HIV prevention programming with

female sex workers: a review of

experiences in sub-Saharan Africa

Matthew Greenall, June 2009

(mgreenall[at]gmail.com)
Review of HIV prevention programming with sex workers in sub Saharan Africa. June 2009

Contents

Table of Contents
Tables 3
Abbreviations 3
I. Introduction 4
1. Renewed focus on HIV prevention with “key populations” 4
2. About this report 4
II. Methodology 6
1. Literature search 6
2. Summary of the results of the literature search 6
3. Classification and presentation of experiences of programming with female sex workers 7
III. Experiences of HIV prevention programming with sex workers 9
1. Improving identification and prioritisation of key populations in responses to HIV and AIDS in
general 9
2. Programmes with female sex workers 10
IV. References 17

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Tables

Summary Table 1: improving identification and prioritisation of key populations 9

Summary Table 2: Identifying, categorising and accessing female sex workers 11
Summary Table 3: Reducing risky behaviour among sex workers 13
Summary Table 4: Influencing structural/environmental risk factors affecting sex workers 14
Summary Table 5: Provision of HIV and sexual health products and services to sex workers 16

Abbreviations

ABC Abstain, Be faithful, use Condoms

AIDS Acquired Immune Deficiency Syndrome
FSW Female Sex Worker
IEC Information, Education, Communication
HAPCO HIV/AIDS Prevention and Control Office
HIV Human immunodeficiency virus
MARPs Most at risk populations
MSM Men who have sex with men
NGO Non governmental organisation
PLACE Priorities for Local AIDS Control Efforts
STI Sexually Transmitted Infection
UNAIDS United Nations Joint Programme on AIDS
WHO World Health Organisation

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Review of HIV prevention programming with sex workers in sub Saharan Africa. June 2009

I. Introduction

1. Renewed focus on HIV prevention with “key populations”

National AIDS programmes in sub-saharan Africa are paying increasing attention to the need to target
prevention efforts toward those most at risk of HIV infection: “key populations”, or “most at risk
populations”. There are a number of reasons for this shift:

Up to date epidemiological analysis has begun to suggest that some HIV epidemics in the region may
not be as “generalised” as was previously believed, with infections among specific groups now
believed to account for a significant proportion of new HIV infections in many countries.
With the arrival of large scale HIV treatment programmes, prevention programmes have become
neglected [1-3], and the numbers of people infected with HIV continue to increase, meaning that it
has become essential to strengthen prevention efforts. At the same time, the arrival of treatment
provides new opportunities for strengthening the effectiveness of HIV prevention efforts.
HIV prevention programmes in many sub-Saharan African countries have been generally limited to
awareness-raising in the general population. Although there are many good examples of effective
focussed programming approaches, coverage of these programmes remains very limited and
insufficient to achieve impact at national level – as has recently been documented in various
countries in sub-Saharan Africa [4-10].
There are very specific reasons why certain groups are more vulnerable to HIV infection: these
reasons are related to the circumstances in which they live, and to various barriers that stand in the
way of them accessing information, skills and services. HIV prevention strategies targeting the
general population tend not to be effective because although they may reach “key populations” to
some extent, they fail to properly address the specific issues faced by these groups. As a result it is
essential to design and implement services that are directly tailored to different population groups.

2. About this report

This report is based on a review commissioned by the HIV/AIDS Prevention Control Office (HAPCO) of
the Amhara region in Ethiopia in June 2009. On HAPCO Amhara’s request, UNAIDS Ethiopia contracted
the UNAIDS Technical Support Facility at AMREF in Nairobi, who in turn contracted me to conduct the
review. The original review covered a number of other population groups; however the present report
reproduces only the sections relating to sex workers. Other sections of the review are available from
the author and eventually online.

The report summarises experiences of countries in sub-Saharan Africa in HIV prevention programming
with sex workers. In so doing it illustrates examples of good practice in identifying sex workers, in
conducting the research needed to design effective programmes with sex workers, and in defining which
services and strategies are necessary and effective for reaching different profiles of sex workers and
engaging them in HIV programmes. Although the social and epidemiological contexts in sub-Saharan
African countries are diverse, they also have much in common in terms of the challenges in working with
sex workers, and the characteristics of effective programmes.

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The report is structured in three sections: Introduction, Methodology, and description of Experiences of
programmes.

