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

Abstract

Globally HIV incidence is slowing, however HIV epidemics among sex workers are stable or increasing in many settings. While laws governing sex work are considered structural determinants of HIV, individual-level data assessing this relationship are limited. In this study, individual-level data are used to assess the relationships of sex work laws and stigmas in increasing HIV risk among female sex workers, and examine the mechanisms by which stigma affects HIV across diverse legal contexts in countries across sub-Saharan Africa. Interviewer-administered socio-behavioral questionnaires and biological testing were conducted with 7259 female sex workers between 2011–2018 across 10 sub-Saharan African countries. These data suggest that increasingly punitive and non-protective laws are associated with prevalent HIV infection and that stigmas and sex work laws may synergistically increase HIV risks. Taken together, these data highlight the fundamental role of evidence-based and human-rights affirming policies towards sex work as part of an effective HIV response. HIV incidence among sex workers remains high in many settings. Here, the authors utilize individual-level data across ten countries in sub-Saharan Africa and suggest that increasingly punitive and non-protective laws are associated with HIV, and that stigmas and sex work laws may operate jointly in increasing HIV risk.

Full text

ARTICLE
The role of sex work laws and stigmas in increasing
HIV risks among sex workers
Carrie E. Lyons 1*, Sheree R. Schwartz1, Sarah M. Murray 2, Kate Shannon3, Daouda Diouf4,
Tampose Mothopeng5, Seni Kouanda6, Anato Simplice7, Abo Kouame8, Zandile Mnisi9, Ubald Tamoufe10,
Nancy Phaswana-Mafuya11, Bai Cham12, Fatou M. Drame4,13, Mamadú Aliu Djaló14 & Stefan Baral1
Globally HIV incidence is slowing, however HIV epidemics among sex workers are stable or
increasing in many settings. While laws governing sex work are considered structural
determinants of HIV, individual-level data assessing this relationship are limited. In this study,
individual-level data are used to assess the relationships of sex work laws and stigmas in
increasing HIV risk among female sex workers, and examine the mechanisms by which
stigma affects HIV across diverse legal contexts in countries across sub-Saharan Africa.
Interviewer-administered socio-behavioral questionnaires and biological testing were con-
ducted with 7259 female sex workers between 2011–2018 across 10 sub-Saharan African
countries. These data suggest that increasingly punitive and non-protective laws are asso-
ciated with prevalent HIV infection and that stigmas and sex work laws may synergistically
increase HIV risks. Taken together, these data highlight the fundamental role of evidence-
based and human-rights affirming policies towards sex work as part of an effective HIV
response.
https://doi.org/10.1038/s41467-020-14593-6 OPEN
1Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, 615 N Wolfe St, Baltimore, MD 21205,
USA. 2Department of Mental Health, Johns Hopkins School of Public Health, Hampton House 624 N. Broadway 8th Floor, Baltimore, MD 21205, USA.
3Centre for Gender & Sexual Health Equity, University of British Columbia, 1081 Burrard St, Vancouver, BC, Canada. 4Enda Santé, Senegal, 56 Cité Comico
VDN, B.P, 3370 Dakar, Senegal. 5People’s Matrix Association, Maseru, Lesotho. 6Institut de Recherche en Sciences de la Santé, Ouagadougou, Burkina Faso,
Institut Africain de Santé Publique, 12 BP 199 Ouagadougou, Burkina Faso. 7ONG Arc-en-Ciel, B.P., 80295 Lomé, Togo. 8Ministère de la Sante et de
l’Hygiène Publique, Abidjan, Côte d’Ivoire. 9Health Research Department, Strategic Information Division, Ministry of Health, Cooper Centre Office 106,
Mbabane, Eswatini. 10 Metabiota. Avenue Mvog-Fouda Ada, Av 1.085, Carrefour Intendance BP, 15939 Yaoundé, Cameroon. 11 DVC Research and Innovation
Office, North-West University, Potchefstroom Campus, Private Bag X6001 Potchefstroom, 2520 Potchefstroom, South Africa. 12 Actionaid, Banjul The
Gambia, MDI Road, Kanifing South PMB 450, Serrekunda PO Box 725 Banjul, The Gambia. 13 Gaston Berger University, Department of Geography, School of
Social Sciences. BP: 234 - Saint-Louis, Nationale 2, route de Ngallèle, St. Louis, Senegal. 14 Enda Santé, Guiné-Bissau. Bairro Santa Luzia, Rua s/n, CP 1041
Bissau, Guinea-Bissau. *email: clyons8@jhu.edu
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In 2019, development and scaling up HIV prevention, diag-
nostic, and treatment strategies collectively have slowed new
HIV infections globally, but not to the extent earlier models
had predicted1. In part, this may be due to stable or growing HIV
incidence among marginalized populations including sex workers
in many settings. Around the world, ~1 in 10 sex workers is
estimated to be living with HIV2. Across concentrated and gen-
eralized HIV epidemics, female sex workers consistently bear a
disproportionate burden of HIV compared with other cisgender
women of reproductive age3. Across low- and middle-income
countries, sex workers have more than a 13 times increased odds
of living with HIV compared with other women3. Available data
of HIV prevalence among sex workers has increased, with a 2018
review finding data points from 101 countries2. Incidence data
remain limited, but where available, suggest continued challenges
in the coverage of effective HIV prevention and treatment
interventions for sex workers2. Furthermore, emerging evidence
suggests that the unmet HIV prevention and treatment needs
within sex work significantly contributes to overall HIV trans-
mission even within generalized epidemics4. Even in the presence
of sustained programs for sex workers, mathematical models
predict that 14–38% of all new HIV infections in Benin, Burkina
Faso, and Kenya could directly or indirectly be due to sex work
over the next 20 years4–7. In the absence of dedicated programs,
this estimate increases to 58–89%4–7. Taken together, these results
suggest an urgent need to improve prevention and treatment
services for sex workers across HIV epidemics.
