Table 4 Studies describing promising structural-level intervention and prevention practices among sex workers in high-income countries
Reference | Country | Study Design / Methods | Population | Context of Promising Structural-Level Intervention and Prevention Practices | Policy Implications |
|---|---|---|---|---|---|
Abel et al., 2012 [101] | New Zealand | Survey and qualitative interviews | 58 sex workers (all genders) | Decriminalization & Safer Work Environments. In context of decriminalization of sex work, risk perception influenced workers’ decisions to operate in street-based, managed or private sectors of the sex industry. | Alongside decriminalization, social and economic policies are required to address risk and develop enabling environments across sex work sectors of sex work industry. |
Anderson et al., 2015 [86] | Canada | 46 qualitative interviews | Migrant/immigrant women (trans inclusive) sex workers and managers/owners of indoor establishments | Decriminalization & Safer Work Environments. Women described how policing practices and licensing requirements for indoor sex work establishments shape violence and conflict with clients. | Removing prohibitive municipal licensing and legislation reform is needed to improve safety of sex work environments. |
Argento et al., 2016 [106] | Canada | 61 qualitative interviews | Cis and trans men who buy and/or sell sex | Community Empowerment & Safer Work Environments. Community-based project; narratives describe how gentrification and online sex work shape social networks, safety, and control. | Critical need to include voices of men and trans sex workers in policy discussions. Supports decriminalization of sex work. |
Cohan et al., 2006 [96] | USA | Cross-sectional | 783 sex workers (all genders) accessing care at peer-based clinic (St. James Infirmary) | Community-led Programming & Integrative Care. Sex worker-led, free medical clinic provides substantial care to sex workers of all genders. | Sex worker-led and integrative, non-judgmental health and support services are key to reducing STBBIs. |
Kim et al., 2015 [98] | Canada | Cross-sectional 2010–2013 | 547 street-involved women (trans inclusive) sex workers accessing women-only drop-in service | Community-led Programming & Integrative Care. Sex worker-specific drop-in service had high uptake (60% used services in last 3 years), associated with increased access to sexual and reproductive health services. | Low-threshold and sex work-specific models for sexual health should be scaled-up. |
Krusi et al., 2012 [76] | Canada | 39 qualitative interviews & 6 focus groups | Marginalized women (trans inclusive) sex workers living/working in low-barrier, supportive housing for women | Safer Work Environments. Unsanctioned indoor sex work environments in the context of supportive housing programs increased sex workers’ control over negotiating transactions and condom use with clients. | Removing social and legal barriers to women-only supportive housing models are critical to facilitate safer indoor sex work environments. |
Krusi et al., 2014 [71] | Canada | 31 qualitative interviews and ethnographic observation | Street-involved women sex worker (trans inclusive) | Decriminalization. Criminalization of sex work and policing practices targeting clients increase risk of HIV/STBBIs. | Decriminalization of sex work is needed to ensure health and human rights for sex workers. |
Lyons et al., 2015 [78] | Canada | Qualitative interviews | 33 trans women sex workers | Decriminalization & Safer Work Environments. Transphobia and criminalized approaches to sex work shape violence and safety with clients and police. | Need for legal reform of sex work laws and culturally competent anti-stigma programs/policies to reduce transphobia. |
Matthen et al., 2016 [81] | Canada | Qualitative interviews | 45 men and trans sex workers and clients | Community-led Research. Narratives revealed highly diverse gender and sexual identities, underscoring importance of giving voice to gender and sexual minority sex workers through community-based research. | Policies and services must reflect diversity and needs of sex workers. Critical need to address homophobia/transphobia and reduce stigma. |
Mimiaga et al., 2008 [45] | USA | Survey and qualitative interviews | 31 MSM sex workers (19 street-involved and 13 internet-based escorts) | Safer Work Environments. Narratives highlight contextual differences in sexual risk-taking among street vs. internet-based workers. 69% reported unprotected serodiscordant sex. | Need for tailored interventions that acknowledge heterogeneity of sex workers and contextual and psychosocial factors influencing workplace safety. |
Parsons et al., 2007 [109] | USA | Qualitative interviews | 46 male sex workers (internet escorts) | Community Empowerment. Highlights the individual and community needs of male escorts. | Importance of addressing community-identified needs beyond safer sex, such as support with business and legal advice. |
Reisner et al., 2008 [51] | USA | Brief survey and qualitative interviews | 32 male sex workers | Integrative Care. Findings highlight valuable intervention components: trauma-informed mental health and substance abuse treatment, access to HIV/STI testing and treatment services, support groups to address isolation/loneliness, skill-building for risk reduction with partners, and paid incentives as add-ons to behaviour change interventions. | Multipronged interventions to reduce sexual risk-taking are needed for male sex workers, including addressing unique socioeconomic and legal needs. |
Sausa et al., 2007 [80] | USA | Focus groups | 48 trans women (85% had ever engaged in sex work); ethnic minorities | Community Empowerment. Participation in sex work and risks were influenced by social networks, cultural norms, immigration, racism, and transphobia | Highlights unique needs of trans sex workers who are ethnic minorities. Further research and polices must be tailored to this key subpopulation. |
Shannon et al., 2008 [70] | Canada | Participatory-based focus groups | 46 marginalized women sex workers (trans inclusive) | Safer Work Environments & Decriminalization. Lack of safe working environment and policing displace sex workers and elevate risk of violence and STBBI. Peer networks improve safe sexual practices with clients. | Socio-structural environment plays key role in shaping drug and sexual risk of HIV. Need for safer work environment supported by legislative reform. |
Underhill et al., 2015 [74] | USA | 31 qualitative interviews | Male sex workers | Decriminalization. Narratives highlight how experiencing discrimination and medical distrust can impede access to biomedical HIV prevention strategies such as PrEP. | There is a need to address multiple stigmas and discrimination that create barriers to STBBI prevention. |
Williams et al., 2006 [108] | USA | Questionnaires to evaluate brief interventions to increase condom use | 112 street-based male sex workers | Safer Work Environments & Integrative Care. Two-thirds of men enrolled in a brief risk reduction intervention completed it. Condom use during paid sex increased post-intervention. | Brief interventions tailored to male sex workers to reduce unprotected anal sex with clients are acceptable and efficacious. |
Whitaker et al., 2011 [75] | Ireland | Qualitative interviews | 31 female and 4 male sex workers (drug users) | Decriminalization & Integrative Care. Sex workers described experiencing stigma and discrimination from healthcare providers, which increased risk of HIV and HCV. | Training for service providers is needed to change language and reduce stigma around sex work. |