HIV infection is not a concern in the workplace, for most people. However, for sex workers, the risk of HIV infection is an everyday reality.
The South African national plan for STI and HIV prevention has many positive goals, such as the 90-90-90 treatment target. This ambitious goal is to ensure that 90% of HIV-positive people know their status, receive sustained antiretroviral therapy and suppress the virus by 2020. But, if we are to achieve this target, then no one can be left behind. There are concerns that the plan does not advocate the rights of sex workers.
As long as sex work is a criminal act, there will be a stigmatised community that is vulnerable to HIV infection. Sex workers are a key population that bear a disproportionately high proportion of the HIV burden compared to other groups in the community. It is estimated that there are nearly 150,000 sex workers in South Africa, and the rate of HIV amongst these people is predicted at around  60% (3). However, due to the criminalised nature of the trade, it is difficult to gather meaningful data.

It is imperative that we decriminalise sex work. Only then can the government install regulations that protect this population. Legislations could include healthcare guidelines as well as prevention tools and contraceptive plans. As well as HIV, sex workers have higher than normal rates of other STIs. Until then, sex workers are still vulnerable to violence, stigma and discrimination when accessing health or safety-related services.

Violence
As well as a high STI burden, Sex Workers are also vulnerable to violence. Globally, around half of sex workers experience some sort of violence at their workplace (1). Perpetrators of violence can include clients but also law enforcers, partners and other sex workers.

Stigma
Prostitution is often not seen as a legitimate occupation and sex workers routinely undergo derogatory comments and abuse. This behaviour is damaging, especially when it comes from healthcare workers and law-enforcement officials, as it deters SW from seeking care or help. Fear of incarceration, restrictions on access to services and no protection from law enforcement from violent customers etc is difficult enough, but there is a dual vulnerability for sex workers. The other being discrimination against HIV.
The HIV epidemic is no stranger to stigma. It is one of the biggest challenges to overcome to beat the virus. Discrimination against select populations: sex workers, men who have sex with men, people who have premarital sex and people who use drugs, means that these populations have the highest burdens of HIV and AIDS
Criminalising sex work increases sex worker’s HIV vulnerability two-fold from stigma against sex work itself and HIV-related discrimination.

Education
Arming sex workers with education is crucial to preventing the spread of STIs. It is crucial to understand why SW need regular health screening, contraception and other STI prevention tools. Were SW to be regulated, then the government could supply frequent protection updates, such as the latest news on PrEP or the vaginal ring that prevent HIV infection discretely. Lack of sex education only contributes to the spread of HIV.
So why is the South African government apprehensive to legalise the trade? Nozizwe Madlala-Routledge, Executive Director and founding member for Embrace Dignity and South Africa’s Deputy Minister for Health between 2004 and 2007, shares her insights.

“The government is concerned about the expansion of the sex trade if it were to be decriminalised. This would expose more people, especially young black and poor women to HIV.”
These are legitimate concerns which must be addressed to meaningfully legalise the sex worker trade. Several countries have legalised prostitution using different approaches with different outcomes.

Decriminalising Sex Work
Sex work in places like Germany and New Zealand is treated like any other industry where workers can sue for fair wages, pensions and healthcare. This gives sex workers the right to negotiate their own working conditions with the knowledge that any abuse or battery can be reported to the police. It has also seen prostitution establishments opening up, giving sex workers a location to trade legally. In New Zealand, where sex work has been decriminalised since 2003, said that prostitutes practised more safe sex and were more likely to report abuse to the police in a study in 2008. (2)
However, Germany is now a sex worker destination; the flood of SW has driven down prices and working standards. Additionally, whilst sex trafficking is on the decline (downloads a pdf), it is also cited as a sex trafficking destination. There are many accounts of victims being seduced from their home country to Germany with no mention that they will be forced to work as prostitutes. In 2015, authorities identified 416 sex trafficking victims.

The Nordic Model
Sweden took an unusual approach to tackling prostitution by legalising a sex worker’s right to sell their body, but it is illegal to purchase sex. This shift in blame was designed to reduce the amount of sex work that takes place in Sweden taking the view that most prostitutes are victims that want to leave the trade. Swedish reports claim that the new legislation has reduced prostitution and sex trafficking.
However, there are other sources that disagree, claiming that this model coincided with the rise of the internet and now sex workers can ‘work indoors’, decreasing the number of SW on the streets but without an overall change. SWEAT, Sex Workers Education & Advocacy Taskforce, comments that the law has driven away ‘good’ clients and left sex workers with a pool of ‘seedy’ clients who they might otherwise have declined to service. Clients want to remain anonymous and sex workers are pressured into jobs they would rather not take.
Additionally, there are no meaningful data on the STI and HIV rates in this community since 1999 which makes it difficult to appraise how effective this method is for HIV and STI prevention.