Despite expanded access to antiretroviral therapy, sex workers
across sub-Saharan Africa continue to have suboptimal HIV
prevention and treatment outcomes8. Progress in scaling up
programs and sustaining coverage of HIV services is undermined
by limited assessment of, and efforts to address structural deter-
minants affecting HIV among sex workers2. Studies have pri-
marily focused on individual-level biological and behavioral risks
for HIV among sex workers with limited examination of higher
level structural determinants2,9. For example, a systematic review
found that fewer than half of epidemiological studies on HIV
acquisition and transmission measure structural determinants
and this was even less common in studies specifically among sex
workers10. Consequently, recommendations have been made for
increased integration of structural-level factors into HIV research
among sex workers11. Although more studies assessing structural
determinants of HIV among sex workers are emerging, few exist
from across sub-Saharan Africa2.
The legal environment, including laws, enforcement practices,
and justice systems, is a key structural determinant of HIV risk
for sex workers and is often stated as a focus for the global HIV
response12–15. Punitive legal environments consistently increase
vulnerabilities among sex workers through further pushing sex
work into unregulated and unsafe work environments, increasing
economic and residential insecurities, and influencing HIV-risk
behaviors14,16,17. Moreover, laws criminalizing sex work may
both increase sex work-related stigmas and potentially contribute
to HIV epidemic growth if the sequelae of these laws increases
vulnerability and decreases engagement in HIV prevention and
treatment services. HIV risks have been characterized in crim-
inalized settings; however, limited opportunities have been
available to compare individual health-related outcomes among
sex workers across differing legal contexts. Systematic reviews and
meta-analyses have leveraged qualitative and quantitative evi-
dence to assess harms associated with sex work policies18. And
ecological studies of country-level data have observed a rela-
tionship between HIV and sex work laws showing a lower HIV
prevalence among sex workers in European countries with partial
legalization of sex work compared with criminalized settings19.
However, characterizing the influence of criminalization and
punitive policies and stigmas towards sex work across settings
with empirical, individual-level data, remains limited18–21.
Stigmas exist at individual, interpersonal, and structural levels,
and represent a process in which an individual is labeled based on
some characteristic linked to a stereotype, often resulting in
limited opportunities and well-being22. Stigma measurement
strategies and mitigation interventions have traditionally focused
on HIV-related stigmas, though emerging research has focused
on stigmas related to sexual behavior among key populations23,24.
Sexual behavior stigmas can include anticipated, perceived, or
enacted stigmas attributable to an individual’s sexual behavior,
including engagement in sex work25. However, the majority of
studies measuring stigmas among key populations have focused
on stigmas affecting sexual and gender minorities, with only 2%
of identified stigma measurement related to sex work26. Under-
standing sex work-related stigmas, especially across different legal
contexts has direct implications for the implementation and
effectiveness of HIV treatment programs. Where assessed, per-
ceived, anticipated, and enacted stigmas consistently challenge
progress along the HIV treatment cascade by limiting engage-
ment in prevention, care, and treatment services27–30. Moreover,
intersecting stigmas have been associated with prevalent HIV
infection and limited uptake of services along the HIV treatment
cascade across sub-Saharan Africa31–33. Separate from HIV-
associated laws, stigma has also been identified as a driver of the
HIV pandemic, and its elimination remains one of the three
pillars of the UNAIDS plan to achieve zero new HIV infections by
203034. Both the World Health Organization and UNAIDS have
recommended increasing efforts to mitigate stigma as critical to
an effective HIV response35,36. However, understanding the dif-
ferent ways in which stigma potentiates individual-level HIV risks
to inform stigma mitigation efforts across different legal contexts
remain limited.
In response, this study aims to use individual-level data to
characterize the relationship between sex work laws, stigmas, and
HIV risks among female sex workers across sub-Saharan Africa.
Collectively, findings from these analyses suggest that increasingly
punitive and non-protective laws are associated with increased
odds of prevalent HIV infection among sex workers. Further-
more, stigmas and sex work laws may operate synergistically in
increasing HIV risks, with generally stronger associations
between stigmas and HIV in punitive and non-protective settings
compared with partially legalized settings. The results suggest that
the increased harmful effects of stigmas in more punitive and
non-protective legal contexts may be due to increased barriers in
the provision or uptake of efficacious HIV prevention and
treatment services, or impunity among perpetrators of stigma and
lack of recourse for sex workers experiencing health and social
stigmas, or more likely, a combination of the two.
Results
Study sample characteristics. A total of 7259 female sex workers
are represented in this analysis.
The distribution of women across countries is: Burkina Faso (n
=698; 9.6%), Cameroon (n=2255; 31.1%), Cote d’Ivoire (n=
466; 6.4%), Guinea-Bissau (n=567; 7.8%), Lesotho (n=744;
10.3%), Senegal (n=758; 10.4%), South Africa (n=410; 5.6%),
Kingdom of eSwatini (n=324; 4.5%), The Gambia (n=354;
4.9%), and Togo (n=683; 9.4%) (Table 1).
In total, 48.6% (n=3526) are living in West Africa, 31.1% (n
=2255) in Central Africa, and 20.4% (1478) in Southern Africa
(Table 2). Overall, 17.4% (1265/7259) of participants are living in
countries where legal status of selling sex is not specified; 26.3%
(1907/7259) where sex work is partially legalized, and 56.3%
(4087/7259) where sex work is criminalized. Participants living in
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countries with generalized HIV epidemics represent 79.6% (5781/
7259) of the study sample with 20.4% (1478/7259) in concen-
trated HIV epidemics.
Demographic characteristics, HIV, disclosure, and stigmas.
Demographic characteristics, HIV risk and status, disclosure,
and stigmas are summarized in Table 3.Themedianageis27
years (interquartile range (IQR) 22–34), and the median years
engaged in sex work is 4 (IQR 2–8). The pooled HIV prevalence
is 28.6% (95% Confidence Interval (95% CI): 27.6–29.7; N=
2070/7230).
