Em Lancet HIV, report by Aaron Reeves and colleagues
Ecological analysis of the association between different legal policies regarding the sex work of 27 European countries and the prevalence of HIV among female professionals. The results suggest that countries where aspects of sex work are fully or partially legalized have a lower burden of HIV among female sex workers than countries that criminalize sex work.
Growing evidence that the criminalization of sex work and application of approaches based on increasing violence and the risks of contracting HIV has recently led to the global call policy to remove all criminal sanctions for sex work.2 Instead, many countries around the world are adopting approaches that only partially decriminalize or legalize some aspects of sex work despite the scarcity of scientific data.
In addition, there is a growing final push for approaches (eg, the Nordic model), where selling sex is legal, but buying sex is criminalized. We recommend Reeves and colleagues1 to try to disentangle the independent effect of these complex legal and application approaches based on this first comparison study at each country level.
This study is timely and provides much needed data on this important but complex issue. It also bears the science, suggesting that the extraction of all criminal laws would be crucial, allowing the step towards reducing HIV prevalence among female professionals.3, 4
However, determining the causal link from ecological analyzes (eg changes in HIV prevalence due to laws) is challenging and needs to be better discussed by the authors, liable to confusion and ecological fallacies. We found that the association remains statistically significant after adjusting for the prevalence of sex workers injecting drugs, gross domestic product, HIV prevalence, and coverage of antiretroviral therapy in the general population.
However, some care is still needed because, in the sensitivity analysis of the magnitude of association for each country, the difference in HIV prevalence was perceptibly reduced when Ukraine, where sex work is illegal, has been removed from the database collected for analyze. Few countries in the analysis where sex work is fully legalized (Germany) or where the search for approaches have been implemented (Norway and Sweden) excludes any conclusions from the studies being done but suggests that low HIV prevalence is associated with a reduction in criminalization.
Temporality issues and enforcement measures (as a proxy for law enforcement) further complicate the assessment of the causal link. Considering that changes in the law would have to precede the date of estimates of HIV prevalence and the slow dynamics of HIV, it is not likely to expect that any changes in the law would have an immediate effect on HIV prevalence (even if new incident cases were reduced ). This relationship between changes in the law and HIV prevalence particularly limits the comparisons with the Nordic model made in this article because Norway made only the purchase of sex work illegal in 2009 after the date of the female professional the estimated prevalence of HIV used in the analysis, which date back to 2008.
The issue of temporality is further complicated by variations in micro-level policing and execution of efforts within countries.
The authors investigated the effect of applying efforts (product due to downstream enforcement) using the World Bank Rule of Law (a measure of trust in the effective and equitable police judicial system) on HIV prevalence, suggesting that fair competition can act as a means of mediation. Although marginalized populations, including female pros, may not be well represented in the rule of law estimates, the findings suggest that where sex work remains fully criminalized, a better relationship with the police is not associated with the reduction of HIV prevalence among female professionals.
Importantly, given the absence of a comparison with fully decriminalized models (no European countries where the sex worker is fully decriminalized), the results presented can not be interpreted as suggesting that legalization is the preferred approach. In fact, we know from various configurations that legalization (which includes the explicit regulation of where and how the industry can operate) rather than decriminalization of sex work (where industry can follow the regulations of other companies) can create a two-level system and the punishment of sex workers and certain coercive practices that stigmatize some female workers and moves them to a marginalized status (eg, individuals who use drugs, female migrant workers) away from social services, In conclusion , despite its limitations, this study provides useful ecological data in many European countries that should raise the attention of governments and policy makers by considering criminalized or end-demand models.
Understanding how criminalization increases exposure to interacting with structural barriers that affect HIV risk and access to intervention and acceptance and how
the elimination of some or all of these reactive structural factors affect the risk of contracting HIV in different settings of ecological and longitudinal levels of individual-level data is the key to HIV prevention, but it is also challenging. Evidence consistently suggests that criminalization could increase the risk of HIV through recurrent police harassment, violence and arbitrary detention or fear of arrests of female pros or clients that may perpetuate unsafe working conditions and risks of drug use, as well as physical and sexual violence against women sex workers without recourse to police as well as judicial protection.
Future research should consider careful monitoring of the application at the municipal level of data capture along with the violence and intellectual level of the female sex worker (eg, female worker policing experiences) to fully disburse as laws and translate to enforcement in the and how this affects the results of violence and the prevalence of HIV for female professionals. Mathematical models anchored in empirical evidence, in collaboration with social scientists and in partnership with the sex work community, remains crucial for attempting to untangle legal and police approaches, violence and HIV burden.3
Whereas many countries are currently reviewing legislation on sex work and based on randomized trials in the community are likely to be possible, and it is crucial for researchers to plan in advance a rigorous follow-up and assessment of the effect of such changes on occupational health, safety and human rights.
We declare to be without competing interests.
- Reeves, A, Steele, S, Stuckler Dr, McKee, M, Amato-Gauci, A, and Semenza, J. National sex work policy and HIV prevalence among sex workers: an ecological regression analysis of 27 European countries. Lancet HIV. 2017; (published online Jan 24.)
- WHO, UNFPA, UNAIDS, and NSWP. Prevention and treatment of HIV and other sexually transmitted infections for sex workers in low- and middle-income countries: recommendations for a public health approach. , 2012 ((accessed Jan 20, 2017).)
- Shannon, K, Strathdee, SA, Goldenberg, SM et al. Global epidemiology of HIV among female sex workers: influence of structural determinants. Lancet. 2015; 385: 55-71
- Harcourt, C, O'Connor, J, Egger, S et al. The decriminalization of prostitution is associated with better coverage of health promotion programs for sex workers. Aust NZJ Public Health. 2010; 34: 482-486
- Decker, MR, Crago, AL, Chu, SK et al. Human rights violations against sex workers: burden and effect on HIV. Lancet. 2015; 385: 186-199