A comprehensive review of HIV/STI prevention and sexual and reproductive health services among sex Workers in Conflict-Affected Settings: call for an evidence- and rights-based approach in the humanitarian response

Available data indicated high rates of sex work in conflict and post-conflict settings globally [11, 30, 33]. A study in Nepal revealed that roughly 19.0% of sex workers reported having entered sex work directly because of subsistence needs attributed to local conflict [30]. Our review of both the qualitative and the quantitative literature pointed to the ways in which poverty, diminished employment opportunities, difficulty meeting subsistence needs, and challenges to sustainable livelihoods in contexts of displacement influenced engagement in sex work within conflict-affected settings [3, 5, 11, 17, 23, 30, 32‐41].

Within the context of family separation resulting from armed conflict, increases in female-headed households were common, and women often experienced reduced access to traditional economic livelihoods, particularly in the absence of male support [36, 37]. Stemming from unequal gender norms and limited economic opportunities for women, existing evidence highlighted how women were particularly likely to exchange sex for money, accommodation, or other goods (e.g., food, clothing, healthcare, favours, gifts, access to education for their children, protection), and even passage across a border [3, 23, 33, 36, 41]. The following testimonial from a Somalian sex worker highlighted how the unequal gendered socio-economic impact of conflict influenced her choice to engage in sex work:

"[The first time I sold sex] I was 12 years old ... my father and mother had died … I didn’t have anyone to take care of me, and [didn’t] have anything to eat or dress in. Being a sex worker was the only choice." (Somalian sex worker aged 25 [35].

Inconsistent condom use within conflict-affected settings was commonly elucidated as a consequence of reduced negotiating power due to financial constraints during times of social unrest [30, 36, 39, 40]. Conflict-affected sex workers in sub-Saharan Africa commonly supported dependent children [14, 42], and having children (especially young children) was associated with increased HIV risks including engaging in unprotected sex for more money [14]. Although further research is needed in this area, two studies suggested increased need/opportunity to charge extra money for unprotected intercourse during or following a crisis [43, 44], including a study of Kenya’s 2008 post-election violence on sex workers and their clients, where dramatic declines in income, expenditures, and consumption in the general population resulted in more unprotected sex [43]. These findings elucidate potentially important effects of active vs. post-conflict settings on the sex industry, where conflict environments with a large presence of military/peacekeeping personnel as potential clients may increase demand for sexual services, (while reducing sex workers’ control to safely negotiate condom use with clients), whereas smaller social and economic crises (represented by dramatic declines in income) may result in more sex workers willingly offering unprotected sex to make up for income shortfalls. Authors further highlight the increased risk for sex workers during times of political and economic crisis, where financial gains of unprotected sex may outweigh the known risk of HIV/STI acquisition. Although sex workers in non-conflict settings also often report economic pressures for unprotected sex for higher pay, our review suggested that these pressures may be amplified within conflict-affected settings.

Displacement and high mobility were common experiences reported by conflict-affected sex workers [11, 35, 45, 46], and clients of sex workers [35, 41, 45, 47], across diverse geographical and socio-political contexts. Within the studies reviewed, displacement and mobility were consistently associated with increased engagement in sex work [35, 41, 45, 48, 49], particularly in the post-conflict stage [35, 45, 48, 49]. While military/peacekeepers commonly purchase sex in conflict-affected environments [2, 16, 34, 38, 41] displacement may increase demand for sex work from other clients particularly during the rehabilitation stages of a conflict, due to men travelling greater distances for employment, and spending greater amounts of time separated from family [37]. Further, in sub-Saharan Africa, the geographical areas most heavily affected by HIV are often those linked with high long-term mobility, adjacent to main transport routes or in border regions [46].