Prevalent HIV infection and legal status of sex work. HIV
prevalence in contexts with partial legalization is 11.6% (219/
1894), 19.6% (248/1265) within contexts without legal specifica-
tion, and 39.4% (1603/4071) within criminalized settings
(Table 4). Legal status of sex work is associated with HIV (X2p
value < 0.001). When compared with settings with partial legali-
zation, criminalized status (adjusted odds ratio [aOR]: 7.17; 95%
CI: 2.71–18.95; pvalue < 0.001), and sex work not being legally
specified (aOR: 2.35; 95% CI: 1.06–5.21; pvalue =0.036) are
associated with increased odds of HIV.
Sensitivity analysis using a random sample of data from
Cameroon showed similar results to the main sample (Supple-
mentary Table 1).
Stigmas and prevalent HIV infection. Prevalent HIV infection is
positively associated verbal harassment (aOR: 1.29; 95% CI:
1.12–1.50; pvalue =0.001); blackmail (aOR: 1.39; 95% CI:
1.20–1.61; pvalue < 0.001); physical violence (aOR: 1.23; 95%
CI: 1.02–1.49; pvalue =0.029); and forced sex (aOR: 1.32; 95%
CI: 1.13–1.54; pvalue < 0.001); and negatively associated with fear
of being in public places (aOR: 0.67; 95% CI: 0.48–0.94; pvalue =
0.024) (Table 5).
Stigma exposure differs between participants with prior
knowledge of living with HIV compared with those without
prior knowledge of living with HIV or not living with HIV
(Supplementary Table 2).
HIV and stigmas by legal status of sex work. The degree of
association between stigmas and HIV varies by legal status of sex
work (Mantel–Haenszel test of homogeneity (MH) pvalue: <
0.01) for all stigma measures assessed except denial of health
services, verbal harassment, and forced sex. Specifically, in
criminalized settings HIV is associated with fear of seeking health
services (aOR: 95% CI: 1.01–1.53; pvalue: 0.041) and mistreat-
ment in a healthcare setting (aOR: 2.15; 95% CI: 1.43–3.23; p
value < 0.001), compared with partially legalized settings
(Table 6).
The relationship between HIV and uniformed officers refusal
to provide protection varies by legal status (MH pvalue < 0.01)
with an increased odds in settings without legal specification
(aOR: 1.64; 95% CI: 1.29–2.08; pvalue < 0.001) and criminalized
settings (aOR: 1.38; 95% CI: 1.10–1.72; pvalue =0.005)
compared with partially legalized settings. Blackmail is associated
with HIV in non-specified settings (aOR: 1.50; 95% CI: 1.37–1.65;
pvalue: < 0.001) and criminalized settings (aOR: 1.35; 95% CI:
1.07–1.71; pvalue: 0.010) compared with partially legalized
Table 1 Summary of data collection.
Region Country Recruitment
dates
Country
sample size
Study sites Recruitment
seeds
Total enrolled
by site
West Africa Burkina Faso January–August 2013 698 Bobo Dioulasso 3 350
Ouagadougou 6 348
Senegal February–November 2015 758 Dakar 9 502
Mbour 3 256
Côte d’Ivoire March–October 2015 466 Abidjan 5 466
Guinea-Bissau September 2017–January 2018 567 Bafatá 3 140
Bissau 8 323
Bissorã 3 45
Gabu 3 59
The Gambia May 2017–May 2018 354 Banjul 9 354
Togo January–June 2013 683 Kara 5 329
Lome 5 354
Central Africa Cameroon November 2015–October 2016 2255 Yaoundé 2 574
Douala 1 457
Bamenda 1 341
Bertoua 1 304
Kribi 1 579
Southern Africa Lesotho February–September 2014 744 Maseru 7 410
Maputsoe 12 334
Kingdom of eSwatini August–October 2011 324 Manzini 14 324
South Africa October 2014–April 2015 410 Port Elizabeth 9 410
Table 2 Study sample by region, legal status of sex work,
and country-level HIV epidemic.
Characteristics Total (N=7259)
N%
Region
Western Africa 3526 48.6
Central Africa 2255 31.1
Southern Africa 1478 20.4
Legal status of sex work
Legality not specified 1265 17.4
Partially legalized 1907 26.3
Criminalized 4087 56.3
Country-level HIV epidemic
Generalized 5781 79.6
Concentrated 1478 20.4
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Table 3 Demographic characteristics, HIV risk and infection, disclosure, and stigma by legal status of sex work.