Although this is not a systematic review, and the nature of the information available, the skills of the
researcher, and the time spent to conduct the review all precluded the use of systematic review and
meta-analysis techniques, it is hoped that it will provide a good bibliographic starting point for
researchers and programme managers.

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II. Methodology

1. Literature search

This report draws on a wide range of literature describing HIV prevention programmes in sub-Saharan
Africa. The two main sources of literature consulted were articles published in peer-reviewed journals,
and reports published by institutions implementing HIV prevention programmes including government
AIDS programmes, NGOs, international organisations, funding agencies and technical agencies.

Documents were identified through searches of online databases and portals, of relevant organisational
websites, and of references appearing in already identified documents. Documents were included in the
original review if they included both a description of interventions or programmes carried out with
different “key population groups” (sex workers, mobile and migrant populations, young people,
injection drug users and men who have sex with men) and robust data relating to their effectiveness or
impact – for instance, before/after evaluations or evaluations comparing intervention groups with
control groups. Document searches were stopped once a sufficient number of examples had been
identified. This is not therefore a systematic review.

2. Summary of the results of the literature search

Documents identified
Based on the criteria described above, and for all of the population groups described (sex workers,
mobile populations, young people and men who have sex with men), a total of 190 documents were
reviewed, including 90 articles published in peer-reviewed journals. Although the majority of the
documents included are monographs describing individual programmes or interventions, the documents
also include 27 reviews (including systematic reviews) which describe and summarise a large number of
programmes and case studies in a range of countries. A number of best practice summaries are also
included. Although these summaries do not include specific case studies, they include useful “state of
the art” recommendations for programming based on a broad range of experiences.

Limitations
The main limitation of the review presented in this report is the relative lack of documentation that
includes both a detailed description of the process and content of programmes with key populations
and a robust evaluation of the effectiveness of these programmes. The most robust evaluations are
those that are published in peer-reviewed journals. A number of randomised controlled trials, providing
very good evidence of effectiveness of the intervention being evaluated, are included in this report.
However, articles in peer-reviewed journals tend to provide only summary descriptions of interventions
and strategies. Moreover, a number of these articles focus on evaluating individual components of
prevention programmes in isolation, rather than assessing the overall effectiveness of intervention
“packages”. Nonetheless, it is possible to draw a certain number of conclusions about the different
services that it is important to provide to each population group.

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Review of HIV prevention programming with sex workers in sub Saharan Africa. June 2009

Although the review primarily concerns sub Saharan Africa, some of the source documents (systematic
reviews) had a wider scope; there are therefore some examples from outside of the region.

Project reports, programme reviews and “best practice” documents contain considerably more detail on
programme implementation, and on the specific strategies adopted to better understand the
vulnerabilities and needs of different “key population” groups and to overcome the barriers to working
with them. However, most of these documents are limited to descriptions of programme processes and
do not present any evaluation data.

There are also variations in terms of the types of data available for each population group. The majority
of available information on sex worker programmes is research-based, with some direct evidence of
impact on reported risk behaviours and on HIV and STI incidence, but with very few detailed programme
descriptions. On the other hand, although there are a number of well-documented programmes on
migrant and mobile groups, few of these have published evaluations.

This report is further limited by the time spent on researching and writing it. It has not been possible to
conduct a systematic literature review, and some important documents have almost certainly been
omitted. Furthermore, in order to keep the report brief, it has not been possible to include detailed
descriptions of programmes. It is hoped that the references provided will serve as a guide for targeted
further reading for those who are responsible for developing programmes in the future.

3. Classification and presentation of experiences of programming with female sex workers

Despite the limitations described above, a composite picture emerges of the types of intervention and
service that are appropriate (the “what”) and of the approaches and strategies that have proven to be
most effective in delivering these interventions and services (the “how”).

The first section of the review describes methods that are used to improve the identification and
prioritisation of sex workers in national responses to HIV and AIDS. Following this, information has been
classified according to one of the following aspects of programming:
Identifying, categorising and accessing “key populations”
Delivering comprehensive HIV prevention packages to sex workers:
- General principles for comprehensive programming
- Strategies to reduce risky behaviour at individual level
- Strategies to influence structural/environmental risk factors
- Provision of HIV and sexual health products and services

The examples identified are presented according to this framework. In most cases, a range of
approaches are presented as there is not one “correct” way. This is because the term “sex worker”
encompasses many different profiles and realities, and because different contexts lend themselves to
different approaches.

