Infection Prevalence and Prevention Among Sex Workers: Information for Health Care Workers

Sex worker taking money from a client.

(Adobe Stock 245203791 bt motortion)

Often referred to as the “oldest profession in the world,” prostitution or sex work dates back thousands of years. It has evolved in its origins, patterns, and methods of advertising over the years. Still, one thing has remained constant: its risk of sexually transmitted diseases (STDs) and sexually transmitted infections (STIs) transmission. Female sex workers remain 1 of the most at-risk populations for STD and STI transmission.

According to the World Health Organization, female sex workers are 30 times more likely to have contracted HIV than other women of the same age; 36% of female sex workers are estimated to have HIV.¹ Sex workers also face the increased risk of contracting infections and diseases such as:

• Syphilis
• Gonorrhea
• Chlamydia
• Trichomoniasis
• Herpes
• Hepatitis
• Human papillomavirus (HPV)

Challenges with Prevention

• Lack of Data

Because of the nature of the activity, especially in countries that have criminalized the act, it is challenging to track the incidence rates of STDs and STIs among sex workers.² Safety concerns and the risk of arrest have deterred many sex workers from advertising their services on the street. They have moved onto modern technologies: the internet. As if it weren’t complicated enough to track infection rates and prevention strategies in person, advertising methods have now moved to a platform known for anonymity. Digital platforms are increasingly popular among the younger generations, and sex work has transitioned into social media, online forums, and darker websites.

• Coinfection Prevalence

Contraction of 1 STD or STI may leave an individual susceptible to coinfection of other STIs and recurring infections. Several countries have concluded that between 7 to 47% of STD cases will have a coinfection present.³ Impaired immune system from the initial infection can make the body vulnerable to contracting other infections; for example, one study found that “contracting syphilis or gonorrhea was correlated with the likelihood of concurrent chlamydia.”³ Individuals under the age of 29 were found to have a higher prevalence of coinfections due to the increased risk-taking behaviors associated with younger ages.

• Socioeconomic Factors

Poverty, lack of education, and drug and alcohol use among sex workers are all major contributing factors to infection contraction. Impaired cognitive function from illicit substances opens individuals up to risky behaviors and impaired judgment.

“Economic vulnerability has been shown to increase workers’ vulnerability to having sex without condoms, reduce their negotiating power with clients, and increase gender-based violence and risk for HIV [or] STI.”⁴ Low-income areas are not typically well-funded in terms of education and resources for those attending school. Healthy practices and prevention measures within the school system aren’t commonly promoted as a part of the daily curriculum, leading to a significant knowledge gap. This lack of education can prove dangerous as children grow older and begin engaging in high-risk activities without knowing the consequences.

• Client Behavior

Cited as one of the most significant contributing factors to unsafe sex practices is the refusal of safe sex practices on the part of the client. Often, threats of violence or bribery to avoid the use of protection are used against sex workers. Without physical protection, the reality of poverty is overwhelming to the sex worker, and it leads to engaging in unprotected sex. Violent crimes have occurred when sex workers have attempted to protect themselves from the contraction of disease.

Treatment and Prevention Measures

• Education

Education and addressing the stigma of prostitution are essential in ensuring that those who engage in the work can better protect themselves from infection and disease. Many times, shame and embarrassment will prevent sex workers from seeking out provider assistance and free supplies to ensure they are protected. Providing an office with free or low-cost sexual protection, offering vaccinations and screenings during visits, and educating the sex workers on the importance of advocating for themselves and consistency in hygiene practices will help reduce transmission rates.

Community outreach and connecting with local programs are great ways to engage with the community and educate current and potential sex workers. Whether offering expertise in designing pamphlets or participating in a vaccination clinic, a medical professional can get involved in many ways.

• Screening Tools and Treatment Measures

The CDC has an excellent screening tool reference on its site that lays out how best to screen individuals based on various factors such as disease and sex.⁵ The latest guidelines for the treatment of STDs can also be found on the CDC’s website.⁶ Consistent screening measures and subsequent treatment of STDs and STIs are essential in limiting the transmission among sex workers and their clientele.

• Coinfection Treatment

Consistent screening practices and early treatment of STIs can aid in the reduction of coinfection rates. Care should be considered with screening; too frequent testing of asymptomatic sex workers can lead to treatment of the STD.3 Increased testing frequency and treatments can lead to a rise in antibiotic-resistant bacterial STIs. Providing a routine, 6-month screening to individuals and encouraging them to see a provider when symptomatic can help prevent antibiotic resistance.³

Sex is an integral and sacred part of our world. Because people decide to make it their source of income, it does not exclude them from having the same access and resources to prevent infection and disease as the rest of society. The infection spreads, and when the at-risk and vulnerable populations of the community are not protected against it, the community becomes vulnerable. Safe sex practices, accessibility to protection, and education for prevention are vital in maintaining a strong community barrier against STIs and STDs.

References

1. Sex workers. World Health Organization July 2022. Accessed May 1, 2024. https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/populations/sex-workers.
2. HIV Risk Among Persons Who Exchange Sex for Money or Nonmonetary Items. Centers for Disease Control and Prevention. March 2022. Accessed May 1, 2024.https://www.cdc.gov/hiv/group/sexworkers.html.
3. Chung SL, Wong NS, Ho KM, & Lee SS, 2023. Coinfection and repeat bacterial sexually transmitted infections (STI) - retrospective study on male attendees of public STI clinics in an Asia Pacific city. Epidemiology and Infection, 151, e101. Accessed May 1, 2024.https://doi.org/10.1017/S0950268823000948.
4. West, BS, Hilton L, Thailand E, Montgomery A, & Ebben AR, 2021. Reimagining sex work venues: occupational health, safety, and rights in indoor workplaces. In Springer eBooks (pp. 207–230). Accessed May 1, 2024. https://doi.org/10.1007/978-3-030-64171-9_12.
5. STI screening recommendations. Centers for Disease Control and Prevention. Accessed May 1, 2024. https://www.cdc.gov/std/treatment-guidelines/screening-recommendations.htm.
6. STI Treatments and Guidelines. Centers for Disease Control and Prevention. October 2022. Accessed May 1, 2024. https://www.cdc.gov/std/treatment-guidelines/default.htm.