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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.

Inclusion health focuses on people in extremely poor health due to poverty, marginalisation, and multimorbidity. We aimed to review morbidity and mortality data on four overlapping populations who experience considerable social exclusion: homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals. For this systematic review and meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library for studies published between Jan 1, 2005, and Oct 1, 2015. We included only systematic reviews, meta-analyses, interventional studies, and observational studies that had morbidity and mortality outcomes, were published in English, from high-income countries, and were done in populations with a history of homelessness, imprisonment, sex work, or substance use disorder (excluding cannabis and alcohol use). Studies with only perinatal outcomes and studies of individuals with a specific health condition or those recruited from intensive care or high dependency hospital units were excluded. We screened studies using systematic review software and extracted data from published reports. Primary outcomes were measures of morbidity (prevalence or incidence) and mortality (standardised mortality ratios [SMRs] and mortality rates). Summary estimates were calculated using a random effects model. Our search identified 7946 articles, of which 337 studies were included for analysis. All-cause standardised mortality ratios were significantly increased in 91 (99%) of 92 extracted datapoints and were 11·86 (95% CI 10·42–13·30; I2=94·1%) in female individuals and 7·88 (7·03–8·74; I2=99·1%) in men. Summary SMR estimates for the International Classification of Diseases disease categories with two or more included datapoints were highest for deaths due to injury, poisoning, and other external causes, in both men (7·89; 95% CI 6·40–9·37; I2=98·1%) and women (18·72; 13·73–23·71; I2=91·5%). Disease prevalence was consistently raised across the following categories: infections (eg, highest reported was 90% for hepatitis C, 67 [65%] of 103 individuals for hepatitis B, and 133 [51%] of 263 individuals for latent tuberculosis infection), mental health (eg, highest reported was 9 [4%] of 227 individuals for schizophrenia), cardiovascular conditions (eg, highest reported was 32 [13%] of 247 individuals for coronary heart disease), and respiratory conditions (eg, highest reported was 9 [26%] of 35 individuals for asthma). Our study shows that homeless populations, individuals with substance use disorders, sex workers, and imprisoned individuals experience extreme health inequities across a wide range of health conditions, with the relative effect of exclusion being greater in female individuals than male individuals. The high heterogeneity between studies should be explored further using improved data collection in population subgroups. The extreme health inequity identified demands intensive cross-sectoral policy and service action to prevent exclusion and improve health outcomes in individuals who are already marginalised. Wellcome Trust, National Institute for Health Research, NHS England, NHS Research Scotland Scottish Senior Clinical Fellowship, Medical Research Council, Chief Scientist Office, and the Central and North West London NHS Trust.

We conducted a systematic review in June 2012 (updated September 2013) to examine the prevalence and factors shaping sexual or physical violence against sex workers globally. We identified 1536 (update = 340) unique articles. We included 28 studies, with 14 more contributing to violence prevalence estimates. Lifetime prevalence of any or combined workplace violence ranged from 45% to 75% and over the past year, 32% to 55%. Growing research links contextual factors with violence against sex workers, alongside known interpersonal and individual risks. This high burden of violence against sex workers globally and large gaps in epidemiological data support the need for research and structural interventions to better document and respond to the contextual factors shaping this violence. Measurement and methodological innovation, in partnership with sex work communities, are critical.

Male sex workers who sell or exchange sex for money or goods encompass a very diverse population across and within countries worldwide. Information characterising their practices, contexts where they live, and their needs is limited, because these individuals are generally included as a subset of larger studies focused on gay men and other men who have sex with men (MSM) or even female sex workers. Male sex workers, irrespective of their sexual orientation, mostly offer sex to men and rarely identify as sex workers, using local or international terms instead. Growing evidence indicates a sustained or increasing burden of HIV among some male sex workers within the context of the slowing global HIV pandemic. Several synergistic facilitators could be potentiating HIV acquisition and transmission among male sex workers, including biological, behavioural, and structural determinants. Criminalisation and intersectional stigmas of same-sex practices, commercial sex, and HIV all augment risk for HIV and sexually transmitted infections among male sex workers and reduce the likelihood of these people accessing essential services. These contexts, taken together with complex sexual networks among male sex workers, define this group as a key population underserved by current HIV prevention, treatment, and care services. Dedicated efforts are needed to make those services available for the sake of both public health and human rights. Evidence-based and human rights-affirming services dedicated specifically to male sex workers are needed to improve health outcomes for these men and the people within their sexual networks.