Total Legal status of sex work
Partially legal Not specified Criminalized
Median Age (IQR) 27 (22–34) 27 (23–35) 25 (21–30) 27 (23–34)
Median years in sex work (IQR) 4 (2–8) 5 (2–9) 4 (2–8) 4 (2–8)
n/N%n/NColumn % n/NColumn % n/NColumn % X2pvalue
Age <0.001
18–24 2689/7236 37.2 648/1897 34.2 625/1265 49.4 1416/4074 34.8
25–30 2050/7236 28.3 530/1897 27.9 342/1265 27.0 1178/4074 28.9
31+2497/7236 34.5 719/1897 37.9 298/1265 23.6 1480/4074 36.3
Education level <0.001
None 1387/7229 19.2 787/1898 41.5 338/1247 27.1 262/4084 6.4
Some primary 1625/7229 22.5 495/1898 26.1 329/1247 26.4 801/4084 19.6
Primary completed/some secondary 3339/7229 46.2 519/1898 27.3 495/1247 39.7 2325/4084 56.9
Completed secondary or post-
secondary
878/7229 12.2 97/1898 5.1 85/1247 6.8 696/4084 17.0
Marital status <0.001
Currently married 166/7242 2.3 48/1906 2.5 67/1264 5.3 51/4072 1.3
Not currently married 7076/7242 97.7 1858/1906 97.5 1197/1264 94.7 4021/4072 98.8
Years in sex work <0.001
<5 3781/7001 54.0 8971834 48.9 665/1202 55.3 2219/3965 56.0
5 or more 3220/7001 45.0 937/1834 51.1 537/1202 44.7 1746/3965 44.0
HIV status <0.001
Living with HIV 2070/7230 28.6 219/1894 11.6 248/1265 19.6 1603/4071 39.4
Not living with HIV 5160/7230 71.4 1675/1984 88.4 1017/1265 80.4 2468/4071 60.6
Knowledge of living with HIV <0.001
Yes 1207/6022 20.0 68/1410 4.8 108/720 15.0 1031/3892 26.5
No 4815/6022 80.0 1342/1410 95.2 612/720 85.0 2861/3892 73.5
Disclosure of sex work to family <0.001
Yes 1627/7250 22.5 409/1902 21.5 188/1265 14.9 1030/4083 25.2
No 5623/7250 77.6 1493/1902 78.5 1077/1265 85.1 3053/4083 74.8
Disclosure of sex work to healthcare
provider
<0.001
Yes 1401/3636 22.0 710/1827 38.9 255/1262 20.2 436/3274 13.3
No 4962/6363 78.0 1117/1827 61.1 1007/1262 79.8 2838/3274 86.7
Stigma
Family exclusion 914/7176 12.7 204/1897 10.8 186/1208 15.4 524/4071 12.9 0.001
Family gossip 1450/7203 20.1 452/1887 24.0 281/1253 22.4 717/4063 17.7 <0.001
Friend rejection 962/7130 13.5 216/1792 12.1 173/1260 13.7 573/4078 14.1 0.109
Afraid of seeking health services 968/7248 13.4 337/1902 17.7 171/1262 13.6 460/4084 11.3 <0.001
Avoided seeking health services 673/6572 10.2 322/1901 16.9 125/1264 9.9 226/3407 6.6 <0.001
Mistreated in health center 190/7170 2.7 67/1821 3.7 15/1264 1.2 108/4085 2.6 <0.001
Health care provider gossip 317/7169 4.4 115/1823 6.3 35/1264 2.8 167/4082 4.1 <0.001
Denied health services 94/7244 1.3 33/1894 1.7 13/1265 1.0 48/4085 1.2 0.127
Police refused protection 1036/7096 14.6 225/1754 12.8 139/1261 11.0 672/4081 16.5 <0.001
Scared in public places 982/6275 15.7 479/1904 25.2 158/696 22.7 345/3675 9.4 <0.001
Verbally harassed 3140/6576 47.8 818/1904 43.0 494/1265 39.1 1828/3407 53.7 <0.001
Blackmailed 2198/7249 30.3 516/1905 27.1 256/1262 20.3 1426/4082 34.9 <0.001
Physical violence*2359/7240 32.6 607/1905 31.9 459/1256 36.5 1293/4079 31.7 0.004
Forced to have sex*2207/7234 30.5 597/1905 31.3 343/1263 27.2 1267/4066 31.2 0.017
*Not specified as attributable to sex work.
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Table 4 HIV infection and country-level legal status.
Legal status of sex work Living with HIV
n/N %ORPvalue 95% CI aOR* Pvalue 95% CI
Partially legalized 219/1894 11.6 Ref. Ref. Ref. Ref. Ref. Ref.
Selling not specified 248/1265 19.6 1.87 0.181 0.78, 4.65 2.35 0.036 1.06, 5.21
Criminalized 1603/4071 39.4 4.97 0.001 1.98, 12.44 7.17 < 0.001 2.71, 18.95
*Adjusted for age, education level, marital status, years in sex work, clustered by site and by country.
Table 5 Pooled relationship between stigma and prevalent HIV infection among female sex workers.
Living with HIV
Stigmas OR 95% CI Pvalue aOR** 95% CI Pvalue
Perceived Family exclusion 1.68 1.46, 1.94 <0.001 1.05 0.84, 1.31 0.686
Perceived Family gossip 1.33 1.17, 1.50 <0.001 0.95 0.78,1.16 0.637
Perceived Friend rejection 1.88 1.64, 2.17 <0.001 1.28 0.98, 1.67 0.068
Anticipated Afraid of seeking health services 1.22 1.05, 1.41 0.008 0.97 0.72, 1.30 0.824
Anticipated Avoided seeking health services 0.75 0.62, 0.91 0.003 0.79 0.48, 1.30 0.358
Perceived Mistreated in health center 1.82 1.35, 2.43 <0.001 1.09 0.44, 2.72 0.849
Enacted Health care provider gossip 1.17 0.92, 1.49 0.197 0.95 0.49, 1.83 0.832
Enacted Denied health services 1.48 0.97, 2.26 0.066 1.10 0.56, 2.17 0.792
Perceived Police refused protection 2.14 1.87, 2.45 <0.001 1.26 0.97, 1.64 0.141
Perceived Scared in public places 0.96 0.83, 1.13 0.673 0.67 0.48, 0.94 0.024
Enacted Verbally harassed 1.32 1.18, 1.47 <0.001 1.29 1.12, 1.50 0.001
Enacted Blackmailed 1.19 1.07, 1.33 0.002 1.39 1.20, 1.61 <0.001
Enacted Physical violence* 1.58 1.42, 1.76 <0.001 1.23 1.02, 1.49 0.029
Enacted Forced to have sex* 1.29 1.16, 1.44 <0.001 1.32 1.13, 1.54 <0.001
Each stigma indicator assessed through a separate model due to collinearity between stigma items.
*Not specified as attributable to sex work.
**Adjusted for age, education level, marital status, years in sex work, country-level epidemic, and clustered by site and by country. Adjusted for disclosure of sex work to family of healthcare provider
when conceptual relevant (social stigma; healthcare-related stigma).
Table 6 Relationship between stigma and HIV by legal status of sex work.
