HIV and sex workers - Monitoring implementation of the Dublin Declaration on partnership to fight HIV/AIDS in Europe and Central Asia: 2022 progress report

The absence of robust data makes it difficult to draw firm conclusions about the risk of HIV acquisition in the sex worker population or their access to prevention, testing, and treatment This also makes it difficult to draw conclusions about the adequacy of the response from individual countries, or to monitor whether the situation is improving or worsening across the region. Generally, data provision is superior in the East sub-region. It is  assumed that better monitoring supports targeted service provision, although it is not clear this is the case for the East sub-region where, for example, poor testing rates among sex workers are still reported. The lack of data in many countries may indicate that the needs of some sex worker sub-populations are not visible, particularly given the common risk-behaviours that exist among at-risk populations – overcoming barriers is crucial to targeting services appropriately to meet the varied needs within the sex worker population. 

The limited data which are available do give cause for concern. Among countries able to report HIV prevalence data within the sex worker population, 71% identified relatively high prevalence. The very limited amount of continuum of care data that was available indicates that barriers towards achieving viral suppression among the  sex worker population exist at each stage of the continuum – diagnosis, access to treatment, and viral suppression  for those on treatment. Improvements in monitoring must take place to ensure that targeted interventions can be implemented effectively if the epidemic is to be tackled, at least in part, through achieving viral suppression among all sex workers living with HIV.

Consistently low coverage of targeted prevention programmes reflects a response that is not meeting the needs of the sex worker population. The failure to implement adequate HIV and STI testing programmes targeted at sex workers across the region does not support public health measures associated with prompt treatment of HIV (i.e. being unable to pass on HIV when the viral load is undetectable). Furthermore, data regarding counselling on safe sex and condom use are almost non-existent, and where they are provided, coverage is poor, meaning sex workers who are at risk are not being educated about how to prevent transmission through these channels. 

The introduction of PrEP may create new possibilities for prevention that are especially important for sex workers in situations where they are unable to negotiate condom use. As sex workers are more likely to be economically marginalised, the removal of cost as a barrier to PrEP is essential. Therefore, it is vital that PrEP programmes are  rolled out universally, as soon as possible.

Priority options for action

• Improvements in monitoring and data collection should be made for the sex worker population on the full range of HIV-related matters – prevalence, access to treatment, health outcomes, prevention programmes, and stigma. To allow for effective targeting of responses, data should be disaggregated by gender, including transgender status, and in intersections with other key populations.
• Data should be collected for all four stages of the continuum of care, and a targeted response to any stage that results in poor viral suppression among the sex worker population should be implemented. This means ensuring that sex workers living with HIV are diagnosed, have prompt access to treatment, and are supported in adhering to their treatment regimen.
• Relevant prevention and testing programmes should be made available to sex workers. This requires investment in targeted interventions, prioritisation of counselling, and particularly, consulting with sex workers themselves to ensure that existing or new services are accessible and meet their needs. 
• Use of PrEP among sex workers should be prioritised through implementing programmes that enable access to PrEP and support its uptake. 
• Barriers to the uptake of services should be addressed through challenging stigma related to both HIV and sex work among healthcare providers, as well as in the wider society, and further empowering this key population through the decriminalisation of sex work.