Both of these studies had different approaches to tackling sex work, which is a complex issue. Whichever direction South Africa chooses, we believe it must be in a direction to help sex workers protect their rights. Madlala-Routledge comments
“Embrace Dignity advocates for the decriminalisation of those selling sex but not for buyers, pimps and brothel owners. We believe decriminalising the women and men who sell sex would protect them against the harms of the sex trade by shifting the criminality and stigma away from those already marginalised by inequality to those exercising power and exploiting a position of vulnerability caused by structural exclusion, economic inequality and patriarchy. The majority of those selling sex are black and poor. This is not something they would do if they had other choices. Most would exit prostitution if they had support. Stigmatising and criminalising them exposes them to more harm and re-victimisation by the police and society.”

Desmond Tutu HIV Foundation
Whilst the Desmond Tutu HIV Foundation doesn’t have any research focussed on sex workers at the moment, there are other projects that sex workers qualify for.

• The AMP study; participants are injected with an infusion of HIV antibodies. This acts like a three-month-long vaccination against HIV. Half of a two-part study, DTHF focusses on women in Sub Saharan Africa whereas the other half focusses on men who have sex with men in the US. To qualify, the women must be at a high risk of an HIV infection, which includes having sex with multiple partners.

• 3 P for PrEP: This study provides a year-long course of the HIV prevention drug, PrEP. This is offered to adolescent women (15-25) who are sexually active. This is a valuable opportunity for this demographic to access this essential prevention drug. This course of drugs is offered on the Tutu Teen Truck, our mobile clinic-on-wheels that drives essential healthcare services straight to the communities that need them in Cape Town.

• The Tutu Truck: is another mobile clinic that also offers free healthcare check-ups for anyone who pops by. Its services include HIV tests, but also TB tests, blood pressure, counselling, family planning and contraception. Anyone can make use of this informative and judgement-free service.

Unfortunately, PrEP is not available for free though public clinics in South Africa. The drug is approved by South Africa’s Medical Control Council but is mostly available on trials and private hospitals and in some universities for students. Government clinics do not yet offer PrEP. Given the conditions sex workers navigate, PrEP is an essential tool that could be utilised to stop the HIV epidemic.

Our Vision
If we want prevention to work, and to achieve the 90-90-90 goals, everyone at risk of HIV must have free access to prevention without discrimination. which some legislation doesn’t currently allow. There is a battle with discrimination but also around laws. We have a vision of what combination prevention looks like.
Legalised sex work, with healthcare assistance and guidelines for workers as well as legal protection against violence and the ability to negotiate contraception. Free and unrestricted access to contraceptive tools, including but not limited to condoms, lubricant, the contraceptive pill, as well as HIV prevention tools such as PrEP and the vaginal ring.
Courses for government workers who deal with sex workers. There are courses and advise for care workers who interact with HIV-positive people, and the next step is sensitisation to sex work. Reducing stigma starts with education.

References

(1) Deering K, et al. (2014) A Systematic Review of the Correlates of Violence Against Sex Workers. American Journal of Public Health. 104(5):42-54.
(2) Prostitution Law Reform Committee (2008). Report of the Prostitution Law Reform Committee on the operation of the Prostitution Reform Act of 2003. In: New Zealand Government (ed.). Wellington.
(3) Baral et al., (2012). Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. The Lancet, Infectious Diseases.
Why we need sex ed
https://blogs.unicef.org/east-asia-pacific/lets-talk-sex-need-sexuality-education-asia-pacific/

Stigma is the main enemy of ending HIV
http://www.reuters.com/article/us-safrica-aids-sex-workers-idUSKCN10S041

Prep not approved everywhere in SA
http://www.mambaonline.com/2015/12/09/prep-approved-sa-mean/

60% of sex workers have HIV?
https://africacheck.org/reports/are-60-of-sex-workers-in-south-africa-hiv-positive-the-data-is-limited/

Sex workers’ HIV prevention needs
https://caps.ucsf.edu/uploads/pubs/FS/pdf/revsexworkerFS.pdf

South African national HIV sex worker prevention plan 2016 – 19
http://sanac.org.za/2016/03/29/south-african-national-sex-worker-hiv-plan-2016-2019/

Decriminalising sex work in South Africa
https://theconversation.com/debate-around-sex-work-in-south-africa-tilts-towards-decriminalisation-59324

90-90-90 The ambitious treatment target to help end the AIDS epidemic
http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf

Written by Caroline Reid