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A short table summarising the key points relating to key issues to be addressed (the basic needs to be
addressed) and strategy (the most proven approaches to addressing these needs) is provided at the end
of the analysis.

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III. Experiences of HIV prevention programming with sex workers

1. Improving identification and prioritisation of key populations in responses to HIV and

AIDS in general

Although the concept of “most at risk populations” or “key populations” is well established, HIV
prevention efforts in many countries are not sufficiently prioritising these groups. It is essential that
national AIDS programmes conduct research to identify them and to assess their relevance to the
epidemic. The principal approach is to carry out surveillance studies with such groups to gather data on
behavioural and biological indicators as well as to estimate the size of each group, and then to use these
data to model the main modes of transmission of HIV.

Methodologies and standards for this type of surveillance are well documented [11-14]. Many countries
in sub-Saharan Africa already carry out surveillance with female sex workers, truck drivers, and young
people; and less often with migrant workers and members of the uniformed services. Some countries in
the region have also started to carry out research with men who have sex with men (MSM), and have
discovered as a result that they have significant MSM populations, and that HIV prevalence among MSM
is often much higher than in the general population. Moreover, MSM frequently face stigma,
discrimination and violence, and are very often missed by HIV and AIDS programmes [15, 16].

A number of national AIDS programmes in sub-Saharan Africa have begun to show leadership in
reducing stigma and discrimination against MSM and in ensuring that their rights are protected and
their needs are adequately met by HIV and AIDS programmes [17, 18]. There may be other overlooked
groups in the region – for instance, some countries have identified the emergence of HIV epidemics
among injecting drug users, again showing the importance of ongoing surveillance efforts.

Although many countries carry out surveillance studies, the data collected are not always effectively
used to help prioritise HIV prevention programmes. It is therefore important not only to gather
surveillance data, but also to use these data for decision making and programme prioritisation. A
number of tools have been developed to support data utilisation and to ensure a more evidence-based
approach to national programme design [20-23]. Exercises aimed at strengthening the collection, usage
and interpretation of data, and at improving understanding of the determinants of HIV transmission,
have been conducted in a number of countries in sub-Saharan Africa in recent years, leading to an
increasing focus of HIV prevention programmes on key populations [4-10].

Summary Table 1: improving identification and prioritisation of key populations

Issues to be addressed
- Poor quality and availability of data
- Denial of the existence or relevance
of certain groups
- Available data not sufficiently taken
into account in prioritisation of
responses to AIDS
Examples of potential strategies, depending on context
- Implement regular sentinel surveillance
- Advocacy with authorities to conduct research with non-
recognised groups (e.g. MSM)
- Make data available to all actors
- Use up to date data as a basis for development of strategic
and operational plans (“know your epidemic/know your
response”)

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2. Programmes with female sex workers

Overview of key characteristics, vulnerability and risk factors of female sex workers
Female sex workers (FSW) are commonly mentioned as priority or “most at risk” groups in national AIDS strategies.
Because they have high numbers of sexual partners, and often limited power to ensure they stay protected, they
are highly vulnerable to STIs and to HIV infection.

It is also common for FSW to face stigma and discrimination as a result of negative attitudes towards them. This
can manifest itself in a number of ways: through unstable housing conditions, abuse from community members,
and stigmatising attitudes from health services. It often results in FSW having unequal access to development and
social services, and often impacts on their children – in many countries the children of sex workers are less likely to
be able to go to school than other children. It is also very common for FSW to face violence from a range of sources
– clients, community members, partners, law enforcement officers, and other sex workers. Violence, and the fear of
violence, can be a major impediment to sex workers protecting themselves from HIV. As a result of all of these
factors, HIV prevalence among sex workers is often much higher than in the general population.

However, coverage of FSW by HIV prevention programmes is very seldom optimal: a recent review estimated that
while national HIV prevention programmes should aim to reach at least 80% of sex workers, in sub-Saharan Africa
only 23% of sex workers are reached by outreach prevention programmes [2]. While sex work programmes do
exist in most countries, they tend to be small scale, and their reach is limited to larger cities and to border towns.

Scaling up programmes with sex workers is made difficult by the fact that many implementers and service providers
are reluctant to work with such a stigmatised group. At the same time, FSW can be hard to identify and to reach,
because in most settings, a large proportion of FSW are working informally and outside of known “hotspots” such
as bars, transport routes and brothels. Moreover, sex workers are often migrants and sometimes mobile, meaning
that some of the challenges related to HIV prevention programming with migrant and mobile groups also apply to
them.

