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Table 4 Studies describing promising structural-level intervention and prevention practices among sex workers in high-income countries

From: Preventing sexually transmitted and blood borne infections (STBBIs) among sex workers: a critical review of the evidence on determinants and interventions in high-income countries

Reference Country Study Design / Methods Population Context of Promising Structural-Level Intervention and Prevention Practices Policy Implications
Abel et al., 2012 [101] New Zealand Survey and qualitative interviews 58 sex workers (all genders) Decriminalization & Safer Work Environments. In context of decriminalization of sex work, risk perception influenced workers’ decisions to operate in street-based, managed or private sectors of the sex industry. Alongside decriminalization, social and economic policies are required to address risk and develop enabling environments across sex work sectors of sex work industry.
Anderson et al., 2015 [86] Canada 46 qualitative interviews Migrant/immigrant women (trans inclusive) sex workers and managers/owners of indoor establishments Decriminalization & Safer Work Environments. Women described how policing practices and licensing requirements for indoor sex work establishments shape violence and conflict with clients. Removing prohibitive municipal licensing and legislation reform is needed to improve safety of sex work environments.
Argento et al., 2016 [106] Canada 61 qualitative interviews Cis and trans men who buy and/or sell sex Community Empowerment & Safer Work Environments. Community-based project; narratives describe how gentrification and online sex work shape social networks, safety, and control. Critical need to include voices of men and trans sex workers in policy discussions. Supports decriminalization of sex work.
Cohan et al., 2006 [96] USA Cross-sectional 783 sex workers (all genders) accessing care at peer-based clinic (St. James Infirmary) Community-led Programming & Integrative Care. Sex worker-led, free medical clinic provides substantial care to sex workers of all genders. Sex worker-led and integrative, non-judgmental health and support services are key to reducing STBBIs.
Kim et al., 2015 [98] Canada Cross-sectional 2010–2013 547 street-involved women (trans inclusive) sex workers accessing women-only drop-in service Community-led Programming & Integrative Care. Sex worker-specific drop-in service had high uptake (60% used services in last 3 years), associated with increased access to sexual and reproductive health services. Low-threshold and sex work-specific models for sexual health should be scaled-up.
Krusi et al., 2012 [76] Canada 39 qualitative interviews & 6 focus groups Marginalized women (trans inclusive) sex workers living/working in low-barrier, supportive housing for women Safer Work Environments. Unsanctioned indoor sex work environments in the context of supportive housing programs increased sex workers’ control over negotiating transactions and condom use with clients. Removing social and legal barriers to women-only supportive housing models are critical to facilitate safer indoor sex work environments.
Krusi et al., 2014 [71] Canada 31 qualitative interviews and ethnographic observation Street-involved women sex worker (trans inclusive) Decriminalization. Criminalization of sex work and policing practices targeting clients increase risk of HIV/STBBIs. Decriminalization of sex work is needed to ensure health and human rights for sex workers.
Lyons et al., 2015 [78] Canada Qualitative interviews 33 trans women sex workers Decriminalization & Safer Work Environments. Transphobia and criminalized approaches to sex work shape violence and safety with clients and police. Need for legal reform of sex work laws and culturally competent anti-stigma programs/policies to reduce transphobia.
Matthen et al., 2016 [81] Canada Qualitative interviews 45 men and trans sex workers and clients Community-led Research. Narratives revealed highly diverse gender and sexual identities, underscoring importance of giving voice to gender and sexual minority sex workers through community-based research. Policies and services must reflect diversity and needs of sex workers. Critical need to address homophobia/transphobia and reduce stigma.
Mimiaga et al., 2008 [45] USA Survey and qualitative interviews 31 MSM sex workers (19 street-involved and 13 internet-based escorts) Safer Work Environments. Narratives highlight contextual differences in sexual risk-taking among street vs. internet-based workers. 69% reported unprotected serodiscordant sex. Need for tailored interventions that acknowledge heterogeneity of sex workers and contextual and psychosocial factors influencing workplace safety.
Parsons et al., 2007 [109] USA Qualitative interviews 46 male sex workers (internet escorts) Community Empowerment. Highlights the individual and community needs of male escorts. Importance of addressing community-identified needs beyond safer sex, such as support with business and legal advice.
Reisner et al., 2008 [51] USA Brief survey and qualitative interviews 32 male sex workers Integrative Care. Findings highlight valuable intervention components: trauma-informed mental health and substance abuse treatment, access to HIV/STI testing and treatment services, support groups to address isolation/loneliness, skill-building for risk reduction with partners, and paid incentives as add-ons to behaviour change interventions. Multipronged interventions to reduce sexual risk-taking are needed for male sex workers, including addressing unique socioeconomic and legal needs.
Sausa et al., 2007 [80] USA Focus groups 48 trans women (85% had ever engaged in sex work); ethnic minorities Community Empowerment. Participation in sex work and risks were influenced by social networks, cultural norms, immigration, racism, and transphobia Highlights unique needs of trans sex workers who are ethnic minorities. Further research and polices must be tailored to this key subpopulation.
Shannon et al., 2008 [70] Canada Participatory-based focus groups 46 marginalized women sex workers (trans inclusive) Safer Work Environments & Decriminalization. Lack of safe working environment and policing displace sex workers and elevate risk of violence and STBBI. Peer networks improve safe sexual practices with clients. Socio-structural environment plays key role in shaping drug and sexual risk of HIV. Need for safer work environment supported by legislative reform.
Underhill et al., 2015 [74] USA 31 qualitative interviews Male sex workers Decriminalization. Narratives highlight how experiencing discrimination and medical distrust can impede access to biomedical HIV prevention strategies such as PrEP. There is a need to address multiple stigmas and discrimination that create barriers to STBBI prevention.
Williams et al., 2006 [108] USA Questionnaires to evaluate brief interventions to increase condom use 112 street-based male sex workers Safer Work Environments & Integrative Care. Two-thirds of men enrolled in a brief risk reduction intervention completed it. Condom use during paid sex increased post-intervention. Brief interventions tailored to male sex workers to reduce unprotected anal sex with clients are acceptable and efficacious.
Whitaker et al., 2011 [75] Ireland Qualitative interviews 31 female and 4 male sex workers (drug users) Decriminalization & Integrative Care. Sex workers described experiencing stigma and discrimination from healthcare providers, which increased risk of HIV and HCV. Training for service providers is needed to change language and reduce stigma around sex work.