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Despite a fair amount of progress on understanding human immunodeficiency virus (HIV) epidemiology globally, the Middle East and North Africa (MENA) region is the only region where knowledge of the epidemic continues to be very limited, and subject to much controversy. It has been more than 25 years since the discovery of HIV, but no scientific study has provided a comprehensive data-driven synthesis of HIV/AIDS (acquired immunodeficiency syndrome) infectious spread in this region. The current report provides the first comprehensive scientific assessment and data-driven epidemiological synthesis of HIV spread in MENA since the beginning of the epidemic. It is based on a literature review and analysis of thousands of widely unrecognized publications, reports, and data sources extracted from scientific literature or collected from sources at the local, national, and regional levels. The recommendations provided here focus on key strategies related to the scope of this report and its emphasis on understanding HIV epidemiology in MENA as a whole. The recommendations are based on identifying the status of the HIV epidemic in MENA, through this synthesis, as a low HIV prevalence setting with rising concentrated epidemics among priority populations. General directions for prevention interventions as warranted by the outcome of this synthesis are also discussed briefly, but are not delineated because they are beyond the scope of this report. This report was not intended to provide intervention recommendations for each MENA country.

This article draws on research with adult sex workers in indoor settings in Great Britain to explore diverse forms of self-employment, employment relationships and small business development, set within the context of changes to the wider economy. It considers how external constraints such as the legal context, social stigma and dominant policy discourses can impact on sex workers’ autonomy and actively work against their safety and wellbeing. The article argues that broad policy and legal approaches which fail to recognise the complexity of sex work constrain sex workers’ opportunities for business development and improvement of their working circumstances. It suggests the need for recognition of sex work as legitimate labour, as a prerequisite for policy changes to support sex workers and pave the way for improved working conditions, not only in managed settings but also facilitating collective arrangements and independent lone working.

Objective: To describe the HIV/AIDS epidemic in mainland China. Methods: We review the magnitude of the HIV/AIDS epidemic and the social characteristics and geographic distribution of at-risk groups in China based on published literature and unpublished official data. Results: Injection drug use has been the dominant route for HIV infection in China, and will continue to be a major risk factor with increasing numbers of new drug users and needle sharing. Commercial plasma donation with unhygienic re-infusion of red blood cells was common in rural communities in the early 1990s. While this is unlikely to constitute a major factor for future HIV spread, those already infected represent a formidable treatment challenge. Huge seasonal work migration facilitates disease spread across regions. Many homosexual men have unprotected sex with men, women, or both, and may contract or spread HIV. Though commercial sex workers have contributed to a small proportion of the reported epidemic thus far, flourishing commercial sex is of growing concern and may have a bridging role in transmitting HIV from core groups to the general population. Conclusion: Increasing numbers of sex workers and drug users, internal migration, high risk behaviours, and low condom use suggest a future upward trend for HIV/AIDS and underscore the urgency of scaling up interventions in China.

Since the beginning of the epidemic sex workers have experienced a heightened burden of HIV across settings, despite their higher levels of HIV protective behaviors (UNAIDS, 2009). Unfairly, sex workers have often been framed as 'vectors of disease' and 'core transmitters' rather than workers and human beings with rights in terms of HIV prevention and beyond. By gaining a deeper understanding of the epidemiologic and broader policy and social context within which sex work is set one begins to quickly gain a sense of the complex backdrop for increased risk to HIV among sex workers. This backdrop includes the critical role of stigma, discrimination and violence faced by sex workers, as well as, the importance of community empowerment and mobilization among sex workers to address these regressive forces. The eight country case studies work to highlight the experiences of diverse populations of and contexts for sex work across settings. Given the limited epidemiologic and intervention evaluation data available among male and transgender sex workers, however, our collaborative team (Johns Hopkins University, or JHU, World Bank, United Nations Population Fund (UNFPA), and Global Network of Sex Work Projects, or NSWP) determined that the systematic review, mathematical modeling and cost-effective analyses would focus on female sex workers. Throughout the process of this analysis as a whole, the participation of sex worker perspectives and sex worker organizations such as NSWP and their regional partners has been critical by providing documents and resources, input and consultation throughout the analytical process.