Findings from numerous contexts, predominantly within sub-Saharan Africa, indicated that women in transit or temporarily displaced due to war or violence were more likely to report having received money or goods for sex than their non-mobile counterparts [26], and this was often linked to enhanced challenges and barriers accessing HIV and SRH services. In a study seeking to understand the relationship between armed conflict and HIV infection among conflict-affected sex workers in Gulu, northern Uganda, 66.5% of respondents reported living in IDP camps, among whom HIV prevalence was 71.9% compared to 63.8% of non-mobile sex workers [11]. In Somalia, mobility of sex workers was further associated with increased HIV/STI risk due to porous borders with countries that have higher HIV prevalences (Djibouti, Ethiopia, Kenya), and the presence of mobile populations associated with other HIV epidemics in the region (e.g., truck drivers and the military) [35].

The presence of military and peacekeepers with expendable incomes represent unique aspects of conflict-affected settings which strongly shape the context of sex work and HIV/STI prevention in such contexts [2, 3, 5, 16, 29, 33, 34, 36, 38, 39, 41, 50]. Combatants and peacekeepers stationed far from home were more likely to frequent sex workers during war and migration [5], had higher rates of STIs than the general population [16], and were more likely to engage in higher-risk behaviour while participating in missions than within their home communities [2]. Even during peacetime, STI rates among armed forces are generally 2–5 times higher than in civilian populations; in times of conflict, the difference can be 50 times higher or more [39]. The circumstances of military service were said to make soldiers both more vulnerable to HIV/STI infection and more likely to transmit such infections – for example, soldiers are typically young, male, sexually active, and separated from their normal partners, which has been shown to facilitate sex purchasing [39]. Peacekeepers may also originate from countries with higher HIV prevalence rates than the local community in conflict, potentially exposing sex workers to further risk [36]. In Gulu, northern Uganda, exposure to war and conflict related events, such as abduction by the Ugandan Lord’s Resistance Army (LRA), was found to significantly increase the likelihood of HIV seroprevalence in sex workers (AOR: 1.62, 95% CI: 1.00–2.63) [11].

Physical, sexual, and emotional violence against sex workers in conflict-affected settings, by both clients and intimate partners was alarmingly high within studies [11, 14, 31, 32, 35, 37, 38]. Among sex workers in post-conflict northern Uganda, almost 50% experienced extreme physical and/or sexual workplace violence in the previous six months, including physical assault, rape, and gang rape [14]. Reports of assault, poor treatment, and threats were commonly reported by sex workers in Somalia, as were rape and refusal to pay [35]. An epidemiological study of 250 sex workers in post-conflict Mekelle, northern Ethiopia, demonstrated high rates of violence, with 46–60% of sex workers reporting rape or forced sex [32]. In Somalia, incidents of violence most often led to physical injuries and damage to property, reducing sex workers’ ability to work, creating medical costs, and leading to a loss of income [35], which in turn, may lead to a greater likelihood of engaging in sex for more money. In conflict-affected Gulu, northern Uganda, 74.7% of sex workers reported that they would experience violence from clients, and 60.8% from intimate partners, if they asked them to wear a condom [31]. Prolonged exposure to traumatic conflicts was found to be linked to severe mental distress, including persistent feelings of despair, hopelessness, pathological fear, and suicidal inclinations, which may have indirect effects on conflict-affected sex workers’ vulnerability to HIV infection, as it not only predisposes women to exploitation or HIV risk, but may also hinder uptake of HIV preventative and treatments services [16, 38].

In Uganda, Ethiopia, and Sri Lanka, criminalization of sex work led to rushed negotiations with clients due to police presence [11, 29, 31], which significantly increased the odds of client violence [14], further undermining uptake of HIV/STI and SRH services [31]. Among sex workers working in post-conflict Uganda, over one-third (37.3%) reported having to rush negotiations with clients as the result of police presence in the last six months [31], and exposure to incarceration (AOR: 1.93, 95% CI: 1.17–3.20) was found to be positively and independently associated with HIV infection [11]. For refugee sex workers in particular, an arrest for sex work could greatly jeopardize an asylum claim, or result in deportation. As a consequence, the high stakes of getting caught force sex workers to take greater risks with their safety, such as working alone or in secluded areas.