At the same time, many programmes with FSW have shown that when they are fully involved as partners in HIV
prevention, they can play a very important role in helping reduce HIV risk among sex workers and in educating
clients.

Identifying, categorising and accessing female sex workers

To be effective, programmes need to know not only who and where FSW are, but also what their
specific vulnerabilities are, as well as the barriers they face in accessing HIV prevention services.

In most settings, there are some sex workers that are highly “visible”, as well as large numbers of sex
workers that are less easily identifiable. Programmes working with sex workers in different countries
have come up with a number of innovative methods for identifying the “hidden” sex work groups. For
instance, an HIV prevention programme in Nairobi, Kenya identified sex workers by investigating the
locations which accounted for the highest numbers of STI cases, leading to the organisation of
community meetings and eventually the establishment of a comprehensive HIV programme [24]. This is
a good example of how to identify and initiate programmes with sex workers – in this case the
programme gradually built its understanding of the profiles, needs and priorities of sex workers. In most

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settings, a large proportion of sex workers do not necessarily “identify” as sex workers, so it is important
for programmes not to impose labels that the individuals concerned do not recognise.

Even in settings where sex work is relatively well understood it is important for programmes to be able
to identify the different profiles or sub-groups, for whom different programme approaches may be
necessary. This is especially useful in cities where the sex work population is large and diverse and
where several parallel programmes are required. This approach was adopted in Addis Ababa in 2002
[25]. An alternative is to carry out a “mapping” exercise: this approach is more commonly used when
the focus is on a specific, defined location where sex work takes place, rather than just focussing on sex
workers. This approach can focus on border towns or truck stops [26, 27], “high transmission locations”
or hotspots [28-32], or small towns [33].

Many programmes have learned that different sub-groups react differently to programme interventions,
thereby showing the importance of approaches that are tailored to each specific subgroup. For
example, a programme in Nairobi found that the least “formal” sex workers worked from home, and
frequently had less access to condoms and other services; whereas street-based sex workers were more
likely to have access to condoms but to experience difficulties in imposing condom use on clients [34]. A
study in Addis Ababa found that condom use among sex workers was higher when they cited condom
use not only as a means of preventing HIV and STIs but also as a means of contraception – indicating the
importance of linking HIV prevention with reproductive health [35]. There are many other examples of
HIV programmes with sex workers that are “contextualised”; in other words that look at broader issues
that affect vulnerability of sex workers, such as reproductive health, violence, stigma and human rights.
Programmes that adopt a broader approach in this way often manage to engage better with sex workers
as they are addressing issues that are real concerns for sex workers but that are also strong correlates of
sex worker vulnerability to HIV; consequently programmes taking this approach have been shown to
have a greater impact, both in Africa [36-38] and beyond [39, 40].

Working with clients can be an important component of HIV prevention with sex workers because the
way clients behave has a clear link with the vulnerability of sex workers. However, clients of sex workers
are not always easy to target as they are a very diverse group. Some of the most innovative techniques
used for identifying and characterising clients have involved sex workers themselves in conducting
research on clients. Examples of how this has been done include a study carried out by sex workers in
Senegalese brothels [41], and research conducted by sex workers on truckers in South Africa [42].

Summary Table 2: Identifying, categorising and accessing female sex workers

Issues to be addressed
- Diversity of the female sex worker
population; high proportion of “non-
identified” sex workers
- Poor understanding of the particular
issues faced by FSW in each location
- Lack of recognition of broader
context of HIV vulnerability of sex
workers
Examples of potential strategies, depending on context
- Include sex workers in sentinel surveillance
- Participatory needs assessments (training identified sex
- workers to conduct assessment work)
- Census/enumeration approaches in large urban centres
- Mapping in sites where sex work is heavily concentrated
- Assessment/formative research work to look at issues such as
human rights, stigma and discrimination, reproductive health.
- Formative research to identify profiles and characteristics of
clients of sex workers

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Delivering comprehensive HIV prevention programmes to female sex workers

General principles for comprehensive programming
As noted above, comprehensive programming with sex workers should combine a package of
components that help to reduce risky behaviour at individual level, that reduce factors in the broader
environment that contribute to risky behaviour, and that ensure continuous access to high quality HIV
and sexual health services. A recent systematic review of HIV interventions for sex workers concluded
that “combining sexual risk reduction, condom promotion and improved access to STI treatment
reduces HIV and STI acquisition in sex workers receiving the intervention” [39]. A comprehensive
approach means not only providing the range of different interventions, but also providing them in a
“linked” way, ensuring that there are referrals and continuity between them. This is especially
important where different implementing organisations are providing different interventions.