The aim of this research is to broaden the knowledge on the social perception of people who pay for commercial sex. An online questionnaire was distributed to 3126 young people in Spain. Respondents did not have a common perception about people who pay for sex, although several considered that a rich-buyer is associated with “partner”, “money”, “education” and “Spanish”; a risky-buyer meets the variables of “satisfying their domination needs”, “reaffirm masculinity”, “is violent” and “do not want to use preservative”; a low-status buyer has “limited money”, “is an immigrant” and “has a low level of education”; an insecure-buyer presents variables indicating that he is “insecure with the opposite sex” and “dissatisfied with their partner”; and a single-buyer “has no couple” and “is single”. These perceptions help to improve awareness campaigns against human trafficking and sexual exploitation and increase the visibility of the responsible parties who pay and encourage these crimes.

ObjectivesRecommendations of ‘social distancing’ and home quarantines to combat the global COVID-19 pandemic have implications for sex and intimacy, including sex work. This study examined the effects of COVID-19 on male sex work globally and investigated how men who sold sex responded to and engaged with the virus in the context of work.MethodsThis study made use of an existing database of deidentified data extracted from the online profiles maintained by male sex workers on a large, international website. Website engagement metrics were calculated for the periods before (September to December 2019) and during COVID-19 (January to May 2020); Poisson regression analyses were used to assess changes over time before and after, while a content analysis was undertaken to identify modes of engagement with the virus.ResultsData were collected from 78 399 profiles representing 19 388 individuals. In the ‘before’ period, the number of active profiles was stable (inter-rate ratio (IRR)=1.01, 95% CI 0.99 to 1.01, p=0.339) but during COVID-19 decreased by 26.3% (IRR=0.90, 95% CI 0.89 to 0.91, p<0.001). Newly created profiles also decreased during COVID-19 (59.4%; IRR=0.71, 95% CI 0.69 to 0.74, p<0.001) after a period of stability. In total, 211 unique profiles explicitly referenced COVID-19; 185 (85.8%) evoked risk reduction strategies, including discontinuation of in-person services (41.2%), pivoting to virtual services (38.9%), COVID-19 status disclosure (20.9%), enhanced sanitary and screening requirements (12.3%) and restricted travel (5.2%). Some profiles, however, seemed to downplay the seriousness of COVID-19 or resist protective measures (14.7%).ConclusionsThese findings support the contention that COVID-19 has dramatically impacted the sex industry; globally, male sex workers may be facing considerable economic strain. Targeted education and outreach are needed to support male sex workers grappling with COVID-19, including around the most effective risk reduction strategies. Those involved with the sex industry must have access to state-sponsored COVID-19 financial and other aid programmes to support individual and public health.

Background For a variety of reasons related to biology, behaviour, and environment, a subset of a population known as female sex workers (FSWs) or female transactional sex workers is at increased risk of health, depression, social stigma and access to timely and quality healthcare when needed. In low- and middle-income countries (LMICs), there was lack of understanding regarding the experiences and healthcare utilisation and behaviours, the health burden among them, their experiences, and how they access health care. Using Anderson’s behavioural model of health service utilisation as a framework, this review aimed to explore the experiences of, and healthcare seeking behaviours of female sex workers in low-and middle-income countries. Methods Six relevant databases such as PubMed, Embase, Global Health, Scopus, Web of Science, and Google Scholar were searched for peer-reviewed research articles published between January 1990 and December 2023 that discussed female transactional sex work in low- and middle-income countries. Subject terms such as: low-and middle- incomes, sex workers (female and male), sexually transmitted infections (STIs) in the sex work industry, prostitution, commercial sex, and health-seeking behaviour were used for the databases search. Out of 6,135 articles that were retrieved for the study, 26 met the inclusion criteria. Of the total number of studies, four were reviews, eight were quantitative studies, six were qualitative studies, and two utilised mixed methods. Findings Results from a thematic analysis of studies that combined quantitative and qualitative methods yielded six overarching themes.The study found that women engaged in sex work for different reasons – to fend for themselves (i.e., livelihood), self-employment and others do it for pleasure. However, force sex or unprotected which can lead to sexually transmitted infections, sexual abuse, job insecurity, were critical risks factors in engaging in sex work. These factors make them vulnerable to predators and health risks. It was found that sex workers were aware of the importance of seeking healthcare, and do make the efforts, however, crucial factors such as difficulty accessing healthcare and maltreatment by healthcare providers and social stigma disincentivises FSW health-seeking behaviours. Sexual workers reported discomfort disclosing their occupations because of the stigma and discrimination which further affects their regular health examinations and obtaining medically approved condoms from healthcare facilities. Conclusion Complex challenges rooted in economic vulnerability, social marginalisation, and limited access to healthcare afflict female sex workers in LMICs. The maltreatment and stigma can potentially affect LMICs from achieving using health facility care, with potential implications on achieving the universal health coverage goals. Comprehensive, rights-based strategies that address structural injustices and empower these women to live healthier, more secure lives are necessary to address their special needs.