Stigmas HIV infection
Test for interaction Partially legalized Selling not specified Criminalized
MH test of homogeneity
pvalue^
Reference
category
aOR** 95% CI Pvalue aOR** 95% CI Pvalue
Family exclusion 0.0002 −0.90 0.53, 1.52 0.699 1.13 0.85, 1.50 0.417
Family gossip <0.0001 −0.76 0.54, 1.06 0.102 1.14 0.86, 1.51 0.353
Friend rejection 0.0062 −1.29 0.89, 1.87 0.185 1.27 0.93, 1.74 0.126
Afraid of seeking health
services
0.0001 −1.28 0.81, 2.03 0.285 1.24 1.01, 1.53 0.041
Avoided seeking health
services
0.0074 −1.44 0.90, 2.29 0.130 1.18 0.81, 1.72 0.376
Mistreated in health center 0.0016 −1.54 0.51, 4.63 0.446 2.15 1.43, 3.23 <0.001
Health care provider gossip 0.0039 −0.86 0.25, 2.91 0.804 1.46 0.78, 2.72 0.227
Denied health services 0.1511 −−−−−−−
Police refused protection 0.0005 −1.64 1.29, 2.08 <0.001 1.38 1.10, 1.72 0.005
Scared in public places <0.0001 −0.87 0.62, 1.21 0.400 0.91 0.65, 1.25 0.543
Verbally harassed 0.1687 −−−−−−−
Blackmailed 0.0025 −1.50 1.37, 1.65 <0.001 1.35 1.07, 1.71 0.010
Physical violence* <0.0001 −0.79 0.62, 1.01 0.070 1.34 1.11, 1.62 0.002
Forced to have sex* 0.0275 −−−−−−−
Each stigma indicator assessed through a separate model.
Mantel–Haenszel test of homogeneity was used to assess effect measure modification between types of stigma and legal status of sex work across each stigma exposure model assessing the association
with HIV status. Those values for which a statistical interaction was observed were assessed through stratified multivariable adjusted models assessing the impact of stigma exposures on HIV status.
^<0.01 significance level for test for homogeneity.
*Not specified as attributable to sex work.
**Adjusted for age, education level, marital status, years in sex work, country-level epidemic, and clustered by site and by country. Adjusted for disclosure of sex work to family of healthcare provider
when conceptual relevant (social stigma, and healthcare-related stigma).
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settings. HIV is associated with physical violence in criminalized
settings versus partially legalized settings (aOR: 1.34; 95% CI:
1.11–1.62; pvalue =0.002).
Discussion
Punitive and non-protective sex work laws are associated with
prevalent HIV infection among female sex workers in countries
across sub-Saharan Africa. The prevalence of stigma is high
among female sex workers and consistently associated with pre-
valent HIV infection, highlighting the importance of structural
determinants alongside more proximal individual-level char-
acteristics. The degree of the relationship between stigmas and
HIV varies by legal status of sex work, suggesting that stigmas
and legal status of sex work may operate jointly in increasing
individual HIV burden. This study further demonstrates the
persistence of certain types of stigmas across differing legal
contexts and suggests that the potential impact of stigmas on HIV
risk and ultimately burden may be greatest in punitive and non-
protective settings. Finally, these results suggest the complexity of
HIV risks among sex workers across sub-Saharan Africa trans-
cending individual-level sexual practices, highlighting the need to
continue to measure and address stigmas to inform a more
effective and efficient HIV response.
The magnitude of the relationship between the legal status of
sex work and individual HIV infection is highest among indivi-
duals in fully criminalized settings, followed by settings where the
legal status of selling sex is not specified. These results are con-
sistent with prior findings from ecological studies19 and highlight
how laws serve as a structural determinant that contribute to
individual-level health outcomes. Findings suggest that written
laws, independent of enforcement practices, influence HIV out-
comes and that explicit legality serves in protecting sex workers.
Moreover, these results suggest that punitive and non-protective
laws may contribute to an environment that perpetuates HIV
risks among sex workers. These findings are consistent with
earlier mathematical models that demonstrated that across gen-
eralized and concentrated HIV epidemics, decriminalization of
sex work could have the largest effect on the course of country-
level epidemics, averting one-third to almost one-half of incident
HIV infections over the next decade10. This reduction would be
through combined effects on violence, harassment by uniformed
officers, and safer work environments collectively mediating HIV
transmission pathways10. Despite these consistent results, the
number of countries decriminalizing sex work has not increased
over the last 5 years2,11.
The relationship between stigmas and HIV varies across dif-
ferent legal contexts of sex work, suggesting that stigmas and sex
work laws interact in increasing HIV risks and ultimately burden.
Sex workers living in settings with criminalized and non-specified
laws generally show a stronger relationship between stigmas and
HIV compared with partially legalized settings. Existing evidence
suggests that sex workers living in punitive and non-protective
settings may experience greater burdens of stigmas than women
living in partially legalized settings37. However, in this study,
women reporting any lifetime history of stigma is not clearly or
consistently higher in criminalized or non-protective settings
compared with partially legalized settings, highlighting that sex
workers across legal environments experience stigmas. Although
sex workers may still experience a greater frequency of stigmas
over the course of their lifetime in punitive and non-protective
settings, the periodicity of stigma experiences among women is
not measured in this study. Given the near universality of stigmas
affecting sex workers, the mechanisms associated with increased
HIV burden may act by amplifying the barriers to safety, as well
as efficacious health services. Specifically, sex workers in punitive
and non-protective environments may be more susceptible to the
harms related to stigmas affecting overall safety in society and in
access to HIV prevention and treatment services. Furthermore,
sex workers in partially legalized or more protective environ-
ments have been shown to have higher levels of social capital,
resiliency, and options for support that can mitigate the impact of
stigmas on HIV risks38. Ultimately, the mechanisms under-
pinning the synergies of stigmas and sex work laws in the burden
of HIV among sex workers likely vary by the specific type of
stigma. The consistency in the findings of the interaction between
laws and stigma in especially punitive legal settings reinforce the
importance of HIV prevention and treatment intervention stra-
tegies tailored for sex workers that consider the legal context
during implementation.