There are many examples showing how when individual interventions are missing from the package, the
effectiveness of programmes is compromised. For instance, programmes in Ghana [43] and the Gambia
[44] that failed to pay attention to condom availability had poor results. Conversely a study in
Zimbabwe showed the limits of programmes that only focus on condom distribution, because condom
use is not determined only by condom availability [45]. Another example from Uganda [46] illustrates
how a lack of collaboration and cooperation between implementing organizations can result in some
components of “comprehensive” programmes becoming neglected, thereby compromising the impact
of the programme – in this example, lack of coordination between different implementers resulted in
condom stock-outs.

There are a number of examples of comprehensive approaches contributing to long-term positive

outcomes in terms of risk behaviour, as well as STI and HIV prevalence, in programmes in sub-Saharan
Africa. The best-documented examples of effective comprehensive programmes with sex workers in
Africa come from Abidjan, Cote d’Ivoire [40, 47-49], and Nairobi, Kenya [24, 34, 50-55]; however there
are a number of additional examples of effective comprehensive programmes, from Benin [56], Kenya
[57-59], Madagascar [60], Nigeria [61], South Africa [59], Tanzania [31, 62], Zaire [63] and Zimbabwe
[64].

These examples demonstrate that combining multiple interventions produces a greater positive impact
than delivering interventions in isolation. They also demonstrate the overall importance of a
comprehensive approach. The remainder of this section draws on these examples to provide more
detail on the way the different components can be delivered.

Component 1: Strategies to reduce risky behaviour at individual level

The most common strategies used in projects with sex workers are peer education, education by
outreach workers, one-to-one counselling (including clinic-based counselling), distribution of
educational materials and group discussions. Many of the examples already referenced above indicate
that the most effective programmes used a combination of these strategies, rather than just one of
them. Programmes that have shown positive results tend to achieve higher rates of protected sex
between sex workers and clients (over 90%), than between sex workers and their stable partners (up to
60%). Nonetheless, the rate with stable partners is exceptionally high when compared with rates of

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condom use in stable couples in the general population in many sub-saharan African countries – which
tends not to exceed 5%. Higher condom use rates in stable relationships can be achieved in the context
of “positive prevention” programming with sero-discordant couples [65], and ensuring sex workers have
access to these programmes (including HIV testing) is therefore an important strategy.

There are a number of reasons why this combined approach is more effective. Each individual responds
differently to different methods. For instance, peer education is a very good technique for ensuring that
information reaches both formal and informal sex workers, and it can also be a very useful method for
sex workers to share the strategies and techniques for keeping safe. However, not everyone is
comfortable discussing sensitive issues with their peers, and peer education and other outreach
activities often take place at times when sex workers are busy with work and not available to discuss for
more than a few minutes. Moreover some individuals prefer receiving advice from health professionals,
and clinic-based counselling in some situations has been shown to further increase condom use rates
achieved by programmes based only on peer education [60]; conversely programmes where condoms
are promoted only using clinic-based counselling have been shown to be less effective, as examples
from Madagascar and the Gambia show [44, 66]. Educational materials are important for supporting
awareness-raising, but they should not be the only method used as not all sex workers are literate. It is
therefore important that sex workers are able to access information and advice in different ways,
including at sexual health clinics.

Group discussion activities have been shown to be a very important complement to individual education
and counselling, and have for example been shown to be a significant factor associated with increased
condom use [54]. They provide an additional opportunity for sex workers to share strategies or
information, for example on potentially violent clients or dangerous situations. As with the other
strategies, it is important not to assume that all sex workers will be willing to participate in group
activities – so it should not be used as a standalone strategy. Programmes that incorporate group-based
work often organise group discussions periodically (monthly or quarterly), while other services such as
peer education are carried out more frequently – there are well documented examples from Kenya [24,
54, 57], Nigeria [61], and Zimbabwe [64].