ObjectivesThough highly vulnerable to HIV and STIs, transgender female sex workers (TFSWs) are understudied in the US HIV and STI response. This study examined the correlates of laboratory-confirmed STIs among a cohort of 62 TFSWs followed over the course of 1 year and explored associations between specimen site and self-reported engagement in insertive and receptive anal intercourse.MethodsParticipants completed an interviewer-administered computer-assisted personal interview at baseline, 3-, 6-, 9- and 12-month visits where self-administered anal swabs and urine samples for gonorrhea, chlamydia and trichomoniasis were also collected. HIV testing was conducted at baseline, 6-month and 12-month visits.ResultsBaseline HIV prevalence was 40.3% with no HIV seroconversions over follow-up. Baseline prevalence of gonorrhea, chlamydia and trichomoniasis was 9.7%, 17.7% and 14.5%, respectively. In the multivariable regression modelling, recent arrest was significantly associated with testing positive for any STI (adjusted risk ratio (RR) 1.77; 95% CI: 1.10 to 2.84). Insertive anal sex with clients was associated with increased risk of testing positive for an STI via urine specimen (RR 3.48; 95% CI: 1.14 to 10.62), while receptive anal sex was not significantly associated with specimen site.ConclusionOur findings confirm a high prevalence of STIs among TFSWs and highlight the importance of addressing structural drivers such as criminal justice involvement as well as the need to ensure screening for STIs at all anatomical sites regardless of self-reported sites of potential exposure. More research is needed to better understand HIV and STI vulnerabilities and appropriate interventions for TFSWs in the USA.

Background/objectivesFemale sex workers (FSWs) are at risk for HIV and physical and sexual gender-based violence (GBV). We describe the prevalence of lifetime GBV and its associations with HIV risk behaviour, access to health services and barriers in accessing justice among FSWs in Cameroon.MethodsFSWs (n=1817) were recruited for a cross-sectional study through snowball sampling in seven cities in Cameroon. We examined associations of lifetime GBV with key outcomes via adjusted logistic regression models.ResultsOverall, 60% (1098/1817) had experienced physical or sexual violence in their lifetime. GBV was associated with inconsistent condom use with clients (adjusted OR (AOR) 1.49, 95% CI 1.18 to 1.87), being offered more money for condomless sex (AOR 2.09, 95% CI 1.56 to 2.79), having had a condom slip or break (AOR 1.53, 95% CI 1.25 to 1.87) and difficulty suggesting condoms with non-paying partners (AOR 1.47, 95% CI 1.16 to 1.87). Violence was also associated with fear of health services (AOR 2.25, 95% CI 1.61 to 3.16) and mistreatment in a health centre (AOR 1.66, 95% CI 1.01 to 2.73). Access to justice was constrained for FSWs with a GBV history, specifically feeling that police did not protect them (AOR 1.41, 95% CI 1.12 to 1.78).DiscussionAmong FSWs in Cameroon, violence is prevalent and undermines HIV prevention and access to healthcare and justice. Violence is highly relevant to FSWs' ability to successfully negotiate condom use and engage in healthcare. In this setting of criminalised sex work, an integrated, multisectoral GBV-HIV strategy that attends to structural risk is needed to enhance safety, HIV prevention and access to care and justice.