Uptake of HIV testing, prevention, and treatment services
remains low among sex workers across sub-Saharan Africa and
globally, in part due to healthcare-related stigmas2,10,39. In these
analysis, higher HIV burden among sex workers was associated
with anticipated and perceived stigmas relating to seeking care in
criminalized settings. Harmful effects of stigma are reinforced by
the experience of intersecting stigmas among sex workers living
with HIV attributable to both sex work and HIV status, as par-
ticipants who reported to be aware of living with HIV prior to
enrollment report higher levels of sex work-related stigmas. The
combined or compounded effect of multiple stigmas may further
influence uptake of services and health outcomes40–42. Leveraging
innovative approaches to provide services outside of health
facilities while working to mitigate observed individual and
intersecting stigmas may facilitate improved service coverage. In
this context, decentralized services have been able to serve sex
workers who were not accessing traditional services and therefore
may provide an avenue to increase coverage and access43–45.To
date, few studies have evaluated stigma mitigation approaches for
people living with HIV and even fewer have aimed to study
stigma reduction for sex workers in healthcare settings across
sub-Saharan Africa24. These results suggest the importance of
protective structures within healthcare systems, such as the
enforcement of anti-discriminatory policies and accountability
mechanisms to ensure culturally and clinically competent services
for all.
Violence affecting sex workers is prevalent across legal contexts
and is associated with HIV among sex workers in this analysis,
consistent with findings from other settings46. Violence has been
associated with HIV risks, such as inconsistent condom use,
difficultly in condom negotiation, recent condom failure, client
condom refusal, and high client volume47–49. In this analysis, the
relationship between physical violence and HIV varies by legal
context, with an increased association in criminalized settings.
Increased legal restrictions on sex work has been shown to move
activities to more hidden settings to avoid detection by uniformed
officers, alongside increased vulnerability to violence and HIV-
risk behaviors such as unprotected sex50. Even when enforcement
efforts prioritize clients or third parties, violence affecting sex
workers persists51. In contrast, the degree of the relationship
between sexual violence and HIV does not vary across legal
contexts. Aligning with findings from other studies, this suggests
that partial legalization, such as the removal of only some aspects
of criminal laws and regulation of sex workers is necessary, but
not sufficient for reducing sexual violence as a risk factor for
HIV52. This is consistent with previous modeling and empirical
work, suggesting that only through full decriminalization, such as
full removal of laws targeting sex industry; access to safer work
environments; and prevention of violence and harassment by
police could law reform as a structural determinant avert violence
and HIV infections10,51. Finally, empirical research pre and post
law reform has shown that in settings where clients and third
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parties are criminalized but not sex workers, rates of both sexual
violence was unchanged from full criminalization53.
Sex workers reporting lack of protection from uniformed
officers is prevalent in this analysis, and likely true in much of the
world54. The lack of protection explains the persistent violence
and blackmail observed among sex workers across legal contexts,
likely due to impunity of offenders. There have been limited
recent efforts among countries or regions to end impunity for
crimes and abuses against sex workers2. In this study, the rela-
tionship between blackmail and HIV is highest in non-protective
settings, followed by criminalized settings. In other settings,
repressive police practice has been associated with violence, as
well as HIV and sexually transmitted infections18. Perceived
stigmas related to policing practices is prevalent and associated
with HIV infection in this analysis, suggesting that legal protec-
tions as well as training and accountability of law enforcement
may support improved HIV outcomes. Here, there is no assess-
ment of enacted stigmas by uniformed officers specifically,
however, this has been observed in other settings55. For instance,
qualitative assessments have reported abusive practices by uni-
formed officers against sex workers, including blackmail, arbitrary
arrest, and violence56,57. Women have also reported that sex or
money are used as compensation for release after arrests56,57.
Among sex workers in Côte d’Ivoire, Burkina Faso, and Togo
who had experienced physical violence and forced sex, a large
proportion reported perpetration by a uniformed officer55,58.In
this study, fear of being in public places is negatively associated
with HIV prevalence overall, prior to stratification across legal
contexts. In part, the lower HIV risk may emerge from protective
behaviors such as avoiding street-based sex work, which has been
associated with increased violence, extortion by uniformed offi-
cers, and increased HIV-related risk behaviors18,59. Combined
structural interventions with uniformed officers involving advo-
cacy with senior uniformed officers, and crisis response
mechanisms have been shown to reduce uniformed officers
arrests and violence, and create a safer work environment for sex
workers60,61.
Several limitations in this study should be considered.
Although data are clustered by site and country to account for the
non-independent nature of observations within each site and
within each country, individual country and site differences may
be lost in the aggregation of data. Legal status categories were
determined based on country-specific legislation where available,
but not necessarily the enforcement practices and justice systems.
Although we are not able to assess causality through cross-
sectional data and cannot account for the relationship between
HIV prevalence and stigmas over time, laws were established
prior to HIV introduction within countries. At a minimum, this
limits the possibility that laws criminalizing sex work were a
result of or influenced by the HIV epidemic. It is possible that
unmeasured confounders preceding both sex work laws and
country-level epidemics may exist and feed independently into
both, thus resulting in uncontrolled confounding. There may also
be unmeasured confounders that are associated with sex work
laws and/or stigmas, as well as causally associated with HIV, but
not on the casual pathway between these exposures and out-
comes. None of the countries included in this analysis meet the
criteria for decriminalized legal status, and therefore this legal
context could not be evaluated. Data were collected over a period
of 7 years, which should be considered in the interpretation of the
results. Enforcement practices, program funding, and other
external measures over time may have influenced stigmas, HIV
status, or HIV risk. Female sex workers living with HIV may
experience intersectional or compounded stigmas due to HIV
status and engagement in sex work, and therefore there is a need
to further evaluate these intersectional stigmas.
In the context of a slowing HIV pandemic, epidemics among
sex workers in most settings across sub-Saharan Africa are stable
or growing. Although others are benefiting from improved pre-
vention and treatment interventions, these data highlight that
both sex work laws and stigmas prevent the effective provision
and uptake of interventions for sex workers across sub-Saharan
Africa. Moreover, the unmet HIV treatment needs among sex
workers results in onward HIV transmissions that are relevant
even in the most generalized HIV epidemics. The data presented
here collectively demonstrate the importance of punitive and
non-protective laws in driving HIV risks among sex workers.