Summary Table 3: Reducing risky behaviour among sex workers

Issues to be addressed/content
- Lack of awareness on sexual and
reproductive health (including STI and HIV
prevention, contraception)
- Low condom use with clients (promotion,
skills building)
- Potential for HIV transmission in stable
relationships
- Violence against sex workers
- Limited skills for avoiding risky sex
- Drug use (where relevant)
Examples of potential strategies, depending on context
- Peer education
- Education by outreach workers
- Clinic based counselling
- IEC materials distribution
- “Positive prevention”/serodiscordant couple
counselling as appropriate
- Group discussion activities; exchanges between
sex workers
- Outreach activities in bars, brothels, “hotspots”

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Component 2: Strategies to influence structural/environmental risk factors

As has already been noted, sex workers’ vulnerability to HIV infection is not just related to individual-
level behaviour – it is also related to the broader context in which they work: for instance how they and
their families are treated by their communities and by local authorities; how clients behave and react to
requests to use condoms; the extent to which violence against sex workers occurs; whether they have
additional sources of income. The vulnerability factors vary in each location, so it is important for sex
workers themselves to identify them, and to discuss how to resolve them. Group based activities – such
as those described above – are an important strategy for addressing these broader risk factors.
However, once again it is important to note that not all sex workers will be willing to participate in group
activities, in particular if participation means publicly acknowledging that they are sex workers.

There are many well documented examples of how associations or groups of sex workers have acted
successfully to address a number of issues: for instance, by collectively agreeing to refuse to have sex
with clients without condoms; advocating with local authorities to crack down on extortion and violence
carried out against sex workers by members of the armed forces; sharing information on violent clients;
reporting violence to authorities; and providing advice to health care workers on how best to respond to
the needs of sex workers [34, 37]. There are other examples of how sex workers have worked
collectively to reduce the risks of violence, often the biggest threat faced by sex workers [36]. Collective
action of this type can also lead to efforts to change policies and laws which discriminate against sex
workers and make them more vulnerable [37].

One of the most common “structural” approaches used in HIV programmes with female sex workers is
the provision of training, and/or microcredit, with the aim of removing women from sex work.
However, although considerable investments are made, a systematic review in 2007 concluded that
there is no evidence of this approach having an impact on HIV transmission at individual level or on
national prevalence of HIV; and very little evidence of this approach having a positive impact either on
participation in sex work or on behavioural risk for HIV infection [67]. A recent study that was published
after this review indicates that microcredit may reduce risk behaviour among older sex workers who are
earning less from sex work than younger sex workers [68]. This suggests that from a public health and a
cost-benefit point of view, “economic empowerment” programmes might be best targeted towards
specific sub-groups such as older sex workers, rather than being a standard component for all sex work
programmes.

Summary Table 4: Influencing structural/environmental risk factors affecting sex workers

Issues to be addressed/content
- Violence against sex workers
- Stigma and discrimination against sex
workers by officials and communities
- Policies/laws that make sex workers more
vulnerable
- Increased vulnerability of specific sub-
groups, e.g. sexually abused children; older
sex workers
Examples of potential strategies, depending on context
- Group discussion activities to identify issues and
to generate collective action
- Advocacy /awareness raising with local
authorities, health care providers
- Legal support for victims of violence
- Economic empowerment programmes targeted to
specific sub groups
- Assessment of legal context and law reform for
greater protection of sex workers

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Component 3: Provision of HIV and sexual health products and services

The main products that must be provided to sex workers within a comprehensive HIV prevention
programme are condoms. The majority of programmes studied for this report paid attention to condom
provision, and to targeted distribution to sex workers. Although male condoms are more commonly
provided, studies in a number of settings have shown that female condoms are both acceptable and
useful for female sex workers, and that making them available contributes to increased protection
during sex [45, 66, 69-71]. Importantly, it is not recommended to provide female condoms instead of
male condoms – but rather, to provide them in addition to male condoms. In many countries a range of
male condoms is available – premium brands which are relatively costly; condoms provided via “social
marketing” which are highly subsidised and therefore more affordable; and condoms provided free of
charge. It is not essential to provide all sex workers with free condoms, and indeed some individuals
prefer to pay for products rather than receiving them free of charge. However, the cost of condoms
must never be a barrier to condom usage, so it is important that each programme assesses whether
condom affordability is an issue for any of the sex workers being reached, and if it is a problem,
provision should be made for free distribution. Ensuring affordable availability of female condoms may
be more challenging as they cost considerably more than male condoms: this needs to be taken into
account in programme costing.

