 and have poor treatment outcomes.11, 12 These findings show that sex workers are exposed to a unique set of factors impeding their health and necessitating increased attention within the global response to HIV.
The context of sex workers' heightened risk for HIV is characterised by various social and structural constraints.13, 14, 15 Sex work is criminalised in some form in 116 countries.16 In many settings, laws, policies, and local ordinances all serve to penalise and marginalise sex workers, and to exclude them from national HIV responses.17 Sex workers experience violations of their human and labour rights. They are also frequently exposed to intersecting social stigmas, discrimination, and violence related to their occupation, gender, socioeconomic position, and HIV status.1, 15, 18, 19, 20, 21 Without addressing these powerful structural challenges, the HIV response in sex workers is likely to be ineffective and unsustainable.
Key messages
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A community empowerment-based HIV response is a process by which sex workers take collective ownership of programmes and services to achieve the most effective HIV responses and address social and structural barriers to their health and human rights.
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Community empowerment-based HIV prevention interventions in sex workers are associated with significant reductions in HIV and STI outcomes and increases in consistent condom use with clients. However, evaluation designs have been weak and geographically restricted. Community empowerment approaches to combination HIV prevention in sex workers are rare and should be expanded and assessed.
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Despite the promise of community empowerment approaches to address HIV in sex workers, formidable structural barriers to implementation and scale-up exist at various levels. These barriers include regressive international discourses and funding constraints; national laws criminalising sex work; intersecting stigmas; and discrimination and violence such as that linked to occupation, gender, socioeconomic status, and HIV.
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Results underscore the need for social and political change regarding the manner in which sex work is understood and addressed, including the need to decriminalise sex work and recognise sex work as work. To help achieve these changes, support for networks and community organisations led by sex workers are needed both globally and locally.
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There is a need to continue to expand and strengthen the evidence base for community empowerment in sex workers, including study designs focused on better capturing and measurement of the process and the effect of empowerment efforts across diverse settings, and further investments in the generation of sex-worker-led, practice-based evidence.
A community empowerment-based response to HIV is a process by which sex workers take collective ownership of programmes to achieve the most effective HIV outcomes and address social and structural barriers to their health and human rights. These efforts are unique in that they are driven by the needs and priorities of sex workers themselves, coming together as a community. Community empowerment in sex workers has been recognised as a UNAIDS Best Practice for more than a decade,22 and continues to underpin key UN policy documents regarding HIV in sex workers.21, 23 Assessments done across various countries have shown community empowerment to be a promising approach to reduce HIV risk in sex workers.24 Results of mathematical modelling suggest that community empowerment efforts can significantly reduce HIV incidence in both sex workers and the general adult population across diverse HIV epidemic scenarios, and that these interventions are cost effective.1, 25 Despite increasing encouraging evidence, government and donor investment in community empowerment-based approaches in sex workers has been low.26, 27
We undertook a comprehensive review of the implementation, effectiveness, and barriers and facilitators of community empowerment-based HIV prevention in sex workers. Within this review, we undertook a systematic review and meta-analysis of the effectiveness of community empowerment in sex workers for key HIV-related outcomes. Additionally, we present four case studies emphasising the social and structural challenges faced by sex workers across settings and their collective responses to reduce their risk for HIV infection and promote their overall health and human rights.