Furthermore, stigmas and sex work laws appear to operate
synergistically in increasing HIV burden, with stigmas having a
greater impact on HIV risk in punitive and non-protective set-
tings. In 2020, there will be more than three times the number of
infections compared with the stated goal of 500,000 new HIV
infections, highlighting the need to do things differently if there is
to be a chance of achieving zero new infections by 2030. Thus,
whether the path forward is driven by human rights or public
health principles, achieving zero new HIV infections in the
foreseeable future can only be realized if we meaningfully address
the structural determinants that contextualize individual HIV
risks among sex workers across sub-Saharan Africa.
Methods
Data collection and participants. Primary data collection was conducted through
10 country-specific studies led by one investigative team. Respondent driven
sampling (RDS) was used in each of the 10 country-specific studies between 2011
and 2018. All country-specific studies were cross-sectional. Data were collected
across 21 sites in 10 countries: Burkina Faso (January–August 2013); Cameroon
(November 2015–October 2016); Côte d’Ivoire (March 2015–February 2016); The
Gambia (May 2017–May 2018); Guinea-Bissau (September–November 2017);
Lesotho (February–September 2014); Senegal (February–November 2015); eSwatini
(August–October 2011); South Africa (October 2014–April 2015); and Togo
(January–June 2013).
RDS, a peer-recruitment method designed to sample marginalized populations,
was administered independently across the country-specific sites to recruit female
sex workers. Recruitment chains were initiated by seeds in each site, who were
individuals selected in collaboration with local community-based organizations to
represent heterogeneity in demographic characteristics and geographic
representation. Initial seeds were provided with three coupons to recruit peers into
the study. Women recruited by seeds and enrolled in the study were provided with
three coupons for continued recruitment of peers. This process was repeated until
reaching the target sample size of each country. Sample size calculations for the
initial data collection were powered to estimate HIV prevalence at each site. The
number of recruitment seeds by study site are provided in Table 1.
Participants were eligible if they self-reported female sex assigned at birth; were
18 years or older; attributed more than half of their income in the past 12 months
to selling sex; and were capable of providing informed consent. Country-specific
eligibility criteria included city or area of residence. All participants provided verbal
or written informed consent. The study complied with all relevant ethical
regulations for work with human participants. Country-specific data collection
were reviewed and approved by Johns Hopkins School of Public Health
Institutional Review Board and/or an ethical review board and related bodies in the
country of data collection. Country-specific ethic committees include: Health
Research Ethics Committee of Burkina Faso, National Ethics Committee of
Cameroon, the Health Research Ethics Committee of Côte d’Ivoire, National
Research Ethics Committee of Guinea Bissau, the Lesotho National Health
Research Ethics Committee, the Senegalese National Health Research Ethics,
Institutional Review Boards of the Human Sciences Research Council in South
Africa, the Swaziland Scientific Ethics Committee, Scientific Coordination
Committee in the Gambia, the Ethical Committee of Togo.
Interviewer-administered questionnaires were conducted, and socio-behavioral
measures were self-reported. All interviews were conducted in a private location
with trained study staff. Biological testing for HIV, including pre- and post-test
counseling, was conducted consistent with country-specific national guidelines.
Participants with a reactive test result were referred to care. Pre-test counseling and
biological testing were conducted prior to administering the socio-behavioral
questionnaires. Post-test counseling and HIV test results were reviewed with
participants after completion of the socio-behavioral questionnaire.
Measures. Individual-level data from socio-behavioral questionnaires and biolo-
gical testing are used for this analysis. Stigma measures are described in Supple-
mentary Table 3. Consistent stigma metrics are used across countries that included
items on ever experiencing stigma relating to healthcare, among family or friends,
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Content courtesy of Springer Nature, terms of use apply. Rights reserved

and the general community. Stigma measures were asked as attributable to
engagement in sex work, except for measures of physical and sexual violence.
Stigma measures were informed by a systematic review of stigma metrics and were
validated with data from Togo and Burkina Faso26,62,63.
Countries are categorized into three regions: West Africa (Burkina Faso, Cote
d’Ivoire, The Gambia, Guinea-Bissau, Senegal, and Togo); Central Africa
(Cameroon); and Southern Africa (Lesotho, Kingdom of eSwatini, South Africa).
Country-level HIV epidemic status is defined for each country as either generalized
or concentrated. These categories leveraged the traditional UNAIDS and WHO
definitions. Thus, a concentrated HIV epidemic includes countries in which HIV
prevalence is consistently over 5% in at least one defined subpopulation, but < 1%
among reproductive aged women; a generalized HIV epidemic has an HIV
prevalence consistently exceeding 1% in adult women. UNAIDS estimates were
used to categorize the country-level epidemics64.
Legal status of sex work for countries in this study is defined and categorized
based on the legal approach: not specified, partially legalized, or criminalized
(Supplementary Table 4). Not specified included countries in which there is not an
explicit law legalizing or criminalizing the selling of sex. Partial legalization is
defined as countries that have legalized an aspect or a mechanism of sex work
under specific circumstances, including legal to sell or legal to solicit, whereas
leaving other aspects criminalized. In some cases, legalization of sex work is
regulated alongside a registration system for sex workers. Criminalized, is defined
as illegal to sell sex, solicit sex, and organize commercial sex under any
circumstance and stipulated punishment under the law. None of the countries in
these analyses was considered decriminalized. This categorization was determined
by leveraging existing legal frameworks for sex work18,65,66. The legal status of sex
work for this analysis is defined by the written law and not based on enforcement
practices.
Statistical analyses. Statistical models were guided by the Structural HIV
Determinants Framework for Sex Work and the Logic Model of Public Health Law
Research10,67.
Data are pooled across countries and analyzed as crude data; RDS-adjusted
weighting is not applied across countries as women do not represent a single
network of female sex workers, violating a key assumption of RDS68. Models are
clustered by country and by site and represent valid sample estimates, but may
differ from population-level estimates given lack of RDS-adjustment69.
Proportions of demographic characteristics, HIV risk and status, disclosure, and
stigmas are described using crude estimates. Person’s Chi-squared is used to assess
the relationship between demographic characteristics and legal status of sex work.