Provision of water-based lubricant, to accompany condom provision, is recognised as a good practice at

international level [37, 49, 72]; however although many programmes in Africa are known to distribute
water-based lubricant to sex workers as part of a comprehensive package, few of the documents
reviewed for this report cover the issue. Nonetheless, distribution of water-based lubricant is
considered by the World Health Organization to be an essential component of comprehensive
prevention programming with sex workers, and should therefore be included [73].

Various methods can be used to distribute condoms and water-based lubricant – and indeed, many of
the examples examined opted for multiple distribution channels, so as to ensure maximum availability.
Condoms and lubricant can be distributed through health services, by peer educators and outreach
workers, and in local stores; many programmes have also ensured condoms are available at locations
such as bars, hotels, and brothels, helping to ensure that condoms are available day and night.

Provision of clinical services is also an essential component of a comprehensive package for sex workers.
These should include STI diagnosis and treatment (which have been shown in many settings to reduce
HIV incidence), as well as HIV testing, care and treatment, and family planning and reproductive health
services. Other medical services, including trauma care for victims of violence, should also be provided.

Considerable research has been conducted in a range of settings to identify the most effective protocols
for providing STI treatment for sex workers, comparing the relative merits of periodic presumptive
treatment (PPT), syndromic diagnosis and management, and screening and treatment [31, 43, 48, 49,
56, 58, 63, 64, 74, 75]. Voluntary and mandatory STI treatment for sex workers have also been
compared. Although mandatory systems and presumptive treatment have been shown to have some

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impacts among those enrolled in the programmes, they tend to reach limited numbers and to exclude
highly mobile or informal sex workers. A recent systematic review concluded that “strong evidence that
regular STI screening or periodic treatment of STIs confers additional protection against HIV [for sex
workers] was lacking” [39], and World Health Organization guidance published in 2008 states that
periodic presumptive treatment “should be considered as a stop gap when good quality services not
available, not a substitute or stand alone strategy” [76].

There are many other important factors to take into consideration in the provision of health services to
sex workers. Ensuring a high quality of services is crucial [49]. Decisions on whether to provide
standalone services targeting sex workers, mobile services in sex work locations, or to improve sex
worker access to services serving the general public, depend very much on the profiles of sex workers
being targeted and on the nature of existing services. Services designed specifically for sex workers
have been shown to be very effective in many countries – though the available examples tend to
concern relatively “formal” sex work settings such as brothels, hotels or hotspots [61, 75, 77-79]. Many
“informal” sex workers are reluctant to associate themselves with services that explicitly target sex
workers, therefore in many settings it is useful to have a combined strategy of targeted services and of
improved access to general population services.

As with condom pricing issues, it is essential to ensure that cost is not a barrier to accessing sexual
health services. Not all sex workers are able to pay for services, and the provision of free or subsidised
services (including providing discount vouchers) are strategies that have been commonly used.

Overall, voluntary and consistent access to good quality and non-judgemental services emerge as the
best practice for service provision to sex workers. Sex workers often face discrimination and stigma
when accessing health care, and there are a number of examples of programmes carrying out training
and sensitisation to improve the behaviour of health care workers [24, 37]. Peer education, outreach,
and group discussion activities have an important role to play in improving access to services – because
they provide channels for referrals and for advising sex workers of where to access services, but also
because they provide opportunities to gather information from sex workers in relation to the barriers
they face in accessing services; once again this shows the importance of comprehensive approaches and
of ensuring strong linkages between the different components of programmes.

Summary Table 5: Provision of HIV and sexual health products and services to sex workers
Issues to be addressed/content Examples of potential strategies, depending on context

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Review of HIV prevention programming with sex workers in sub Saharan Africa. June 2009

- Limited availability of male, female condoms - Supporting a range of condom distribution

and water based lubricant
- Limited access to sexual and reproductive
health, HIV and other health care services
(including: HIV testing, HIV treatment, STI
treatment, contraception, trauma care, drug
use)
- Financial barriers to accessing products and
services
channels
- Strengthen health systems to ensure complete
package of SRH services is on offer
- “Sex work friendly” training to health care
workers and authorities
- Referrals to services by peer educators/outreach
workers
- Subsidising/providing free services
- Providing specific/mobile health services for sex
workers in certain situations (e.g. relatively formal
settings)

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