"When I entered the circle of refugees who sell sex, the first thing I learnt was to avoid places the police patrol. When a Ugandan prostitute is arrested, the police have sex with her if she wants to be released without trying. What will happen to me, a refugee?" (31-year-old sex worker from Congo) [23].

Criminalization further propagates an environment in which violence against sex workers is tolerated, resulting in severe vulnerabilities in which sex workers are unable to seek protection from law enforcement authorities [11, 23, 29, 31, 32]. In Uganda, many sex workers revealed that they failed to report human rights violations to police, for fear of re-victimization from public disclosure of their sex work [23]. Numerous instances were documented in which perpetrators of ‘hate-crimes’ against sex workers went unpunished because the victim refused to report the case. In this way, current legal responses to sex work may inadvertently protect perpetrators of violence, and simultaneously expose sex workers to injustice by curtailing access to mechanisms of legal redress [23].

Displaced persons in Uganda were found to have varying levels of awareness of the legal frameworks governing sexual conduct and relationships within their contexts of displacement [23]. In post-conflict states, criminalization has been revealed to undermine effective HIV and harm reduction programmes, by driving key populations underground, and creating environments in which abuses against sex workers’ human rights are tolerated [51, 52]. Further, incarceration may elevate the risk of HIV transmission through a lack of access to condoms, harm reduction supplies, or antiretroviral medicines, as well as through increased vulnerability to human rights violations or sexual assault during detention [52].

During acute stages of conflict when food insecurity, sanitation, and related infectious diseases (e.g., cholera) remain pressing priorities, provision of HIV/STI and SRH services may be negatively impacted, both for the general population and for key populations, including sex workers. Unfortunately, our review identified very few studies describing the nature of HIV/STI or SRH services offered or utilized by sex workers within conflict or post-conflict settings. Available evidence generally indicated that conflict-affected populations face unique obstacles to accessing HIV/STI information, treatment, condoms, and other SRH services. For example, migrant populations often face substantial barriers to access, including the potential for being turned away by providers on account of their status as foreigners [26]. In addition to these already pervasive barriers, evidence suggests that access to HIV and SRH services in conflict-affected settings may be particularly challenging for sex workers, due to the additional marginalization, discrimination, and stigma sex workers face on the basis of their occupation [3]. In post-conflict Gulu, northern Uganda, and over half (55.5%) of sex workers reported experiencing difficulty accessing condoms [11]. In general, HIV, STI and SRH services for conflict-affected sex workers were found to be extremely limited, or where available, lacking in scope, scale-up, and reach (e.g., local-level condom distribution, occasional offers of HIV testing) [3, 11].

Sex work specific recommendations are largely absent from international guidelines regarding HIV/STIs or SRH in conflict and emergency settings, including those of the United Nations High Commissioner for Refugees (UNHCR), The Joint United Nations Programme on HIV and AIDS (UNAIDS), United Nations Security Council, and the World Health Organization (WHO). Currently, United Nations agencies (such as UNHCR and UNFPA), bilateral donors, and non-governmental organizations offer policy and programme support for the provision of HIV/STI and SRH services to refugees and IDPs in emergency settings. The Inter-Agency Working Group (IAWG) on Reproductive Health in Crisis, spearheaded by UNHCR and UNFPA, has produced a manual specific to humanitarian settings that serves as a guide to SRH and HIV/STI services beginning with the onset of an emergency, and continuing as the situation stabilizes [55]. The Inter-agency Field Manual on Reproductive Health in Humanitarian Settings incorporates technical standards set by the WHO, and advocates for increased HIV/STI and SRH services for displaced populations as part of broader primary health care activities. It has identified programmatic strategies to facilitate this process, including implementation of the Minimum Initial Service Package (MISP), a set of priority actions in response to the life-saving reproductive health needs of populations at the onset of an emergency. Services included in the MISP for emergency situations include: supplies for infection control, safe deliveries and management of obstetric emergencies, treatment for victims of sexual violence, condoms, oral and injectable contraceptives, drugs for the treatment of STIs, emergency contraception and HIV post-exposure prophylaxis for survivors of rape, and manual vacuum aspiration equipment for the treatment of post-abortion complications [56]. The manual additionally includes guidance on strategies and priorities that should follow when the situation has stabilizes, including adolescent reproductive health, family planning, maternal and newborn health, comprehensive abortion care, gender-based violence, management of sexually transmitted infections, and HIV. While the need for tailored programming or policy recommendations specific to key populations, such as sex workers are largely absent, a number of chapters (e.g. family planning, STI, HIV) do provide insight on how to address the needs of sex workers most effectively. Examples include suggestions to integrate violence reduction strategies in sex work settings, to consult with local staff about how condoms can be made available to sex workers in a culturally sensitive way, to offer regular STI screening services, to work with law enforcement to ensure sex workers have the ability to protect themselves and to ensure safer sex practices by their clients, and to include them from the start in programme design, implementation and monitoring [55]. An overwhelming challenge to provision of these services which is also elucidated, is the reality that health centres in countries with laws against prostitution or discriminatory practices against people engaged in sex work (i.e., the majority of countries worldwide), do not offer services to sex workers [55].

