Sex workers are a key population for HIV exposure and transmission in South Africa. A study found high HIV prevalence among sex workers, ranging from 17% to 69% in different locations. Recommendations include decriminalizing sex work, providing comprehensive health services tailored to sex workers' needs, sensitization training for stakeholders, and addressing gaps in knowledge through further research. Addressing the vulnerabilities faced by sex workers is critical to the national HIV response in South Africa.

1. Sex Workers – a Key Population
Andrew Scheibe, MBChB
Sex worker symposium
Boksburg, 22 August 2012

2. Overview
• Background
• Methods
• Outcomes
• Limitations
• Recommendations
• Key Points

3. Key Populations
• Refers to people most likely to be exposed to HIV
or to transmit it
• Their engagement is critical to a successful HIV
response
• Includes people living with HIV
Source: South African National Strategic Plan on HIV, STIs and TB (2012 – 2016)

4. Background
Aim
• Provide evidence-informed recommendations to improve
HIV interventions targeting key populations in South
Africa
Objectives
• Gaps – knowledge, policy, programming
• Stakeholder consultation & consensus building
• Recommendations for National Strategic Plan
– Men who have sex with men (MSM)
– Sex workers
– People who inject drugs and other drug users
– Migrants and mobile populations
– Detained persons and prisoners

5. Methodology for key population gap analysis
Stakeholders identified
Stakeholder engagement Electronic contact (165)
December Telephonic interviews (12)
2010 Face-to-face interviews (6)
Literature review Peer reviewed articles, grey literature,
guidelines, progress reports
(>170 documents)
Key informant feedback Electronic feedback of template
(150 sent out, 21% response rate)
Workshop participation
Stakeholder consultation
June Regional workshops Pretoria workshop (n=60)
2011 Cape Town workshop (n=41)
National workshop SA AIDS conference workshop
(n=72)
September
2011 Consolidation of recommendations

6. Outcomes
September 2011
Policy brief developed
Circulated at NSP summit
October 2011
Key Populations, Key
Solutions report published
December 2011
NSP launched
Including Key Populations

7. Limitations
- Obtaining diverse participation in process
- Limited data on key populations
- Poor response to electronic requests for
information

8. Sex worker vulnerabilities
Vulnerabilities Current situation in South Africa
Lack of specialised services
Scanty and ineffective public and donor funding
Restricted
access to Condom available in primary health clinics, but limited in sex work settings
health services
Syndromic treatment of symptoms within general STI services limited
Limited access to health information and family planning counselling.
Restricted
Laws against gender-based violence seldom enforced, police do not act on sex
access to legal
worker complaints
protection
Unsafe work
Unsafe venues
conditions
Obtaining clients and negotiation often occurs in alcohol settings
Stigma Difficulties in negotiating safe sex
Judgmental health care workers
Despite the threat of fines or imprisonment, women enter sex work in response to
Economic the demand for paid sex and pressures of providing for dependents, as they have
vulnerabilities few alternatives
Source: Richter, 2010

9. Findings: HIV epidemiology
Location Date Prevalence Sample Methods
KZN 1996/7 50% 145 Cross-sectional survey, truck stops.
(Ramjee, Abdool Karim, & Strum, 1998)
KZN 1996/9 56% 472 Screened for HIV-positive cohort study.
(Connolly et al., 2002)
Joburg 1998 45% 247 Outreach recruitment
(Rees et al. 2000)
Carletonville 1998 69% 121 Cross-sectional surveys
(Williams et al., 2003)
Joburg 1996/7 46% 295 Cross-sectional survey among female sex
workers.
(K. L. Dunkle et al., 2005)
CT, DBN, 2001 17 – 66% 249 Cross-sectional survey, results stratified by
Joburg race
(Leggett, 2008)
Durban 2004 60% 775 HIV prevention trial
(van Loggerenberg et al., 2008)
CT, DBN, 2005 34% 67 A rapid assessment
Joburg (Parry, Dewing, et al., 2009)
Joburg 2010 26% 343 Sex workers attending health services at
brothels
(Sibanyoni, Gay, Venter, Klaas, & Motlokoa,
2011)

10. Recommendations (1)
Address knowledge gaps
• Conduct more research on sex work and sex worker needs
Decriminalisation & protection of sex workers
• Decriminalisation of sex work and removal of criminal laws and
municipal by-laws
• Protection of sex workers under existing labour & occupational
health and safety law
Capacity building
• Capacity building of sex workers is required for them to exercise
their rights
Increased representation
• Increase sex worker presentation and participation in the HIV
response

11. Recommendations (2)
Sensitisation training
• Sensitisation training programmes for key stakeholders
(HCW, police, customs officials, journalists, judiciary, and teachers)
Improved access to comprehensive package of
health services
• Access to sexual and reproductive health services, including:
– HCT and ART
– STI and TB screening and treatment
– Family planning and termination of pregnancy services
– Medical male circumcision
– PAP smears and
– Access to mental health and substance abuse services

12. Recommendations (3)
Sex worker specific health services
• Where sex work prevalent – specialised clinics &
mobile services providing:
– Peer educators to provide condoms (particularly
female condoms) and lubrication
– IEC materials and linkages to services for sex workers,
their clients
– General public education and anti-stigma campaigns
• Where infrequent - integration of sex work-
friendly services

13. Key Points
• Sex workers are a Key Population
• Documented vulnerability to HIV due to
various factors, not due to sex work per se
• High HIV prevalence indicates that services to
date NOT effective
• Essential to include sex workers as a focus for
national HIV prevention efforts
• Key Population, Key Solution was a part of
this journey

14. Resources
• Key Populations, Key Solutions – policy brief
www.iom.org.za/publications/KeypopPolicybrief.pdf
• Key Populations, Key Solutions – report
www.migration.org.za/sites/default/files/publications/201
1/2011_-_key_population_report.pdf

15. Acknowledgements
Ben Brown Marlise Richter Helen Rees Roeleen Booi Tabiso Chaka-Ramela
Zoe Duby Monika Dos Santos Francois Venter Geraldine Pienaar
Linda-Gail Bekker Sally Shackleton Danga Mughogho
John Mkandawire Kholi Buthelezi
Heston Philips Cynthia Totten Zwoitwajo Nevhutalo Mikey Meji He-Jin Kim
Olga Lyan Karen Kraan Brian Tkachuk Liesl Theron
David Bayever
Pascal Manini
Nono Simelela Miriam Sabin Sibongile Shoba Robert Hamblin
Catherine Sozi Bret Miner
Carlos Toledo
Eleanour Gouws Alex Semba Ashika Maharaj
Gerrit Maritz Anindya Chatterjee Elizabeth Weich
Marina Rifkin Allanise Cloete
David Makapela Luisa Frescura Bronwyn Myers
Charles Parry
Dabea Gaboutloeloe Nelly Mary Apiyo Oscar Radebe Jill Hendersen
Andreas Pludderman
Sikhulilie Ngqase Tim Barnett Mwaka Kevin Rebe Sarah Fisher
Jo Veary Petal Petersen Brian Kanyemba Glenn de Swardt Robert MacDonald
Sasha Gear Tara Carney Lavinia Brown Stacey-Leigh Manoek Amanda Brinkman
Franz Trautman James McIntyre Elise Batist Miriam Chipimo
John-Peter Kools Helen Struthers Nienke van Schaik Elsa Oliveira
Paul Boyce
David Burrows Aretha Louw Deon Benetatos Alex Hamblin
Oratile Moseki
Ancella Voets Nonandi Diko Mmapaseka Letsike Greer Schoeman
Dawie Nel Naomi Webster
Gerard Lombard