Sex work and young women: a cross sectional study to understand the overlap of age and sex work as a central tenet to epidemic control in South Africa.

Adolescent girls and young women (AGYW) engaging in sex-for-money transactions are at risk of HIV infection. A better understanding of the demographic, socio-economic factors and risks of HIV acquisition is required to guide appropriate public health interventions targeting young sex workers in South Africa. A cross-sectional survey of Female Sex Workers (FSWs), using a chain referral sampling method, was conducted across 12 sites in South Africa in 2019. Three thousand and five participants were enrolled and interviewed assessing demographic characteristics, sexual behaviour, substance use and HIV testing and treatment. Of 3005 women, 13.3% were ≤24 years old (young FSWs); of these, 60.0% entered sex work aged ≤19 years. Economic factors were the primary drivers of entry into sex work. HIV prevalence amongst young FSWs was 40.4%, with 12.4% recently infected. Younger FSWs were significantly less likely to know they were HIV positive (87.6% versus 92.1%), to report any ART exposure (75.2% versus 87.6%) and to be virally suppressed (58.1% versus 75.2%) compared to older FSWs. Our findings highlight that many FSWs enter sex work at a young age. It is essential to develop tailored services and interventions that improve access to HIV prevention and treatment services addressing specific needs.

The HIV Cascade of Care and Service Utilisation at Sex Work Programmes Among Female Sex Workers in South Africa.

Female sex workers (FSWs) in South Africa experience a uniquely high prevalence of HIV. We describe the HIV cascade of care (CoC) in FSWs in South Africa, and explored service utilisation at sex work programmes. A cross-sectional, study enrolled FSWs across 12 sites in South Africa. Participants were recruited using chain-referral method. Inclusion criteria: ≥ 18 years, cis-gender female, sold/transacted in sex, HIV positive. 1862 HIV positive FSWs were enrolled. 92% were known positive, 87% were on antiretroviral treatment (ART). Of those on ART, 74% were virally suppressed. Younger FSWs were significantly less likely to be on ART or virally suppressed. Female sex workers using HIV services from specialised programs were 1.4 times more likely to be virally suppressed than non-program users. The pre-COVID-19 pandemic HIV CoC amongst FSWs in South Africa shows striking improvement from previous estimates, and approaches achievement of 90:90:90 goals.

Sexual IPV and non-partner rape of female sex workers: Findings of a cross-sectional community-centric national study in South Africa.

BACKGROUND: Globally female sex workers (FSWs) are vulnerable to violence from intimate partners, police and clients due to stigma and criminalisation. In this paper we describe South African FSWs' exposure to violence and factors associated with having been raped in the past year. METHODS: We conducted a multi-stage, community-centric, cross-sectional survey of 3005 FSWs linked to sex worker programmes in 12 sites across all nine provinces that had a SW programme. Adult women who sold sex in the preceding six months were recruited for interviews via sex worker networks. Survey tools were developed in consultation with peer educators and FSWs. RESULTS: In the past year, 70.4% of FSWs experienced physical violence and 57.9% were raped: by policemen (14.0%), clients (48.3%), other men (30.2%) and/or and intimate partner (31.9%). Sexual IPV was associated with food insecurity, entering sex work as a child, childhood trauma exposure, post-traumatic stress disorder (PTSD), drinking alcohol to cope with sex work, working more days, partner controlling behaviour, having an ex-client partner, and having no current partner to protect from ex-partners. Rape by a client, other men or policemen was associated with food insecurity, childhood trauma, PTSD, depression, using alcohol and drugs, being homeless or staying in a sex work venue, selling sex on the streets, working more days and having entered sex work as a child and been in sex work for longer. CONCLUSION: South African FSWs are very vulnerable to rape. Within the social climate of gender inequality, sex work stigma, criminalisation, and repeated victimisation, the key drivers are structural factors, childhood and other trauma exposure, mental ill-health, circumstances of sex work and, for SIPV, partner characteristics. Mostly these are amenable to intervention, with legislative change being foundational for ending abuse by policemen, enhancing safety of indoor venues and providing greater economic options for women.

Intersections of Sex Work, Mental Ill-Health, IPV and Other Violence Experienced by Female Sex Workers: Findings from a Cross-Sectional Community-Centric National Study in South Africa.

Female sex workers (FSWs) are at increased risk of mental health problems, including mood disorders and substance abuse, and we need to understand the origins of these to treat and prevent them, and particularly understand how the context in which they sell sex impacts their mental health. We conducted a multi-stage, community-centric, cross-sectional survey of 3005 FSWs linked to SW programmes in twelve sites across all nine provinces of South Africa. We interviewed adult women who had sold sex in the preceding six months, who were recruited via SW networks. We found that FSWs have very poor mental health as 52.7% had depression and 53.6% has post-traumatic stress disorder (PTSD). The structural equation model showed direct pathways from childhood trauma and having HIV+ status to mental ill-health. Indirect pathways were mediated by food insecurity, controlling partners, non-partner rape, harmful alcohol use, substance use to cope with SW, indicators of the circumstances of SW, i.e., selling location (on streets, in taverns and brothels), frequency of selling and experiencing SW stigma. All paths from childhood trauma had final common pathways from exposure to gender-based violence (non-partner rape or intimate partner violence) to mental ill-health, except for one that was mediated by food insecurity. Thus, FSWs' poor mental health risk was often mediated by their work location and vulnerability to violence, substance abuse and stigma. The potential contribution of legal reform to mitigate the risks of violence and mental ill-health are inescapable. Treatment of mental ill-health and substance abuse should be an essential element of FSW programmes.