The Prevention and Treatment of HIV and other Sexually Transmitted Infections for Sex Workers in Low- and Middle-income Countries, the product of a joint consultation between the WHO, UNFPA, UNAIDS, and the Global Network of Sex Worker Projects (NSWP), summarizes best practices for evidence-based HIV/STI programming for the general population of sex workers [57]. Research and consultation with sex work groups and key humanitarian and global health organizations could be useful to assess the extent to which key principles and practices described in this document (e.g., voluntary HIV testing, decriminalization, community engagement) may be applicable to conflict-affected settings, as well as to articulate and develop strategies to address the unique challenges faced by sex workers in these settings.

Initial steps have been taken to more explicitly address HIV/STI and SRH within the context of sex work in some refugee programmes in the East and Horn of Africa, Latin America and parts of Asia [3]. Based on these experiences, and under the overall framework of the UNAIDS Guidance Note on HIV and Sex Work, UNHCR and UNFPA produced a brief Technical Note on HIV and Sex Work in Humanitarian Settings [3]. Its primary objective is to inform humanitarian agencies of steps that can be taken to integrate sex worker-inclusive programming into emergency responses. Its recommendations reflect experience from a number of different settings, and are meant to be adaptable to many different conditions and cultural contexts. The Technical Note highlights three pillars which aim to: [1] assure sex workers’ universal access to prevention, treatment, care and support; [2] strengthen partnerships with sex workers through community consultation; and [3] reduce vulnerability and address structural issues. The Technical Note also addresses “key activities per phase,” which assign importance of activities for the preparedness, emergency, and stabilized phases of a conflict or humanitarian emergency [3]. While these recommendations offer valuable guidance for staff in the field, it is largely up to programme staff to adopt these strategies, and further development of policy guidance to explicitly protect the distinct needs and rights of sex workers in conflict settings may be needed.

Strong global evidence indicates that community empowerment approaches to HIV programming for sex workers, including specific efforts to carefully involve consultation, leadership, and partnership with sex workers in the design and provision of services, are linked to improvements in service uptake and access [3, 58]. A growing number of countries that have scaled up sex worker-led/inclusive interventions have reported stabilization, and even reversal, of their HIV epidemics [3]. Despite the demonstrated effectiveness of community-based sex work HIV prevention programmes, few countries have scaled-up such initiatives [59]. In low and middle-income countries, HIV programmes have traditionally followed generalized approaches, with insufficient attention being paid to the individuals and groups at highest risk of acquiring and transmitting HIV/STIs.

In light of evidence that general-population local health services may not be equipped to meet sex workers’ needs and circumstances [23], there remains a need for targeted approaches to offering and delivering HIV, STI and SRH services for sex workers in displacement and post-conflict contexts, with a particular need for programming efforts that acknowledge and address the diversity of conflict-affected sex workers, including both cis-gender women and those who identify as gender/sexual minorities.