Female sex workers (FSWs) bear a disproportionately large burden of HIV infection worldwide. Despite decades of research and programme activity, the epidemiology of HIV and the role that structural determinants have in mitigating or potentiating HIV epidemics and access to care for FSWs is poorly understood. We reviewed available published data for HIV prevalence and incidence, condom use, and structural determinants among this group. Only 87 (43%) of 204 unique studies reviewed explicitly examined structural determinants of HIV. Most studies were from Asia, with few from areas with a heavy burden of HIV such as sub-Saharan Africa, Russia, and eastern Europe. To further explore the potential effect of structural determinants on the course of epidemics, we used a deterministic transmission model to simulate potential HIV infections averted through structural changes in regions with concentrated and generalised epidemics, and high HIV prevalence among FSWs. This modelling suggested that elimination of sexual violence alone could avert 17% of HIV infections in Kenya (95% uncertainty interval [UI] 1–31) and 20% in Canada (95% UI 3–39) through its immediate and sustained effect on non-condom use) among FSWs and their clients in the next decade. In Kenya, scaling up of access to antiretroviral therapy among FSWs and their clients to meet WHO eligibility of a CD4 cell count of less than 500 cells per μL could avert 34% (95% UI 25–42) of infections and even modest coverage of sex worker-led outreach could avert 20% (95% UI 8–36) of infections in the next decade. Decriminalisation of sex work would have the greatest effect on the course of HIV epidemics across all settings, averting 33–46% of HIV infections in the next decade. Multipronged structural and community-led interventions are crucial to increase access to prevention and treatment and to promote human rights for FSWs worldwide.

Female, male, and transgender sex workers continue to have disproportionately high burdens of HIV infection in low-income, middle-income, and high-income countries in 2018. 4 years since our Lancet Series on HIV and sex work, our updated analysis of the global HIV burden among female sex workers shows that HIV prevalence is unacceptably high at 10·4% (95% CI 9·5–11·5) and is largely unchanged. Comprehensive epidemiological data on HIV and antiretroviral therapy (ART) coverage are scarce, particularly among transgender women. Sustained coverage of treatment is markedly uneven and challenged by lack of progress on stigma and criminalisation, and sustained human rights violations. Although important progress has been made in biomedical interventions with pre-exposure prophylaxis and early ART feasibility and demonstration projects, limited coverage and retention suggest that sustained investment in community and structural interventions is required for sex workers to benefit from the preventive interventions and treatments that other key populations have. Evidence-based progress on full decriminalisation grounded in health and human rights—a key recommendation in our Lancet Series—has stalled, with South Africa a notable exception. Additionally, several countries have rolled back rights to sex workers further. Removal of legal barriers through the decriminalisation of sex work, alongside political and funding investments to support community and structural interventions, is urgently needed to reverse the HIV trajectory and ensure health and human rights for all sex workers.

Female sex workers (FSWs) are disproportionately affected by HIV. Inconsistent condom use (ICU) represents the most proximal risk for acquisition and transmission. We evaluate associations of partner-specific factors including physical and sexual violence, coercion, and substance use with ICU with clients and regular non-paying partners, respectively, among FSWs. Baseline survey data from a prospective cohort of 250 street-based FSW in Baltimore, Maryland, USA included partner-level drug and alcohol use, violence, condom coercion and ICU, in addition to individual and structural exposures. Logistic regression analyses were stratified by partner type, followed by path analysis where indicated. Within client and regular non-paying partnerships, FSWs reported prevalent recent violence (34.8%, 16%, respectively), condom coercion (42.4%, 9.9%, respectively) and ICU (39.2%, 44.4%, respectively). Recent physical or sexual violence enabled coercive condom negotiation (AORclient 8.22, 95% CI 4.30, 15.73; AORnonpayingpartner 3.01 95% CI 1.05, 8.63). ICU with clients was associated with client condom coercion (AOR 1.76, 95% CI 1.03, 3.02), and client intoxication during sex (AOR 2.25, 95% CI 1.13, 4.45). In path analysis of client-FSW partnerships, condom coercion fully mediated the influences of both sex worker intoxication and recent violence on ICU. ICU with non-paying partners was associated with FSW intoxication during sex (AOR 8.66, 95% CI 3.73, 20.10), and past-year police violence (AOR 2.92, 1.30, 6.57). Partner-level substance use and gendered power differentials influenced FSWs’ ICU patterns differently by partner type. ICU with clients was rooted solely in partner factors, and coercive condom negotiation mediated the roles of violence and partner-level substance use on ICU. By contrast, ICU with non-paying partners was rooted in partner-level substance use and police violence as a structural determinant. Addressing HIV risk behavior for FSWs requires condom promotion efforts tailored to partner type that addresses power differentials.