Legal status of sex work and HIV are assessed through simple and multivariable
logistic regressions. Multivariable logistic regression models adjusted for age,
education level, marital status, and years in sex work and account for clustering
within sites and within countries. Although the country-level epidemic
(concentrated vs. generalized) is associated with HIV prevalence, it is not
considered a confounder in our conceptual model, but rather a mediator between
sex work law and HIV prevalence, as sex work laws in each country preceded the
introduction of HIV within the countries.
Logistic regression models are used to assess associations between various
stigma exposures and the outcome of HIV status. Stigma exposure models were run
separately due to collinearity between stigma items. Multivariable logistic
regression models adjusting for country-level epidemic, age, education, marital
status, and years in sex work, and respective disclosure variables when conceptually
relevant (disclosure of sex work to family; disclosure of sex work to healthcare
provider) were run for each stigma exposure. All models account for clustering by
site and by country.
To explore joint mechanisms through which the relationship between stigma
indicators and HIV status may be modified by legal status, the relationship between
stigma indicators and HIV status is stratified by country-level legal status of sex
work. The MH is used to assess differences between stigma and HIV across
different legal statuses, using a significance level of p<0.01
70. Values for which a
difference was observed were assessed through stratified multivariable adjusted
models assessing stigma exposures on HIV status. Effect measure modification
between stigma and HIV by legal status of sex work was assessed using an
interaction term of stigma and legal status in logistic regressions with HIV modeled
as the outcome. Effect measure models adjust for country-level epidemic, age,
education, marital status, years in sex work, and respective disclosure variable when
conceptually relevant; models account for clustering within sites and within
countries.
Due to the large sample size from Cameroon, sensitivity analyses using a
random sample of data from Cameroon (n=700) were conducted.
All analyses were conducted in Stata v.15.1. (College Station, Texas, United States).
Reporting summary. Further information on research design is available in
the Nature Research Reporting Summary linked to this article.
Data availability
The data that support the findings of this study are available from the corresponding
author upon reasonable request.
Code availability
The custom code in these analyses are available from the corresponding author upon
reasonable request.
Received: 13 May 2019; Accepted: 18 January 2020;
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Acknowledgements
We express our sincere appreciation to the participants of this study. In addition, we
acknowledge the crucial role of the community groups that make great personal and
professional sacrifices to serve the unmet health and advocacy needs of those most
marginalized in the HIV response. We would also like to thank the data collection and
study coordination teams across the different countries. The work was funded through
USAID, PEPFAR, Global Fund to Fight AIDS, Tuberculosis and Malaria, and NIH.
Work in Togo and Burkina Faso was supported by Project SEARCH, which was
funded by the US Agency for International Development (USAID) under Contract
GHH-I-00-07-00032-00 and by the President’s Emergency Plan for AIDS Relief
(PEPFAR). Cameroon study was supported through the CHAMP project, which was
led by CARE and funded by PEPFAR through USAID. Work in Côte d’Ivoire was
funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria through the
Government of Côte d’Ivoire National AIDS Control Program (PNPEC) contract to
Enda Santé, and subcontracted for technical assistance to Johns Hopkins University.
Work in Guinea Bissau and The Gambia was funded through Global Fund to Fight
AIDS, Tuberculosis and Malaria. Work in Senegal was funded through HIV Preven-
tion 2.0 (HP2): Achieving an AIDS-Free Generation in Senegal and supported by the
USAID under Cooperative Agreement No. AID-OAA-A-13-00089. Work in Lesotho
was funded by USAID (AID-674-A-00-00001) and implemented by Population Ser-
vices International/Lesotho (PSI). Work in eSwatini was funded by PEPFAR through
the USAID Swaziland (GHH-I-00-07-00032-00). Work in South Africa was funded in
part by a grant provided by the MAC AIDS Fund (grant No.GR-000001400). C.E.L.'s
effort was supported by the Johns Hopkins HIV Epidemiology and Prevention Sci-
ences Training Program (5T32AI102623-08). S.B.'s effort was supported by the
National Institute Of Mental Health of the National Institutes of Health under award
number R01MH110358; and the National Institute Of Nursing Research of the
National Institutes Of Health under award number R01NR016650. Publication was
NATURE COMMUNICATIONS | https://doi.org/10.1038/s41467-020-14593-6 ARTICLE
NATURE COMMUNICATIONS| (2020) 11:773 | https://doi.org/10.1038/s41467-020-14593-6 | www.nature.com/naturecommunications 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved

supported by The Foundation for AIDS Research (amfAR); the National Institute Of
Mental Health of the National Institutes of Health under award number
R01MH110358; the National Institute Of Nursing Research of the National Institutes
Of Health under award number R01NR016650; The Linkages across the Continuum of
HIV Services for Key Populations Affected by HIV (LINKAGES) project funded by
PEPFAR and USAID and led by FHI360; and the CHAMP project. Finally, this
publication was made possible by the Johns Hopkins University Center for AIDS
Research, an NIH funded program (P30AI094189). The funders had no role in study
design, data collection and analysis, decision to publish, or preparation of the
manuscript.
Author contributions
C.E.L. and S.B. collaborated on the conceptualization of the study. C.E.L., S.B., S.S., S.M.
collaborated in analytic plan, analyses, and interpretation. D.D., T.M., S.K., A.S., A.K.,
Z.M., U.T., N.P.M., B.C., F.D., M.A.D., S.B. collaborated on study design, implementa-
tion, and investigation. C.E.L. and S.B. led initial drafting of the manuscript with S.S.,
S.M., K.S., D.D., T.M., S.K., A.S., A.K., Z.M., U.T., N.P.M., B.C., F.D., M.A.D. con-
tributing to specific sections and review and revisions.
Competing interests
The authors declare no competing interests.
Additional information
Supplementary information is available for this paper at https://doi.org/10.1038/s41467-
020-14593-6.
Correspondence and requests for materials should be addressed to C.E.L.
Peer review information Nature Communications thanks John Dovidio and the other,
anonymous, reviewer(s) for their contribution to the peer review of this work. Peer
reviewer reports are available.
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ARTICLE NATURE COMMUNICATIONS | https://doi.org/10.1038/s41467-020-14593-6
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