The psychological health of female sex workers (FSWs) has emerged as a major public health concern in many low- and middle-income countries (LMICs). Key risk factors include poverty, low education, violence, alcohol and drug use, human immunodeficiency virus (HIV), and stigma and discrimination. This systematic review and meta-analysis aimed to quantify the prevalence of mental health problems among FSWs in LMICs, and to examine associations with common risk factors. The review protocol was registered with PROSPERO, number CRD42016049179. We searched 6 electronic databases for peer-reviewed, quantitative studies from inception to 26 April 2020. Study quality was assessed with the Centre for Evidence-Based Management (CEBM) Critical Appraisal Tool. Pooled prevalence estimates were calculated for depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal behaviour. Meta-analyses examined associations between these disorders and violence, alcohol/drug use, condom use, and HIV/sexually transmitted infection (STI). A total of 1,046 studies were identified, and 68 papers reporting on 56 unique studies were eligible for inclusion. These were geographically diverse (26 countries), representing all LMIC regions, and included 24,940 participants. All studies were cross-sectional and used a range of measurement tools; none reported a mental health intervention. Of the 56 studies, 14 scored as strong quality, 34 scored as moderate, and 8 scored as weak. The average age of participants was 28.9 years (age range: 11-64 years), with just under half (46%) having up to primary education or less. The pooled prevalence rates for mental disorders among FSWs in LMICs were as follows: depression 41.8% (95% CI 35.8%-48.0%), anxiety 21.0% (95% CI: 4.8%-58.4%), PTSD 19.7% (95% CI 3.2%-64.6%), psychological distress 40.8% (95% CI 20.7%-64.4%), recent suicide ideation 22.8% (95% CI 13.2%-36.5%), and recent suicide attempt 6.3% (95% CI 3.4%-11.4%). Meta-analyses found significant associations between violence experience and depression, violence experience and recent suicidal behaviour, alcohol use and recent suicidal behaviour, illicit drug use and depression, depression and inconsistent condom use with clients, and depression and HIV infection. Key study limitations include a paucity of longitudinal studies (necessary to assess causality), non-random sampling of participants by many studies, and the use of different measurement tools and cut-off scores to measure mental health problems and other common risk factors. In this study, we found that mental health problems are highly prevalent among FSWs in LMICs and are strongly associated with common risk factors. Study findings support the concept of overlapping vulnerabilities and highlight the urgent need for interventions designed to improve the mental health and well-being of FSWs.

Following recommendations by the World Health Organization in 2015, and key clinical trials, countries in sub-Saharan Africa, the region with the highest burden of human immunodeficiency virus (HIV), developed policies that incorporate pre-exposure prophylaxis (PrEP) into national HIV-prevention strategies. By the end of 2019, more than one third of people receiving PrEP globally were in Africa. Crucial understandings gained from early rollout among at-risk populations, such as HIV-serodiscordant couples, adolescent girls and young women, female sex workers, and men who have sex with men, include the importance of strategies for maintaining persistent adherence to PrEP and novel approaches to making PrEP services accessible, simplified and efficient. This Perspective will discuss the current status of these programs and how to further widen their implementation. PrEP is being incorporated into national HIV-prevention strategies in African countries, with key at-risk populations being prioritized. Expansion of these programs will require better access to and communication about these therapies.

Female sex workers are a population who are at heightened risk of HIV infection secondary to biological, behavioural, and structural risk factors. However, three decades into the HIV pandemic, understanding of the burden of HIV among these women remains limited. We aimed to assess the burden of HIV in this population compared with that of other women of reproductive age. We searched PubMed, Embase, Global Health, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Web of Science, and POPLine for studies of female sex workers in low-income and middle-income countries published between Jan 1, 2007, and June 25, 2011. Studies of any design that measured the prevalence or incidence of HIV among female sex workers, even if sex workers were not the main focus of the study, were included. Meta-analyses were done with the Mantel-Haenszel method with a random-effects model characterising an odds ratio for the prevalence of HIV among female sex workers compared with that for all women of reproductive age. Of 434 selected articles and surveillance reports, 102 were included in the analyses, representing 99 878 female sex workers in 50 countries. The overall HIV prevalence was 11·8% (95% CI 11·6–12·0) with a pooled odds ratio for HIV infection of 13·5 (95% CI 10·0–18·1) with wide intraregional ranges in the pooled HIV prevalence and odds ratios for HIV infection. In 26 countries with medium and high background HIV prevalence, 30·7% (95% CI 30·2–31·3; 8627 of 28 075) of sex workers were HIV-positive and the odds ratio for infection was 11·6 (95% CI 9·1–14·8). Although data characterising HIV risk among female sex workers is scarce, the burden of disease is disproportionately high. These data suggest an urgent need to scale up access to quality HIV prevention programmes. Considerations of the legal and policy environments in which sex workers operate and actions to address the important role of stigma, discrimination, and violence targeting female sex workers is needed. The World Bank, UN Population Fund.